23C-093 98 BAKER HILLRD COMMONWEALTH OF MASSACHUSETTS BP-2021-1904
Map:Block:Lot:23C-093-
001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2021-1904 PERMISSION IS HEREBY GRANTED TO:
Project# 2021 ROOF Contractor: License:
Est. Cost: 19750 JACK E MORSE ROOFING
Const.Class: Exp.Date:
Use Group: Owner: BROWN, ANDREW & HELENA PORTER-BROWN
Lot Size (sq.ft.)
Zoning: URB Applicant: JACK E MORSE ROOFING
Applicant Address Phone: Insurance:
2 LILAC AVE 4133749064
CUMMINGTON, MA 01026
ISSUED ON:09/20/2021
TO PERFORM THE FOLLOWING WORK:
STRIP&REPLACE ROOF, INSTALL WATER & ICE BARRIER
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.
Signature:
1. • ''c ' 9 CS-41 I i '
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
If
�o
N yo
"' SikA r The Commonwealth of Massachusetts
Board of Building Regulations and Standards
. FOR
.-1 cv '' MUNICIPALITY
E Massachusetts State Building Code, 780 CMR USE
W a o Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised Mar 2011
(ltt1J a One-or Two-Family Dwelling
�'� This Section For Official Use Only
( '--' ' Building Permit Number: ZCll--(tf C D to Applied: 4i 1 Zo( ZG 2
i‘()1071-C.> I
Building Official(Print Name) iggnature Date
SECTION 1: SITE INFORMATION
1.1 Property ddress: 1.2 Assessors Map& Parcel Numbers
CI Gi x-- nc._�,.�� l Aove eNA- 23C—013—Oo (
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❑ Private 0 Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
\
2.1 Owner'of Record:.. n ,�"
f.j w.c Pa v e r a/LQwn/ /(J d y Y H-�G ►'u+n /(,(/a. (1 0�0 2
Name(Print)/ L D' d'ty,Sttatte,,ZIP n L
R (/ I a-ko ( • 6 i 7 v v 7 -)7a �.p ,..r YYo„h{4 E ISM.".e 4,
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) 0 Alteration(s) 0 Addition ❑
Demolition 0 Accessory Bldg. 0 Number of Units Other 0. Specify: p00- R Gl to c.er—'A---
Brief Description of Proposed(Wnork2: ST P' e St:,. �
(Co „ •J:.t T Z.....j s f 44)% c_c -+ (A,re a.,—
IN pY 4Z4 fi e:. A.y..d 11 C.C.-k /Ata_rc.i c I\►A \C S-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee: $40— Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee
0 Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
/Y Check No.U 1 1 Check Amount:'A�0--
6.Total Project Cost: $ r CIi7 S U 0 Paid in Full 0 Outstanding Balance Due:
City of Northampton
Massachusetts k
,
t ' 411 DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 44 ib1
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS,ROOFS,RENOVATIONS,ROOF MOUNTED SOLAR,ETC.
1. Building Permit Application signed by legal owner and filled out
by owner or authorized agent.
2. One set of plans and specifications of proposed work(Digital and hard copy).
3. Construction Debris Affidavit filled out and signed by applicant.
4. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance.
6. Energy Conservation Compliance Certificate (new /replacement windows).
7. Home owner's License Exemption Form (if applicable).
8. Note any Special Permit requirements(if applicable).
9. Energy Code-all new construction(Gut/Rehab) requires a HERS Rater Affidavit
.10. Please provide the appropriate,fee in the form of a check made.payable to: The City of
Northampton.
4
11
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 1 01 `1' 1 ( L 20'Z 1
3 AJ (sV-Ai License Number Expiration Date
Name of CSL Holder
L, l A U l -L List CSL Type(see below) (LG
No.and Street Type Description
�` u �` I r/ 1 /c A '1 6 U Unrestricted(Buildings up to 35,000 cu.ft.)
l� t �Q V U �i R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
� �J SF Solid Fuel Burning Appliances
%1 J /14 'q 664 el, I Insulation
Telephone Email a dress „[ (.X D Demolition
5.2 Registered Home Improvement Contractor(HIC) t\ 9, . c t Of!Z.az 3
Sh -i— 14—"— HIC Registration Number Expiration Date
HIC Company2-- LNare t in HICP Registrant Name -kicks L
f,��No.and Street
(lMrr"-"`��L- Q�i d a (l/\•;;(,�Sd,. Email address
City/Town,State,ZIP Telephone 7�'�i
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must a completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Iss ce of the building permit.
Signed Affidavit Attached? Yes No . ❑
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 3-AGk,
to act on my behalf,in all matters relative to work authorized by this building permit application.
1.46A4.4L. ie. I°vt4v-gyaw,,
_... 0 -.,) I
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under ains and penalties of perjury that all of the information
conta' din this application is true ate to the best of my knowledge and understanding.
