24D-239 (5) BP-2021-2223
176 PROSPECT ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
24D-239-001 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-2021-2223 PERMISSION'S HEREBY GRANTED TO:
Project# ROOF Contractor: License:
Est. Cost: 12000 ROBERTS ROOFING 099404
Const.Class: Exp.Date:01/21/2022
Use Group: Owner: SULLIVAN REAL ESTATE LLC
Lot Size (sq.ft.)
Zoning: URC Applicant: ROBERTS ROOFING
Applicant Address Phone: Insurance:
30 Edwards Rd 4134410350
WESTHAMPTON, MA 01027
ISSUED ON:11/29/2021
TO PERFORM THE FOLLOWING WORK:
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:
I ` J! . '1 •
Fees Paid: $100.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
City of Northampton
* G
'`,1:-''
�� ire i.P.r, Massachusetts r
�� Ic IL BUILDING INSPECTIONS � $�,�
4' DEPARTMENT OF • Municipal Building )
� �u°� 212 Main Street MA _
Northampton, 01060
Li
? 2021
PROCEDURE FOR OBTAINING A BUILDING PERMIT F R
N�Qv�s
DOORS,
RENOVATIONS,ROOF MOUNTED SOI[[.AI APT of BUILD
INSPECTIONS
ROOFS, TON.MA 01060
1. Building Permit Application signed by legal owner and filled out
by owner or authorized agent.
ofplans and specifications of proposed work(Digital and hard copy).
2.One set yapplicant.
3. Construction Debris Affidavit filled out and signed filled out and signed by applicant.
4. Worker's Compensation Insurance Affidavit
5. Contractors must supply a copy
CSL,HIC, and proof of Liability Insurance.
Compliance Certificate(new / replacement windows).
6.Energy Conservation licable}.
7.Home owner's License Exemption Form(if app
8.Note any Special Permit requirements (if applicable).
Code—all new construction(Gut/Rehab)requires a HERS Rater Affidavit
9.Energy Co to:The City of
10.Please provide the appropriate fee in the form of a check made payable
Northampton. .
►uo l 1215 RE-P-coc-
The Commonwealth of Massachusetts
wt Board of Building Regulations and Standards FOR
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
Build' Permit Number: �l0- 24> Date Applied:
I EVI -> .1/ Z -Z3_
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address/7 �� .2 Asssssf DQap&Parcel Numbers
IJ/
Li 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 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owne of R rc agi y'_ //
Name(Print) O ---� City,State,(ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(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 Work2: v
44--(77
SEC ON 4:ESTIMATED CONSTRUCTION COSTS
�*`S ated Costs:
Item "' and Materials) Official Use Only
1. Building 4���)z). 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical ' ❑Standard City/Town Application Fee
❑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. 0 Check Amoun
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
/
SECTION 5: CONSTRUCTION SERVICES
5.1 C instruction Supe ' r License(CSL `/D
Cf► `t
!� License'Number Expiration Date
Name ICSL Holder
,i.c.,e,,„---,,,,,,b,r J` List CSL Type(see below)
No.and Street C Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
City/Town,State,ZIPR Restricted 1&2 Family Dwelling
Masonry
7 r'C l_l M Roofing Covering
( l V WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Register Home Im rovement Contractor(HIC) /17 4 4 _
HIC Registration Number Expiration to
HIC Co an Nam e '
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 authoriz y this building permit application.
„(
Print�fwne�r s�NEle ignature) / .._____
/� 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.
o/ eee - .et-S //---A7-- /
Print Owners or Authorized Agents 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"
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
- ,-.....
"sp
Boston, JIA 02114-2017
WWW.mass.govidia
IVotters'Compensation Insurance Affidavit: Builders/(.7ontractorsiElectricians/Plumbers.
Tel BE FILED IN run ritE PEILVIITTENG AUTIIORITN'.
Applicant Information Please Priat Legibly
Name(/los iniess.Organuattonilbdt viduai):
Address: ,56
tizcei
City/StateiZip: ki/7. .0)/.,? (00- Phone#: — 6
Are yew as employee Cheek tat appropriate hot: Type of project(required):
1.0 I am a empl.qer*tit _empioyees(full anidor part-titnek• 7. 0 New construction
2 a,ole proprietor or paitriership and have no employees ti4korkeng fur roe in Cp,o4
[No work any capacity.. ers'comp,insurance matined„] S. cj Remodeling
9. Et Dernotium
3FJ I am a homeowner doing all work myself.[No workers'conip inanrainke rimantedi"
101:1 Building addition
4.C]I am a homeowner and will be hiring contractors to LAnuluet all*ark on my property. I will
emure dial all ooninietors either have*otters"conicerraottort insurance ow are aole i[ID Electrical repairs or additions
additiori
proprie"es t %aft DO employers. 12.0 Plumbi repairs erwral contmetor and I have him'tbe sub-contracgors livxd an the anath he ed set
ar............ ng or
5 am a z s
13
or,..--:"
oot repairs
These suti-cuntraetors fat employees and have workers comp.insurance)
60 art a einpuration and its officers have exercised then right of exemption per MtaL c. 14.Ej Other
152.¢1(41,and we have no employee*[No workeri.comp.umurance reammil
Any applicant that chock%but 41 must also fill out the section below Showing their-*otters'compensation rt,i 10!111.10Mtai.WIT.
f Homeowners who sabarit this atfetkivit unlit:sting they are cuing all work and then hire tititsitle coat:racks-,rrnot submit a new affidavit inalunting such.
:Contractors that check this box must attached an additional sheet.Aim,mg the name of the,u+-cinitraclit-,arIJ.r.a:c..hclhcr,or not thole mum,.ha,o
,..ninlio.ec, If thir s ub-c unit ackv.ha a.ernplaytm ihe.,must provide their workeis comp.is.,,:,_:.-r,i,r.l'....::
I am an employer that is providing waricvs'compensation insurance for my employees. Below is the policy and job site
information_
-Insurance Company Name:
Policy#or Self-Ins.Lie.t$: Expiration Date: /
Job Site Address: . City/State.,2ip: . 7 2 ..—)
Attach a copy of the a orkers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure cover.4,7e as required under MGL 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 tine of up to$250.00 a
day against the Yiolator.A oipy of this statement may be forwarded to the Office of investigations of the DIA for insurance
et)+,erage veritic.:;1,.I:.
I do hereby ceritfv ander the palls, and . allies of perjury that the information provided above is true and correct_
Sismature: 1)ate: /1-0,p2-----r 2(
Phone ti: zyt4 FO 3: X
Official use only. Do not write in this area. to be completed by city or town official
City or Tr.'s%n: Permit/Licrisse it
Issuing Authority (circle one):
I. Board of Health 2. Building l)epa ri meta 3.City a Goo Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone 4: