11A-019 12 EAST CENTER ST BP-2020-0379
GIs#: COMMONWEALTH OF MASSACHUSETTS
May:Block: 11A-019 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2020-0379
Project# JS-2020-000650
Est.Cost: $24225.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SURGE HOME CONCEPTS LLC - DAVID WOELPER 110193
Lot Size(sq. ft.): 73790.64 Owner: MERRIAM PEGGY A
Zoning: URA(100)/ Applicant: SURGE HOME CONCEPTS LLC - DAVID WOELPER
AT. 12 EAST CENTER ST
Applicant Address: Phone: Insurance:
66 SOUTH BROAD ST SUITE E8 (413)454-2154 WC
WESTFIELDMA01085 ISSUED ON.9/24/2019 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 9/24/2019 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Northa pt Status of Permit:
Building Depa merit Cc/ Cub Cut/Driveway Permit
212 Main S eet LC� 4f I"Mr/Septic Availability
Room 1 0 r/Well Availability
Northampton, A o o6&EP 2 3 Tw Sets,of Structural Plans
phone 413-587-1240 ax 3-587-1272 201-3 PISite Plans
�FPz oFsu Ot er S ecify
APPLICATION TO CONSTRUCT, ALTER, REPAIR—,-RAar T GEp �IIOL H A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This section to be completed by office
i�
(/cggf(-. ) z�4- Map _ Lot 0 /c/ Unit
Zone Overlay District
Elm St.District CB District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Dec, 7�evP;4po 1 �) E (�eV +eA -
Nam4PRnO Current Mailing Address:
NIS) 599 assn
Telephone
Signature
2.2 Authorized Agent:
Cc.I e b DU "C-1 r-C)a'd S t
Name(Print) Current Mailing Address:
.� (q (3) 3 �� - ISIS
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building S (a) Building Permit Fee
2. Electrical ( t7S (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) ,
5. Fire Protection 7
6. Total = 0 + 2+3+4 +5) 1 Check Number
This Section For Official Use Only
Building Permit Number: DateIssued:
Signature: l Z3 ZD� 7
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors I]
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[O) Other[d]
Brief Description of Proposed
Work:,n v-F(" n[cC 151%,-5 le� teo tace vl,�'f�l v] P �✓
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. if New house and or addition to existinci housing, complete the followin
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, f e55 y '7)-1 ee o,,c4 as Owner of the subject
property I
I ,
hereby authorize C4`C( p J OL.,u4 '
to act on my behalf, in all matters relative to work authorized by this building permit application.
5
Signature of Owner Date
Cc'de OC4
as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
CC,( P�) ()u vc, I
Print Name
C"/
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Pr 4 cJ AA ''o e�Pew 1 ( Ci 3
License Number
k 1 S (xtekt, 51' Pd%/Oci -,cl-AU
Ad ss Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
�{ Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, §25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... 6Y No...... ❑
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant information I SUA.X�e &U�
GL
Name(Business/organizatlonal/ndividual): /�
Address �2 (9 J�� 1,1Loc �4 City:
State: MA tip: 61 d FS Phone#: T3 3g{21 S S S
9Are ou an employer?Check the appropriate box: Type of project(required):
1. 1 am an employer with) % (employees(full and/or part time)• F-1 7. New construction
2. 1 am a sole proprietor or partnership and have no employees working for me in any ❑8. Remodeling
capacity.(No workers'comp.Insurance required.)
a9. Demolition
❑3. 1 am a homeowner doing all work myself.(No workers'comp.Insurance required)t ❑10. Building addition
4. 1am a homeowner and will be hiring contractors to conduct all work on my property. Fill. Electrical repairs or additions
I will ensure that all contractors either have workers'compensation Insurance or are
sole proprietors with no employees. ❑12. Plumbing repairs or additions
a
S. I am a general contractor and I have hired the sub-contractors listed on the attached 13. Roof Repairs
sheet. These sub-contractors have employees and have workers'comp.Insurance,t
6. We are a corporation and its officers have exercised their right of exemption per MGL. �14. Other
c.152,61(4),and we have no employees. No workers'comp.Insurance required.)
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit Indicating such.
!Contractors that check this box must attach an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation Insurance for my employees. Below Is the policy and fob site Information.
Insurance Company Name: (ZAdJI`Q�S 12 21 c
Policy#or Self-Ins.Lic.#:
C� H O U3 $Z3 G 1 to l e Expiration Date: �
Job Site Address: (f(-114- - ` r
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL.c.152,§25A Is a criminal violation punishable by a fine up to$1,500.00 and/or one-year
Imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. A copy of this
statement may be forwarded to the office of Investigations of the DIA for Insurance coverage verification.
AI do hereby certUy under the pains and penaltles of perjury that the information provided above Is true and correct,and that clicking this
checkbox and ping my name in the
�fled below will act as my signature. �� t
Name: ✓" _____- Date: 1
Phone#: �� Email: (aJ
DATE(MMMONYYY)
CORD° CERTIFICATE OF LIABILITY INSURANCE 1 04/28/2019
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT.BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder In lieu of such endorsement(s),
CONT
PRODUCER NAME:CT Gloria Linzi
Bates Fullam Insurance Agency,Inc PHONE . (413)737.3639 1Arc No): (413)731.8255
976 Elm Street ADDRESS: glinzl®batesfullam.com
INSURERS AFFORDING COVERAGE NAIC N
West Springfield MA 01089 INSURER A: Western World Insurance CO
INSURED INSURER B: NGM Insurance Company 14788
Surge Home Concepts,LLC INSURER C: Nautilus Insurance Co.
60 So.Broad St,Unit E8 INSURER D: Ohio Casualty Insurance Company 24074
INSURER E
Westfield MA 01086 INSURER F:
COVERAGES CERTIFICATE NUMBER: 18-19 GL.XS,IM,BA REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF INSURANCE POLICY NUMBER MMIDD/YYYY MMIDDIYYYY LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 6 1,000,000
MI SES 6 100,000
CLAIMS-MADE �OCCUR
MED EXP(Any oneperson) s 6,000
A X $500 Dad Per Claim NPP8525290 12/21/2018 12/21/2019 PERSONAL I ADV INJURY : 1,000,000
G6N'LAGGREOATE LIMITAPPLIES PER:
OENERALAGGREGATE 2.000,000
POLICY❑JECT F�LOC PRODUCTS-COMP/OP AGO =
1,000,000
OTHER: COMBINED SINGLE LIMIT
AUTOMOBILE LIABILITY Ea a dant s 1,000,000
ANYAUTO BODILY INJURY(Par parson) 6
B OWNEDSCHEDULED M1 P9684G 05/04/2018 05/04/2019 BODILY INJURY(Per accident) 6
AUTOS ONLY AUTOS 6
HIRED NON-OWNED t
x AUTOS ONLY x AUTOS ONLY 6
X UMBRELLA UAB OCCUR EACH OCCURRENCE 6 1,000,000
C
EXCESS LIAB AN061397 12/21/2018 12/21/2019 AGGREGATE 6 1,000,000
CLAIMS-MADE
s
DED I I RETENTION6OT
WORKERS COMPENSATION I PTUTE ER
AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED? NIA to be sent separately
E.L.DISEASE-EA EMPLOYEE i
(Mandatory In NH)
If yss,describeunder E.L DISEASE-POLICY LIMIT 6
DESCRIPTION OF OPERATIONS below
Leased Equipment 175,000
D INLAND MARINE BM058487311 12/22/2018 12/22/2019 Deductible $1,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If mon space Is requAd)
Construction Management for Resident)a)Properties.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Kim Fuller
17 Mockingbird Lane AUTHORZED REPRESENTATIVE Q
Westfield MA 01085 -•`i�' '
®1988.2016 ACORD CORPORATION. All rights reserved.
ACORD 26(2016103) The ACORD name and logo are registered marks of ACORD
DATE(MWDDIYYYY)
coROm CERTIFICATE OF LIABILITY INSURANCE F04/26/2019
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
BELOW CERTIFICATEVERAGE AFFORDED
THI3 CERTIFICATEFIRMATIVELY OR NEGATI
0 NSURANCE DOES NOTLCONST TU�TE A CONTRACT BETWEEN EXTEND OR ALTER THE OTHE ISSUING NSURER(S)BY TAUTHOR AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the poilcy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement s, CO
cT Sonia Per
PRODUCER A Ee FAX
PHONE 413 737-3539
BATES FULLAM INSURANCE AGENCY INC 71NSURER;A:
AIL s e batesfullam.com
INSURER(S)AFFORDING OVERAGE NAIC0
975 ELM ST v' —`-
WEST SPRINGFIELD MA 01089 TRAVELERSINDEMNITY CO OF AMERICA 25666
INSURED URER
SURGE HOME CONCEPTS LLC INSURERC:
INSURER D
66 SO BROAD ST UNIT ES INSURER E;
WESTFIELD MA 01085 INSURER P:
COVERAGES
CERTIFICATE NUMBER: 395313 REVISION NUMBER:
THIS OD
IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAEF ID CLAIMS.