Se_ Gd ZdZ.
Print Owner' 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.Eov.!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"
I.
The Commonwealth of Massachusetts
f Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
1451
WWW-mass.gov/dia
MOriters' Compensation Insurance Affidavit:BuildersiContractomElectriciansiPlumbers.
TO RE FILED WITH THE PERMITTING AtITHORI I N.
Applicant In El)Cilia tion Please Print Legibls
.....-:1,,,
Nall] liustram&Organitationilniliv idual'0: -,...)I-)cdt,
Address: 2 1___ \ A c i ,•2—
City/State/Zip: C S II hA, Phone#: 3 7 9- cioc ki
A.,.r yea au inelikiyre Check the appropriate hot:
Type of project(required):
2,17
I. am a employer with _ employees(full orator part-tiniel• 7. [3 New constructioo
2 I am a sak proprietor or partners/Op and have no employees working for ax in g. 0 Remodeling
any mipacity.[No workers'torrip insuranee required"
9. 0 Demolition
3{:j I am a hornisavaner doing all work myself.[tio workaaa'entrap..imairame requirell"
i 0 0 Budding addition
41.0 I am a homowner and will he hiring oantracturt to canchaet all work on my primerty. I will
ensure that all calm:mars archer have waricer3'LVInticiMiatiOn InSiUranir Olf aite aiiii 11E3 Electrical repairs or additions
proprietors with no anolayeta
12.0 Plumbing repairs or additioil,
sCi 1 am a geissui contractor and I ha..e hired the tors listed on the attaLthed sheet.
130 Roof repairs
rtwse t.h-conirsekrts nave employees and have wr -niers'comp."insitraneei,
9.0
6.0 We are a‘-isipsaranors and its officers have exercised then right of exemption per IAA c. 144:Other 0c
152,§filli,and we have no employees.[No workers'comp,inaurame ra4utrail
'Any applicant that cheeks box trl must also fill nut the section below show iny their viatica-3'compensation polar.,information_
+Homeowners who itthmit dm affidavit indicating they are doing all work arid then hire isounie contractort must submit a new:affidavit Indic:limn such.
!Contractors that check this box must attached an silditional sheet showing the name of the vidi-ciattrscters'.and'tea.31tetha-or not[how araiti3,3 h..va
etrirlcoac., 11-..1..a 301--corttratetorN 13a,a etrtrloy3v3.'boy neat pm"ikic that WO(Ler3',a,:nrit3 r..,h.,...1,huallv 1
.. „.... -
I am on employer that is providing workers'compensation insurance fir my employees. Below is the policy and job Nile
information.
Insurance Company Name:
Policy#or Self-Ms.Lie.#: 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 MGL c. 152,425A is a erialifini violation punishable by a line up to$1,500.00
arki3Of one-year anprisonimmt,as well as civil penalties in the form of a STOP WORK ORDER and a tine 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.
I do hereby certilv ten, : t .pains and penalties of erjury that the information provided above is true and correct
Signature: Date: e..0 4— Z.-id Z Cl Z 1
Phone#: , 1
Lt
Official use only. Do twit'rite in this area,to be completed by city or town official.
C'ity or Town: Permit/License#
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone 4:
City of Northampton
Massachusetts ° t
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building y, +-
Northampton, MA 01060
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 3P--204( - ct+ 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:
The debris will be transported by:
Name of Hauler:
Signature of Applicant: Date: Cc-eV(' ~ 16 7441
City of Northampton
,"Bfx�f�'��.t�`- y. S`�,:.•�„ SAC-..
Massachusetts .4 ' ..
id •t * ,�
E DEPARTMENT OF BUILDING INSPECTIONS
-;. . 212 Main Street • Municipal Building
Northampton, MA 01060
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, (insert full legal name), born_ (insert
month, day,year), hereby depose and state the following:
1. I am seeking a building permit pursuant to the homeowners'exemption to the permit requirements of the
Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or
work on a parcel of land to which I hold legal title.
2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'
exemption, does not involve the field erection of manufactured buildings constructed in accordance with
780 CMR 110.R3.
3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2:
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
there is, or is intended to be, a one-or two-family dwelling, attached or detached structures
accessory to such use and/or farm structures. A person who constructs more than one home in
a two-year period shall not be considered a home owner.
4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I
qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of
the project or work on my parcel, I am not engaged in construction supervision in connection with any
project or work involving construction, reconstruction, alteration, repair, removal or demolition
involving any activity regulated by any provision of the Massachusetts State Building Code.
5. If I engage any other person or persons for hire in connection with the aforementioned project or work on
my parcel, I acknowledge that I am required to and will act as the supervisor for said project or work.
Signed under the pains and penalties of perjury on this day of , 20_.
(Signature)