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44-049 (2)
14 AUTUMN DR BP-2021-1040 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:44-049 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-2021-1040 Project# JS-2021-001773 Est.Cost: $6100.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq.ft.): 10018.80 Owner: PATILLO ANTHONY L&VICKI A Zoning: Applicant: PATILLO ANTHONY L & VICKI A AT: 14 AUTUMN DR Applicant Address: Phone: Insurance: 14 AUTUMN DR (413) 585-8688 () FLORENCEMA01062 ISSUED ON:3/23/2021 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 NORTHAMPTOTP71 OLATION OF ANY OF ITS RULES AND REGULATIONS. • Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 3/23/2021 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner j155' 'N'''N, The Commonwealth of Massachusetts 4' f W Board of Building Regulations and Standards ,� CIPA ITY Massachusetts State Building Code, 780 C1v>R,, n� .�. cQ� USE/ Building Permit Application To Construct, Repair,Renovate ,>`'' mplish a'1 --R-cZd A!ar 2011 One-or Two-Family Dwelling /t� :::\'''.>„‘" 1 This Section For Official Use Only ',nJG'io,� Building Permit NumbekAoll"IU`/ Date Applied: 31242. l ( l Lou1'S tt DSbroc�c 3lzlizl B ild1f ing Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 As es rs Map&Parcel Numbe 9 -FL v2EuCt- MA, 1i AuTIAiv►A 7r' r 7 1.1 a Is this an accepted street?yes 1./ no Map Number Parcel Number P 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: " N-T Ho lv'-t PAT 11Lc) f L o2E"tCC) M A otO62_ Name(Print) City, State,ZIP r l 1/4-1 AtA--14 AA.Ii j)rr v. VO 5E5 ya9q a-paifl o Cowtc,asTin 6,r No.and Street Telephone Emai Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other Specify: Roo f fNEr BrieffDescription of Proposed Work': P SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 1. Building Permit Fee: Oy 0 Indicate how fee is determined: 2.Electrical $ ltandard City/Town Application Fee 0 Total Project Cost3(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees: $ #'�© Suppression) *lb Check No�.�Check Amount: t d Cash Amount: 6.Total Project Cost: $ �PIoC/ PaidArl_ in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Re ant Name No.and Street Email address City/Town,State,ZIP Telephone SECTION 6: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 No 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Print Owner's Name— (E r ' u Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Afl i Ol) eaf�l;�a 312.1 I 2-1 Print Owns or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" City of Northampton ,,,:v.,,,,,,,,v, i :,- Massachusetts ��. ..,, ,,, �� ,A. : , 666 „ y: ; jy DEPARTMENT OF BUILDING INSPECTIONS ``•� f 212 Main Street • Municipal Building yJti a� -^�� Northampton, MA 01060 SSV4 `1�� CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number kX is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: Vd I I z lc-eC cl, ( N5 The debris will be transported by: Name of Hauler: KI N 6l 6OWj BIA 1(,P6R J : r Signature of Applicant: Bill-AN '0 R-tt•E Date: 31 7A J 2-1 The Commonwealth of Massachusetts i lin,kzt-771 Department of Industrial Accidents frh$t 1 Congress Street,Suite 100 1 Boston, MA 0 2114-2017 www.mass.gov/dia %Yorkers'Compensation Insurance Affidavit:Builders!ContractorslEkctricians/Plumbers. TO BE FILED WITH THE PERMFITINC AUTHORITY. Attnlicant Information Please Print i:eeihly Name(Husincssiorg,antzauon Individual): AN-1140 01 Pa tl L Address: l 14 i tv.inn n 1)r t v e City/State/Zip: 'FI CR EN CC, M-- 0 toe-2— Phone#: 9 I-5—50 6 4 9.9 Are yeti as employer?Cheek the appropriate boa: Type of project(required): l.❑1 am a employer with euyrloy'ees(full and'ot part•tinw i.• 7. 0 New construction 2L1 I am a auk proprietor or partnership and have nu employers working fur me in IL I,Remodeling any capacity.(Nu workers'comp.insurance required.) t--++ 9. ❑Demolition .3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.)" 10 Q Building addition 4.0 l am a ltumeuwne7 and will be hiring cwaursclurs to conduct all work on my property. I will K t nsure that all contactors either hate workers'compensation insurance or are sole 1 I.Q Electrical repairs or additions pruprietun w ith no employees_ 12.0 Plumbing repairs or additions 5n I am a general contractor and I have hired the sub-contractors listed un the attache!sheet_ These sub-euntracturs have employees and hay a workers'camp.insurance. 138 Roof repairs 6.0 We are a corporation and its offerers have exercised their right of exemption per MGL c. 14.00thet 152,§11:4),and we have no employees.[No workers'camp.insurance required.) 'Any applicant that chocks box al must also fill out the section below show ing their worker.'compensation policy information. +Homeowner,who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidav it indicating such. !Contractors that cheek this box must attached an additional sheet show ing the name of the subcontractors and state whether or not those entities Lase employees. If the sub-contractors have er g:luy'ees.they must pros iJc their worker'comp.policy number. 1 am an employer that is providing workers'contirensgion insurance for m 'employees. Below is the policy a ndyob she information. \. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City' tatefZip: Attach a copy of the workers'compensation policy d laration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,R25A is a criminal violation punishable by a fine up to S 1,500.00 andi'or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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. 1 do hereby Certi .under ,.. J.+ ,.;:'d penalties of perjury that the information provided above is true and correct. Sib attire: Date: 3� Zl1 1 Phone:: `3 C S sr 99 Officiaal/� l use onit. Du not write in this'wag,to be completed by chi or town official. ('its or Town: Permitlicense 4 Issuing Authority (circle one): I. Board of Health 2.Building llepartn:rnt 3.('it),Iowan Clerk 4. Electrical Inspector 5. Plumping Inspector 6.Other Contact Person: Phone#: VA PR I ((-Le c9 co m c p t N o-