35-142 (6) BP-2021-2348
35 WESTWOOD TERR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
35-142-001 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-2021-2348 PERMISSIONIS HEREBY GRANTED TO:
Project# ROOF Contractor: License:
LOCAL BUILDING AND
Est. Cost: 5700 REMODELING 102453
Const.Class: Exp.Date:03/16/2023
Use Group: Owner: LORENCO, TERESA M. &PETER A.
Lot Size (sq.ft.)
Zoning: WSP Applicant: LOCAL BUILDING AND REMODELING
Applicant Address Phone: Insurance:
P O BOX 892 (413)626-5296 WC531S623162011
Thomdike,MA 01079
ISSUED ON:12/29/2021
TO PERFORM THE FOLLOWING WORK:
FINISH ROOFING ON HOUSE
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 (g- i
A
Fees Paid: $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
/
% �C. ::
e The Commonwealth of Massachusetts! c.
` Board of Building Regulations and Stands. ���� MU
R
Massachusetts State Building Code, 780 GIVI iki,, I�,. FOR
ALITY
.41
4"'",,,(Ni r, , JSE
Building Permit Application To Construct,Repair,Renovate 6. i" 'Revised Mar 2011
One- or Two-Family Dwelling ----,:::2:,, ,,; „044?
This Sec,t,ion For Official Use Only
Building Permit Number: OP-A I • a3y Date Applied:
� ' �, �� ri
►a/ q7al
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1 Property Address: 1.2 Assessors Map&Parcel Numbers
s w�sr w�c'p fiEt f�rr��ct- lh/1 36' )yi
1.1 a Is this an accepted street?yes X no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
. 1:St► LON t1VCC1 35 IN1=5T Wi(4) TER FLORFIVCC /1i
Name(Print) City.State.ZIP
,3-331-q63$L TTr1/144bP05A N4Hoo,Cc1N
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK`'(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied X Repairs(s) V.. Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg.0 Number of Units 1 Other 0 Specify: _
Brief Description of Proposed Work'-: S1,74(1 ROOF ^ T N E Roof ihAS SIR f ppI 0 I Ivip
7Cr- i DATER L ) 1?'i R (l€rFERtll4 Calt/tRATTCA, ti r s r 1VE`E2 SHC/U MCP BACK tip
to FTII/rSF1
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials)Use Only
I. Building $ " 780 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost`(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Feel.._
Check No.iYUI Check Amount: Cash Amount:
6.Total Project Cost: $ 5 700 ❑Paid in Full ❑Outstanding Balance Due:
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
IS-IG2L(53 3-16-23
4 Pi Plv\I (O(i 1 Al C l 1 License Number Expiration Date
Name of CSL Holder
Po�? S t2 T tmvatiet PA 0107 List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35.000 cu.ft.)
R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
i(3 626 C2g6 t 0C, t-13 JT 1-1 /V6 as 6mi t.co it l Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
l6 9457
HIC Company Name or ILI strant Name HIC Registration Number Expiration Date
No.and Street _ • • " LOCAL (30 L UJ 16 f�G IrearL l0117 P.O.SOX 992 Email address
City/Town,Sti'""��010� Telephone
64W SECTION OR1CL RS'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 authorized by this building permit application.
12-zo�2(
` PrintName(Electronic Signatu re) Date
C SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
0 By entering my name below.I hereby attest under the pains and penalties of perjury that all of the information
N contained in this application is true and accurate to the best of my knowledge and understanding.
C'/'/r ?/,i//e1( /2-20-z(
Print Owrter's or Authorized Agent's Name(Electronic Signature) Date
I� NOTES:
A1. 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. I42A_ 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"
,---., 0 C 0(,Uf
ACC)R EP CERTIFICATE OF LIABILITY INSURANCE DATE$111111100/YYTY)
THIS CERTIFICATE IS ISSUED AS A MATTER OF CATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTERD OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS Gtx I It-ICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the poricy(ies)must be endorsed. if SUBROGATION IS WANED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the '
certificate holder in lieu of such endorsement(s).
PRODUCER coNTACTFame Debra DeSanlis
GAUDETTE INSURANCE AGENCY INC w�REi.Ere: (508)234-6 33 FAX
i SIDO.Mk
�F5s: ddeSantiSiggaudette-insurarice.COm
ONE PLUMMERS CORNER eisimen(s)AFFDaa.GCOVERA E I NilNcs
WHITINSVILLE MA 01588-.___-. RsNer uA: LM INS CORP 33800
#iSURED - ..
INSURER IS: i
LOCAL BUILDING&REMODE.MIG LLC 9SURETC: -
NSURER 0: i
PO BOX 892
rNSUIER E-
THORNDII<E MA 01079 DISR/BtF:
COVERAGES CERTIFICATE NIJER: 705140 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. ►OTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAIMS.
