32-013 (3) 125 CROSS PATH RD BP-2021-1141
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32-013 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-2021-1141
Project# JS-2021-001915
Est.Cost: $2500.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Coast.Class: Contractor: License:
Use Group: BAYSTATE EXTERIOR RESTORATION INC CS-089485
Lot Size(so. ft.): 114127.20 Owner: HAGGERTY LYLE E
Zoning: Applicant: BAYSTATE EXTERIOR RESTORATION INC
AT: 125 CROSS PATH RD
Applicant Address: Phone: Insurance:
87 SHATTUCK RD (413) 549-6824 WC
HADLEYMA01035 ISSUED ON:4/7/2021 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 NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
I if Cgil •
Certificate of Occupancy Siguaturj i i
FeeType: Date Paid: Amount:
Building 4/7/2021 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
nLL.cr v CU
APR - 7 2021
i r):'�T Or--pU�'VC
The,Corrnnzomn �l'k,O , �Nfisett FOR
Board of Building egu tihns-and-Stand rds
-0/ Massachusetts State Building Code, 780 CMR MUNICIPALITY
USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This/Section For Official Use Only
Building Permit Number:Nu 8 0 4-011 i Date Applied:
4 -y Stu !cuss 747
14-7 21)1I
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 PrOge ty Attire s 1.2 A,gsearrs Map&Parcel Nu�e;sue
�=j c, 1 i4 bd� �
1.1a Is this an accepted street?yes no Map Number Parcel Number
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 GICheck if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record': t
Name(Print) City,State,ZIP
i-a a4 145l-`` L NI Oil) 3 ao- a i 11
No.and Street Telephone Email 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) Addition 0
Demolition 0 Accessory B1d B�u ber of Units Other pecify:
BriifAscription 0,.Proposed Work2: 1
.3-:_iNLa 4) ufk_ tf. ,,leter=r1)
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 2car 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $ ,/�
Check Noll 3lCheck Amount: 1W Cash Amount:
6.Total Project Cost: $ ?i�j� ` 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 r ction S $ ' ' or License(CSL) r ` g6P- S
• . .Ca License Number Expi ati n Date
Name of CSL Holder
g-7 s _ /, D ( , List CSL Type(see below) . a
GA.No.andStreet �j�K �Q'\ Type Description
` l �� C �C,- U Unrestricted(Buildings up to 35,000 Cu.ft.)
M J R Restricted 1&2 Family Dwelling
City/ own,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
•
03 37 - ' s/ 'CET SF Solid Fuel Burning Appliances
,y�,�-1 d n`!Iv _ I Insulation
Te ephone Email address D Demolition
5.2 Registered Home Improveme Contractor(HIC)
451 �3�aa
Z' S' e., 1x4.�,�re, c t. . --1, __ 'HIC Registration Number xpiration Date
HIC I'mpany Name or HIC Registr t Name
No.and Street Email address
City/Town,Stat , 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 CONTRACT APPLIE ^R.BUILDING PERMIT
I,as Owner of the subject property,hereby authorize C-t�lAl .
to act on my behalf,in all matters relative to work authorized by this building permit application.
L 1 5~a
Print 0 ner's Name(Electrooicignature/ Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my na • I•ow,I hereby attest under the pains and penalties of perjury that all of the information
c ' ed in this apt licati, is true and accurate to the best of my knowledge and understanding.
Pr t Owner's or Authorized A ent's Name(Electronic Signature) ate
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"
The Commonwealth of Massachusetts
tl • _ .%K Department of Industrial Accidents
swis_X. I Ill I Congress Street,Suite 100
r
Boston,MA 02114-2017
>"+_1v K'IfJll:ntaSS. dVidiR
1ltukers' Contltensation Insurance AlTidasit:Builders.+Contractors Faectriciamrl'Iuuihers.
It)HE FILED WI I'll TIIE 'F: '1II 1-F1\G Al 11101,11 I'I.
Aptllicant Ltformaticin Please Print [.e ihi
Name(Husincs&Organizatian Indii'dual): Rick._ ` .Nikx CAV
Address: LQRCe-- .
CityfState/Zip: .LI ma1i S Phone#: 0 7z(",:;)7/ __ ., .. . _..
Art:sou an�employ rr:'t hock c appropr a bus Type of project(required):
935,T n�t enrplvyer with -..employees(full:warm part-tirael.• 7. 0 New construction
20 I am a sale proprietor or partnership and have no employees working tier me in K. 0 Remodeling
any eapacity.[No workers'comp.insurance reatnirnl.]
9. ❑Demolition
31:j ham a homeowner doing alp work myself.[No workcxs`comp.insurance requital]"
4.0 I am a home owner and will be hiring contractors to conduct all work on my prcrperty. 1 w ill
I El Building addition
ensure that all contractors eitherha.Vc workers'cexrrpensatrun insurance us are sole I I.D Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
501 am a general contractor and 1 Itave hired the sub-euntrticiurs listed on the attached sheet. 13 oof repairs
These ads-contractors have employees and hove workers'comp.insurance.:
n.0 We an a emporatiun and its officers have exercised their right of exensption per M(L e.
14.0 Other
152,*1(4),and we have no employees.[No workers'comp.insurance required]
'Any applicant that checks box al mint also till out the section below showing their workers'compensation policy information.
Homeowners who submit this:arida%it indicatine they are doing all work and then hire outside emitracton mist submit a new afTidm it indicating such.
lContracturs that check this boa must koala d an additional sheet showing•the name of the sub-ccmtractews and state whether or nut those entities have
n.tplo.ec. II tlx:-,ub-coniraetors lone omplo:,ceN.dncy taus]pre,.IJC thee nu otters'comp.p 'lley numnber.
1 oar an employer that is providing n'orkers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: a--i-rS S ,
Policy#or Self-ins.Lie.#: lQ L C u, - to 8 cD- ( 3 3 1 Expiration Date: ' J3, �a_ l _...
Job Site Address: 3 CP-o c2,. f poi, City/Statei'Zip: n /M IAA: Ql0(ocj
Attach a copy of the workers'compensation policy declaration page(showing the policy number a expiration date).
Failure to secure coverage as required under MCiL c. 152,§25A is a criminal violation punishable by a tine up to$1,500.00
andior oriel ' prisonment well as civil penalties in the form ot'a STOP WORK ORDER and a tine of up to$250.00 a
day against a v�iu ator.A py of '-statement may be forwarded to the Office of Investigations of the DIA for insurance
co%erat;e ve ifica L",-,
, r
/dr+hereby 'ertfjj r a e' t et c on pcvraltiex of perjury that the iriforntation provided abov,istr and correct.
Stature: s Date:
Phone : 3) 37 C)-7/F
Official use only. Do not write in this area,to he completed hi'city or town official_
('its or Town: Permit/License#
Issuing Authorit% (circle one):
I. Board of health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
G.Other
Contact Person: Phone#:
City of Northampton
' Massachusetts 4, .. e11
t;r4 ,
DEPARTMENT OF BUILDING INSPECTIONS
\ +w 'i a:, 212 Main Street • Municipal Building
* Northampton, MA 01060 s'fkv_.. ,3' '
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 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:
r
(,,,,.,
Location of Facility: Va.(
The debris will be transported by:
Name of Hauler: 22-CreYe4,^MoL-.,
Signature of Applicant: Date: q(3-10---4