31A-032 (3) 21 FRANKLIN ST BP-2020-1065
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:3 1 A-032 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRAC KING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2020-1065
Proiect# JS-2020-001808
Est.Cost: $12600.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: A & J HOME IMPROVEMENT INC 101017
Lot Size(sq. 1): 37592.28_ Owner: SILBERSTEIN HARVEY
Zoning: URB(100)/ Applicant: A & J HOME IMPROVEMENT INC
AT. 21 FRANKLIN ST
Applicant Address: Phone: Insurance:
60 WASHINGTON AVE (413) 467-1500 0 WC
SOUTH HADLEYMA01075 ISSUED ON.4/20/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & INSTALL RUBBER ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. 1wi1ding 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 4/20/2020 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
u0 F
Department use only
City of Northampton I ^ Status of Permit:
Building Department >C✓ rb CuttDriveway Permit
s
t� 212 Main Street qoR _ 'gweilSepticAvailability
ROOM 100 W4f4 / eil Availability
` Northampton, MAO,Oli(3Two S61i of Structural Plans
phone 413-587-1240 Fax 413 a7��272 Intl a Plans
Ot r Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE MOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map Lot 10 �a Unit
21 Franklin St. Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Harvey Silberstien 21 Franklin St Northamptoin, Ma.
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) 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 12600.00 (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=(1 +2+3+4+5) Check Number /70
This Section For Official Use Only
Date
Building Permit Number: Issued:
Ju
Signature:
Building Commissioner/Inspector of Buildings Date
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑✓
Or Doors E]
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other[O]
Brief Description of Proposed Remove old rubber roof and install new TPO.060 rubber roofing.
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa. 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, ftay y-c Y SJ /J-Py-S �� ��Vok as Owner of the subject
property
A&J Home Improvement,Inc.
hereby authorize
to act on behalf, in all matter tive rk authorized by this building permit application.
Signature of Own Date
1, ` , 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.
Print Name
S u ne gent 12-
Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Andrew J. Deren
License Number
60 Washington Ave. CSSL101O17
Address Expiration Date
South Hadley, Ma. 01075 11/2021
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
135399
AdcTress Expiration Date
Telephone y/3 S^2f=/ q, 03/31/2022
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....... Ld No...... ❑
City of Northampton
\SS
r ••1 Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS s
212 Main Street •Municipal Building � ca
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:
(Please print house number and street name)
Is to be disposed of at:
(P ease print 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 Ap ant 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
UV
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017w
wwmassgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/tndividual):A&J Home Improvement,lnc.
Address:60 Washington Ave.
City/State/Zip: South Hadley, Ma.01075 Phone#:413 575-1290
Are you an employer?Check the appropriate box: Type of project(required):
1.❑✓ I am a employer with 5 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.]
3.R 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition
10❑Building addition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof rep airs
These sub-contractors have employees and have workers'comp.insurance.[
6.❑We arc a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other
152,S 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:Liberty Mutual
Policy#or Self-ins.Lic.#:WC531621875019 Expiration Date:05/11/2020
Job Site Address:21 Franklin St. City/State/Zip:Northampton,Ma.
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.
Ido hereby certify unj#rthe Rains and penakie, f perjury that the information providedabove istrue and correct.
Si afore: ` Date: l D Z :2-6
Phone#•
Official use only. Do not write in this area,to be completed by city 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#: