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23A-028 (3) 53 PARK ST BP-2020-0573 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23A-028 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-2020-0573 Pro'ect# JS-2020-00098 Est.Cost: $9000.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: BOB THIBODO ROOFING & SIDING 065699 Lot Size(sa. 111 8712.00 Owner: KOSTEK PETER A& Zoning: URB(100)/ Applicant. BOB THIBODO ROOFING & SIDING AT. 53 PARK ST Applicant Address: Phone: Insurance: P O BOX 201 413 527-7663 0 WC NORTHAMPTONMA01061 ISSUED ON.11/4/2019 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. Buildio-, Inspector Underground: Service: Meter: Footings: Rough: Rough House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire DeDartment 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 Sip-nature: Feer e: Date Paid: Amount: Building 11/4/2019 0:00:00 $40.00 12 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only ����-r City of Nortampfo — Stdtus of!Permit: Building De artment ,� Curb CutfDriveway Permit IIlk' 212 Main treet NODI � 4 ?O Sewer/Setic Availability Room 1100 Water/W II Availability _ p Northampton, MA Q �r r t�� Twa'sets�f Structural Plans phone 413-587-1240 Fax 41 tW : 2 -ILL— IotiSite flans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION Q P— 2-'0 -' ? 1.1 Property Address This section to be completed by office Map a Lot cov '?—'9Unit Zone Overlay District Elm St.District CB District SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ,zo NZ�P")b/' rint) Curre ailing Address: r �� b5 O Telep one S gnat r 2.2 Authorized Agent: 1CL-1p0:11 11 NarrfY(PrintT Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) r- Check Number / This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 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 Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg&paved parking) #ofParking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DON'T KNOW Q YES 0 IF YES, date issued:L-- s . IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: I C. Do any signs exist on the property? YES 0 NO Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES i NO 0 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 Q NO I IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Yf Or Doors C] Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [E:] Siding[O] Other[�] Brief PTscription of Proposed Work: vv-�C��!'� `(�c%� .v,�oy;��t�-�•��n CTS\\ ��1�lh G c,y ^ � S'I1���1� 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 existing housing, complete the following: 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, C C��� _��S , as Owner of the subject property hereby authorize [3a bC`�Jj�i ct on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, as Owner/Authorized Agent hereby declare that the statemen s 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. 1) nN� :=tKOL� S.2 &0 Print tame Signa�tu a of O�vner/Age t Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor`: ,,l Not Applicable ❑ Name of License Holder: C��� 1 lJ A,40 (/ )L �Gl License Number aa -7�&Tress Expiration Date Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ � A�> , )pvc1x-0 \ S� l I Co�mganv Name Registration Number Address Expiration Date 'F�, �h.:�C7�t�► Telephones 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....... 46 No...... ❑ City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS ? 212 Main Street •Municipal Building �� r Northampton, MA 01060 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: s �c" rV 5 �' q (D Y C (Please print house number and street name) Is to be disposed of at: (Please p int name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (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. The Commonwealth of Massachusetts Department of Industrial A cciden ts - I Congress Street,Suite 100 0 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 Please Print Le ibl Name(Business/Organization/Individual): l Address:`;�, t+ SV `,(N C.( v <�- _. City/State/Zip: Phone Are yo an employer?Check the appropriate x: Type of project(required): 1.7am a employer with r employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 [J Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑ umbing repairs or additions 5.]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.t p 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(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. t Homeowners 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 attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I arrr an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name:_ ) - Policy#or Self-ins.Lic.#: U �\_'— Expiration Date: Job Site Address: 'r F City/State/Zip: Yyk Attach a copy of the workers'compensation policy declaratio 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature.A r_ Date: 1 - (4 - 1 -3 Phone#: (—( 13 Official use only. Do not write in this area,to be completed by cin,or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: