31B-001 (3) BP-2021-2234
44 BANCROFT RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
31B-001-001 CITY OF NORTHAMPTON
Permit: Exterior Res
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2021-2234 PERMISSION IS HEREBY GRANTED TO:
Project# roof Contractor: License:
Est. Cost: 3000 ROBERTS ROOFING 099404
Const.Class: Exp.Date:01/21/2022
Use Group: Owner: WARD FRAZER D&ALEXANDRA L M KELLER
Lot Size (sq.ft.)
Zoning: URA Applicant: ROBERTS ROOFING
Applicant Address Phone: Insurance:
30 Edwards Rd 4134410350
WESTHAMPTON, MA 01027
ISSUED ON:11/29/2021
TO PERFORM THE FOLLO WING WORK:
install flat 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.
Signature:
1, . y2 Ti
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Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
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1 , The Commonwealth of Massa9huse s No
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Board of Building Regulations and Sta ds 2021 CIPALITY
Massachusetts State Building Code, 78 MR USE
Fpr 0
Building Permit Application To Construct,Repir;-Rend� Reviled Mar 2011.
One-or Two-Family Dwelling -- °n- "sq,6,nTian+r;
This Section For Official Use Only_ `�_
Build' Permit Number: 04)—a/. .2.? 3 Date Applied:
(Z�5 /� I I•261.ZZ/
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address 2 Assessors Map&Parcel Numb b/
1/ ekfri__
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 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Oer'ofor��
---)
Name Pnnt City,State,ill,ZIP
��( ) � ^� tY
No.d Stieet� ��[[["'J1 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) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work':
c76,444(9.161X-A'(/7.V SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
( r and Materials)
1.Building qae r 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
$
City of Northampton
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Massachusetts
cari
DEPARTMENT OF BUILDING INSPECTIONS
_ 212 Main Street • Municipal Building
Northampton, MA 01060
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.
I
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor 'cense(CSL)
Q'rlcl e-{ .)/ , -
...-ailr,/��i4/ ' /I �/� i License Number Expiration Date
Name C L 41 der
11 / List CSL Type(see below)
�% - /i ��� /9i
No.and Str-A Type Description
-2 ei-47 UUnrestricted(Buildings up to 35,000 cu.ft.)
/ R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
_ ' Roofing Covering
Window and Siding
F Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered.Home Improvement Contractor(HIC) /7/ C 6( 5 ,C-g
HIC Registration Number Expiration Date
HIC C pany ame or HI egistrant 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 0 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 autho ' d by this building permit application.
fi4 (7 4
Print Owner's�Elbctronic Signature) 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.
d4 in Ay ,e es_ -k' 5 it;3 /
Print Owner's 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"
‘i.
The Commonwealth of Massachusetts
to
fl Department of Industrial Accidents
12: 1 1 Congress Street,Suite 100
Boston,MA 02114-2017
www.ntass.govidia
-._ ... ..... '
‘ 40 kers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
10 HE 1-11.1.0 WITH TILE PEBMIll'INC;AUTHORITV.
konlicant Info r in a tio n Please Print Ligiblv
Name t Liusan:--.(,/rganiz.atioa lnkill.iLluall: — -
,
Address: 36
k.., ...)
City/State/Zip: -0 /da 7 Phone
Are!tom an vinplo:i tr.'Check the appropriate Gin: Type of project(required):
LE:11 am 2 employer with _erriptoyers lfW1;And-or part-little}• 7. 0 New construction
2 r*..- . a Ault pr.iprietor or partnership and hare nu erriployers working fur me in 8. 0 Remodeling
an eapiteiry,[No worker comp,num-atom required,'
9. El Demolition
.3.0 lam a homeowner doing all work noelt[Tio wurkers'conv insurance requaredi'
10 El Building addition
4.0 I am a hotisews-rszr and will be harms elnaracturs to nduct all work on my poverty. I will
enitur that all contracturs ether haw wklaterA'compensation insurance er are sole 1 1 I:3 Elec '-al repairs or Afirlitions
propnietorn ik ith no employees..
1.2.ll PI .ing repairs or additions
6.61 am a gerund contractor and I have binrd the sub-ernstractors listed on the anaeised sheet.
13 17. ' b.(repairs
These sob-contractors hia'.c employees and have workers, comp.insurance.;
14.0 Other
fi.rfi We age a Coepor.Ohun and lt.3 officers ha ce elerviseti diva rIght of eaemption per NCI.c.
1.12,11(4).,and we have no erivloyees.[No workers'comp.insurance requital
"Arty applicant that ehoeks box 41 mita alma Id/our the seetisni below 414...Akins their workers'conr,c7i,alion poltci,iatierniation_
*Homeowners who intimit Chit,attlitakit indica-Una filo/ire doing all Work and then bee outside colora..A,:rs mini submit a new affidv,it ir.dh,aime si,ch
tContracton that check this Iv i.muit att-tchial an ahhttunal AL,evil shoe.irm the name af titc sub-cuntrwitx,and iuie*briber ..,t nut thane,-..ml.itit..-1 kr,
Ltmrlo.......cc-, If the.,ub-cottar.hr.,,t,I...%.:,_I:irl,,,,:..,:,.th,,, 11:u,t rtl.,1,k F:1,...'IP A Oth.,:r.,'..%'111r.
. .
I am an employer that is providing workers'compensation insurance for tin employees. Below is the policy and fob site
information.
Insurance Company Name: __.
Policy#or Self-ins.Lic.#: Expiration Date: /`,/•-•,,g7
• i
Job Site Address: CityiStateiZip: /* ---'i.-
Attach a copy of the workers'compensation policy declaration page(showing the policy numb and expiration date).
Failure to secure coverage as required under MGL c. 152.§25A is a criminal violation punbliable by a tine 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 tine of up to$250.00 a
day against the violator.A copy of this statement may be tbrwarded to the OtTice of Investigations of the DIA for insurance
coverage verification.
I do hereby Certi ander the pains and , dues of perjury that the informal:ion provided above is true tind it,rri.i.1.
Signature: Date: /1----07"--r (
Phone#: 71e-ft ,- 6 ISFD
r! Official use only. Do not write in this area,to be completed by city or town official
'-, City or Town: Permit/License#
i 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#:
r
City of Northampton
•_`" Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
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 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: v v Date: //7/34‘b9/
City of Northampton
Massachusetts At,
toi
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building S�
, a s
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)