LTR% TYPEOFINSURANCE new wvn^ POLICY MUM 1 arovtiiklitFF fE7�_.._ UNITS
c t�00fYYYYE' ____
eRg ai
L. iOD LeBBW.LM IX l EACH OC $ -
. s TO IEHTED
AItilS-LIADE OCCUR _ *sses ma om S n 4
{ Q
---t ____ NREDSW Oaf anepeism) 'S
WA � `PERSONAL&AW PUIJW i S
' Gen.Al TEUNITAPPLESPat GENERAL A CIE $
�.^PO CY __I J cr LOC ,
c
PRODUCTS-WIMP AGG'S
S OILER: % .S
MNOTIOGIE UNNU r OONRERED nt}-SrNGT E min' s
�
_t ANT AUTO .
Ail OWN® -- g,T ,.BODILY @LAJRY tPer person) ;$
i AUTOS ,AUTOS N/A i BODILYMIRY eraefaieq,$
HAT®AUTOS r -1 Mar i S
'.lA UM i ;OOC11+2 I
it�
f EACH i
ExcessUAB ~1
I CURMSWDE N/A r I i 4 AGGREGATE I s
t DED °RETENTIONS II
womcars CON EIrATMN z I I
ATMEIMOYERS'unaaIrY Y!N> { .X S STATUTE
A OF ME EREXC!ANYPROPRiETORMALUOEC iRFJCECUIWE mp Na 1 NIA' WC531S623162011 10/19/2021 10/19/2022 EL EACHAtXDBIT _L$ 1.000Jalb
Mandatory in MRt
EL MUM-EA S 1
DkD desvON OF O + E .DISEASE-POLICY lJ ET $ 1,000,000 -,
.SCPoPTIQiJ OF OPERATIONS below � .
N/A
oescrePTION OF OPERATIONS!LOCATIONS r Y@YCLES(ACORD 101.Additional Remarks Schedule.may be attached if more space is required)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B.no authorization is given to pay
claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the
issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification
Search tool at www.mass-gov/lwd/Workers-.ompensationfuwestigationsl.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE W91 BE DELIVERED IN
Paul Davis Restoration ACCORDANCE WITH THE POLICY PROVISIONS.
300 John Dietsch Blvd
AUTHORIZED REPRESENTATIVE
MA 02763 \�I F Y _
N Attleboro Daniel M.Wiley,CPCU,Vice President-Residual Market-WCRIBMA
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
A Oe CERTIFICATE O Bi NSURANCE DATE
'
v82021
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND COWERS NO RIGHTS UPON THE CERTIFICATE HOLDER..THiS
CERTWICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTTME A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: I the certificate holder is an ADDITIONAL INSURED,the polrcy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsem ntfs). .
PRODUCEin CONTACT
Nouse LePAnn Watterson
Gaudette insurance Agency,Inc. PHONE
Est 508 21i6 1 FAX war.508 234$121
1 Plummers Comer
Whitinsville MA 01588 �: .com
INSURBTO4 AFPORONGCOVERAGE _ WIC It
USURER A:Mantic Casualty Insurance Co
INSURED — —__ WCALBU-01 INSURER a:Commerce Insurance Company _ 34754
Local Building&Remodeling LLC
4212 Church Street INSURER c:
PO Box 892 INSURER D: _
Thomdike MA 01079 ifSURER E: _
i INSURER F: i
COVERAGES CERTIFICATE NUMBER:157875326 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WiTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AM)CONDITIONS OF SUCH POLICIES_LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
som I 'ADDLMUSU POUCY EFF I POLICY EXP I LINTS
LIR TYPEOFIISUtANCE �g NUM MI POLICY alYYYY) t�MOnvvY)
A X !COMMERCIAL GE LIABILITY 1 M2050010200 1W1F1020 10t1/2021 EACH OCCURRENCE I$1.000,000
{ 1 5—(1
DANA,E TO RENTED
s I CQAIiSYAOE 'OCCUR 1 =PAS(Ea 000 sTen e) $100.000
f U®EW Vag e*p +) 115.000
1 PERSONAL&ADV woww $1,000,000
GEHL AGGREGATEMINTAPPLESPER 1 GENERAL AGGREGATE $2.0MW°
POLiCY J 1 LOC PRODUCTS-OOLPiOPAUG $1,00Q000
OT}ER
B AUTOMOBILELNBIIiY FCSOBi V102021 1/102022 �aiNIEG SINGLE um. s1aok000
s ANY AUTO
BODILY INJURY(Ps person) $
OWNED I X (SCHEDULED • BODILY INJURY(Pat raids* S
.ONLY 1 NON-OWNED
X AUTOS ONLY X AUTOS ONLY i ,
(Pot accideatl, PROPERTY DAMAGE S
���+�, S
UMBRELLA UAB / OCCUR , 1 EACHO ICE $
EXCESS UM CLAYg,MADE i AGGREGATE S ,
DED RE-famous
T •$
WORMERS - 1 STATUTE I t ER
AND EMPLOYERS'LIABILITY vie
NTYPROPRETORIPARTNERIEIECUT1VE n,CIA El.EACHACCLENr $ _..