LIMITS
INSR TYPE OF INSURANCESUBA CYN MBER
EAGHOCCUR�RENNTCE _
cOMMERCIAL G ENERAL LIABILITY =
—
CLAIMS-MADE F1 OCCUR —
MED EXP An one rson t
NIA PERSONAL&ADV INJURY $
GENERAL AGGREGATE f
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS.COMPIOP AGO S
POLICY a JECT D LOC :
OTHER: N MIT 3
ccidantl
AUTOMOBILE LIABILITY BODILY INJURY(Per person) $
ANY AUTO BODILY INJURY(Per accident) S
ALL OWNEDSUTODDULED NIA R P G i
AUTOS NON-OWNED
HIRED AUTOS I I AUTOS =
EACH OCCURRENCE f
*nETPNTION
OCCUR =N/A AGGREGATE CLAIMS-MADE f
X T T
WORKERS COMPENSATION
AND EMPLOYERS'UASILITY YIN E.L.EACH ACCIDENT S 600,000
ANYPROPRIETOWPARTNERIEXECUTIVE 1NIA WA NIA 6HUB7H82381818 12/21/2018 12/21/2019 E.L.DISEASE-EA EMPLOYEE $ 500,000
A OFFICERIMEMBEREXCLUDED9
(Mandatory In NH) E.L.DISEASE-POLICY LIMIT S 500,000
If ge,describe under
DESCRIPTION OF OPERATIONS below
NIA
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached K more apaoe is required)
Workers'Compensation benefits Will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization Is given to pay
claims for benefits to employees In states other than Massachusetts if the Insured hires,or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was Issued(unless the expiration date on the above policy precedes the
issue date of this certificate of insurance). The status of this coverage can be monitored dally by accessing the Proof of Coverage-Coverage Verification
Search tool at www.mass.gov/lwd/workers-compensaUontinvestigations/.
CERTIFICATE HOLDER CANCELLATION
SHOULD XPIRATIIONH ABOVE
DATE POLICIES DESCRIBED C
HEREOF, NOTIICE WILLL CBE
THE DELIVERED ELLED BEFO
IN
ACCORDANCE WITH THE POLICY PROVISIONS,
Kim Fuller
17 Mockingbird Lane AUTHORIZED REPRESENTATIVE
Westfield MA 01085 Daniel M.C ,CPCU,Vice President—Residual Market—WCRIBMA
r y
®1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
— Type: LLC
Registration: 186413
SURGE HOME CONCEPTS, LLC ,
66 SOUTH BROAD ST Expiration: 11107!2020
`=
SUITE Ewj
WESTFIELD, MA 01085
SCA A 20M-Oa 17 Update Address and Return Card.
Office of Consumer Affairs 8 Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE: LLC before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
186413 11'07;2020 1000 Washington Street-Suite 710
SURGE HOME CONCEPTS,LLC Boston,MA 02118
DAVID WOELPER
66 SOUTH BROAD ST
SUITE E Undersecretary Not valid without signature
WESTFIELD.MA 01085
® Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-110193
Construction Supervisor
DAVID WOELPER a e
115 GARDEN STREET
WEST SPRINGFIELD MA 01089 "
Expiration
Commissioner 02x0912020
I�
HIGH 1136413 Date:
CSLfi110193 ..
; U R- E H-HIUME GUNCEP T
(413) 342-1585 - SURGEHOMECONCEPTS.COM
Residential and Commercial Roofing Systems
Customer: 6eor' �ljgm Phone: '113, SN.2-Po
Address:M t- Ire
�� Email:
leed," 17M 0i0s:7 Mer r!wn 4gonw►(!'<f4'.j'�-
Roofing Proposal
Provide permits for work on home
Provide Dumpster to haul-away all roofing debris
Strip all existing roof faces to existing sheathing
Inspect sheathing and roof framing for damage
If new plywood is needed the additional charge will be$75/sheet installed
If more work has to be done a quote will be provided immediately
Install F8 drip edge around all eves and rakes of roof faces—Color:
Install Ice and water barrier 6'up(two courses)from eves on all roof faces
Install all new pipe flashing boots
Install synthetic underlayment on remain roof faces
Install starter shingle along all eves and rakes of roof faces
Install architectural shingles on all roof faces
Install rolled ridge vent
Install matching cap shingles
Additional info:
Price includes all mate Is,lab r,t res and perm t fees �_ 1/K K You r 'e Man/ .v4 /
Shingles will be Atlas a in color:
All applicable shingle accessories to be Atlas bran
Includes 25 year craftsmanship warranty from Surge Home Concepts
Includes Atlas Signature Select warranty Start Date:
Includes 3M Scotchgard lifetime stain warranty Completion Date:
Attention homeowners:Please cover all personal belongings in the attic,garage,or storage areas due to the possibility of roofing debris or dust coming
through the cracks of the wood.Surge Home Concepts will not be responsible for the debris or dust in the areas mentioned.Homeowner must remove i
valuable items from walls to prevent damage during siding projects.Also SHC is not responsible for gaps from siding on home and roof line due to mutt)
layer roof strips.A 3.5%fee will be added if payment is made via credit or debit transaction.AN material is guaranteed to be as specified.All work to be
completed in a workmanlike manner according to standard practices.Any hidden conditions are not covered under this document and may become an
extra charge.Any afteretion or deviation from the above specifications must be made in writing on an addendum contract and may become an extra
charge over and above the amount stated herein.This agreement is contingent upon delays beyond our control.Owners to carry fire,tornado,and other
necessary insurance.Our workers are fully covered by Liability and Workmen's compensation insurance.Homeowner agrees to pay for all work as set
forth in this document.If the homeowner defaults,homeowner agrees to pay all costs of collection,including reasonable attorneys fees,in addition to
other damages incurred by contractor.An 18%per month service charge will be assessed for all payments not made within 10 days of due date per the
schedule below:
We purpose herebyto furnish material and labor,complete in accordance with the above specifications,
for the sum of. $ y-Said amount shall be paid as follows:
Down:$ 7500. ,Start:$ 12 ,Half:$ Completion:$
Note:This proposal may be withdrawn by us if not accepted within 3 days.
YOU,THE BUYER,MAY CANCEL THIS TRANSACTION ATANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DAY OF
THIS TRANSACTION.THIS SALE IS SUBJECT TO THE PROVISIONS OFT HOME SOLICITATION SALE ACT AND THE HOME IMPROVEMENT
ACT.THIS INSTRUMENT IS NOT NEGOTIABLE.
Sbanature of contractor or authorized representative:
•(gVlfe)haveread the terms etas herein,they have been explained to(me/us),and(IIWe)find them to be satisfactory and hereby accept
them.S lure of Homeow r:
x l ZO/
City of Northampton
Massachusetts '" .
) w ,L
DEPARTMENT OF BUILDING INSPECTIONS ti}
212 Main Street • Municipal Building
Northampton, MA 01060 rS .......,%�O
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes, a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L. Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeownerd
has contracted with a corporation or LLC, that entity must be registered.
Type of Work: �,U cow � Est. Cost:
Address of Work: I a �- C e
Date of Permit Application: q/16 Aim)
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law(explain):
_Job under$1,000.00
_Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
Qu(,/id w6-e( 9e:;2,,^ I SSG W 13
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage --- _. —
Setbacks Front
Side L: R: L:= R:=
Rear 0
Building Height U
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved �� C
parking)
#of Parking Spaces C V
Fill:
volume&Location ".__ . _._.__---.. .-_.___._..
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO o DONT KNOW ® YES o
IF YES, date issued:C_____..®___-...�
IF YES: Was the permit recorded at the Registry of Deeds?
NO o DON'T KNOW o YES o
IF YES: enter Book Page� _ and/or Document#11 ..�J
B. Does the site contain a brook, body of water or wetlands? NO • DONT KNOW o YES o
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
0 0 �.
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading, excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES o NO 40
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
SSS.•.,r,�s�c
f Massachusetts
i I A "
1 a,
DEPARTMENT OF BUILDING INSPECTIONS Z
212 Main Street •Municipal Building yobbo`
Northampton, MA 01060 srk ....
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
I -)�' F, C6a,ter �+
(Please print house number and street name)
Is to be disposed of at:
cg� eUIW45�'c
Y
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
L4
(Company Name and Address)
Signature of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.