24A-226 (5) 43 PILGRIM DR BP-2021-1265
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24A-226 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Siding BUILDING PERMIT
Permit# BP-2021-1265
Project# JS-2021-002101
Est.Cost: $20000.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: PHILIP SHUMWAY INC 105743
Lot Size(sq.ft.): 1 1020.68 Owner: CRAWLEY SARA
Zoning: URA(100)/ Applicant: PHILIP SHUMWAY INC
AT: 43 PILGRIM DR
Applicant Address: Phone: Insurance:
P 0 BOX 522 (413) 687-9400
HADLEYMA01035 ISSUED ON:4/30/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:SIDING
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:) ` ' i
FeeType: Date Paid: Amount:
Building 4/30/2021 0:00:00 $60.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
,p--15.,)$'(-1,..._
' / 06) - Zi.?
1,. The Commonwealth of Massat4 ells (99
CY
Board of Building Regulations and§( ds �0�1MNIC FALITY
Massachusetts State Buildinb Cade;91 ,
� �,....1��TNc,^ USE
Building Permit Application To Construct, Repair,Renovat evised Mar 2011
One-or Two-Family Dwelling 706004,8
This Section For Official Use Only
Building P rmit Number:mbe --1205 Date Applied:
EV ttJ I Kpn /M. 1/-30-2ozl
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
43 Pilgrim Drive �c(A. ��P
1.1 a 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❑ Zone: _ Outside Flood Zone? Municipal 0 On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
'�tro( c—/'ct./ie,7 /',�.tir{fir. r' el
Name( `nt) , City,State,ZIP
1 rgr(A\ , _revc. _
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building 0 Owner-Occupied 0 Repairs(s) Iedr'Alteration(s) 0 Addition ❑
Demolition ❑ Accessory Bldg. 0 Number of Units Other ❑ Specify:
Brief Description of Proposed Work': ' 'i T
t n ( 1
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I.Building $ 1. Building Permit Fee: S Indicate how fee is determined:
D Standard City/Town Application Fee
2-Electrical 0 Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (I-IVAC) $ List:
C5. Mechanical (Fire
Suppression) $ Total All Fee, g
Check No,O Check Amount:+11)
0 Cash Amount:—
6.Total Project Cost. S
,� 640 0 Paid in Full Outstanding Balance Due: i
El
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CBI.) 105743 0 (/"?
Shumway Services — License Number Expiration Date
Name of CSL holder
PO Box 522 List CSL Type(see below) U
No.and Street
Hadley MA 01035 Type Description
iC tyTlown,State,ZIP U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
M Masonry
413-687-9400 shumwayservices(i',�cmail.com RC Rooting Covering
Telephone Email address WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
D Demolition
5.2 Registered Home Improvement Contractor(HIC) 178390
gi
ki`�"tt^".4 sert"/ H1C Registration Number Expiration Date
HIC Company Name 6r HIC Registrant 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 pettnit,
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
CONTRACTOR OR OWNER'S AGENT APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize Shumway Services
to act on my behalf,in all matters relative to work authorized by this building permit application.
G 4/12/21
Owner's Signature Date
SECTION 7b:APPLICANT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this ap lication is true and accurate to the best of my knowledge and understanding.
Contractors/Ow is Agent/Owner Signature ate
I. 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 es1 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.govdps
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"
4 it a tqi trork 0 n -L
�..�' The Commonwealth of firssuc/ %scth Department of Industrial Accidents
f . 1 Congress Street, Suite 100
�` Boston, MA 02114-2017
:l www.ntuss.gtitt/din
t.� Workers' Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILE!)WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leiibly
Name(Business/Organization/individual): $kt..i.t k7 j c( f' Ct_Address: 1Q Ak $ ,
City/Sta ,;Zip: q2 I G�i�t. }0) Phone#: (� I�f 6( 7 4 6.i M
Are y an employer?Check the appropriate box: Type of project(required):
I I am a employer with employees(full and/or part-time).' 7. ❑New construction
ID I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
Ej
1 am a homeowner doing all work myself.[No workers'comp,insurance required.]r
9. ❑Demolition
10[�Building addition
❑1 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. 12.0 Plumbing repairs or additions
❑1 am a general contractor and t have hired the sub-contractors listed on the attached sheet. t 3.0Root repairs
These sub-contractors have employees and have workers'comp.insurance.
261
0 Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14. tier 5.r
152,*1(4).and we have nu employees.[No workers'comp.insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.•
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 t.bis Lox must attached an additional sheet slowing 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:—W d5Ci? — -- _
Policy#or Self-ins.Lic.s1: Lo G l`i -2 4 5- Expiration Date:
Job Site Address: City/State/Zip:___
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGE 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 da hereby certi k cur the pains and penalties rjtrrp-th ilie-tn orii:ation provided abos,eis true,4nd correct.
Signature: . . Date: L 0:17/..d.
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#:
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste 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.
Address of the work: ' e,s t 4
The debris will be transported by: 74/`\ki5
The debris will be received by: Uct l(e) (G c
Building permit number:
Name of Permit Applicant j Lt�M t,,,4 g
tO.2,/r2‘
Date Sigiature of Permit Applicant