( aodemryisNM EL.DISEASE_EAR,$
VO LION OF OPERATIONS below - - I EL DISEASE-POLICY MST S
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1,40010 N't.Addiion,ilmarks Schedule,may be anudlied if mare spare is rewired)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
TIE EXPIATION DATE THEREOF. irOTiCE WLL BE DELIVERED IN
ACCORDANCE Willi THE POLICY PROVISIONS.
Window World
1 641 Daniel Shea Hwy AUTHORIZED REPRESENTATIVE
Bekhertown MA 01007
_V.:..e..;3
01988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(20161)3) The ACORD name and logo are registered marks of ACORD
sanax.sa a®n.amaYsn.ar 3.a!US
ArrtY co:;t?rrhAtnittlr: Contact Information: MA License 41.02453
T r,x Cell:(413)626-5296 MA Reg.#169957
flier:tiii(e..MA
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
The vtottraillof:ti,c s t potr€orttt the work specified above for the SUM of:S 5,700
s}s Tftr+ttsrtnd Seven Hundred Dollar)
goo iti due upin .,-)!,:•!:tian of the roof work.. Received on:
tfray tieots;n• ;tot rq,-;t:zc.l%+•ithir:»tune period 01'30 days we will he charging interest at an APR of 18%,equivalent to 1.5%per
month on the vtimain:rin ha;ttncc:.
:•k; t r, Date: i-/f1( c3�'
c' strta:totSi}; la urs:� 14 ley Date: 12//19/2021
ihepiloallag;schedule will be adhered to unless circumstances beyond the contractors control arise including
weather or rtnevirr;ed probtente with other jobs.
Soiledulc!d to fkgifa:..._,. Expected Date of Completion:
Repli(red P,gri iXs
The fc.11to lag bt,:iioi4 Dorn its toe requiied.It is the obligation of the contractor to secure such permits as the
l olm..owners's i t::t:inilts;tg.Perttcii
•
f ; r': •
I.,. ass ,.aut,ucrite Local l-Tailding and Remodeling to act as my agent to secure all necessary permits to
early ottl all v,ork wtaied in tl, c ttvoact.
Wttrranty
:': I0-5,e:tr warrant) will be provided by Local Building on all Labor.
NOTES;
-Extra care will be taken t.o protect shrubbery and plants but we cannot guarantee against damage due
to the nature oi'the work ors:•rmed,
rrvperty is tote sti.i pt w9'itlt commercial grade magnets to remove any excess debris.
41ilpplicable, I.ccai Building will remove and reinstall any satellite dish,however,the homeowner is
responsibic for any hoe ttrttir needed..or any charges that come along with it.
-"T rc a J.oserrco had the old shingles stripped and disposed of by Manuel Leyton prior to Local
Building 4rni Remodeling gettios involved.
pi • ; sign below statkig you've read all understand the conditions shown in this contract.
Page 2 of 3.Contract 21.10,35 Wag Wood Fr.,Flotonce,MA
Local
Building and Remodeling
Anthony Robitaille Contact Information: MA License#102453
P.O.Box 892 Cell:(413)626-5296 MA Reg.#169957
Thornlike,MA 01079
Amendment:
I,Teresa Lorenco a of contracted h any other companies involving the roof work.
(Sign Here--4X )4i ..(,e r ,„ )
^`_t,>`,,r:° .;F t:?o•� ..�5 ti t. �e. ?�a�1,111 ..3.1.>X..y(:.4 '�}.:f..iii. .. ..t.'.'ad
.a,• :� � y r. , tL./ lifr �. a r_ . J.
fir., - _ - _ :. ;�i.• "riff: _. — '
.: ,.. ..:.� !!. :Fr;..•i.T��' ._;:. •AV K'. j.. a''.f r', '�'.'. 'L{y .. ..- _,._ t'i_:'. ..�5 '.1* (tr.. . ..r
;.. r}i>�:; 2:.: .. .?*Q'I, .'J::. ,, tr.:.._:•:i;. :::+7-: ..a .. •...4:5,• 'j z
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The Commonwealth of Massachusetts
Department of Industrial Accidents
="'=al= 5 Congress Street, Suite 100
1 Boston, MA 02114-2017
-, — www.mass.gov/dia
ing
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): LOCAL BUILDING&REWPGDE G
442 CHURCH STRtt:t
P0 BOX 892
Address: THORNDIKF,w1A 01079
City/State/Zip: Phone#: (13 62 6 SZ?t?
Are you an foyer?Check the appropriate box
V Trtx���( )-
1. I am a employer with 1 employees(full and/or part-time).* 7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8_ D Remodeling
any may-[No workers'comp-rnsrsance required.)
t 9. ❑Demolition
3.11 I am a homeowner doing all work myself.[No workers'comp.insurance required.)
4_0 I am a homeowner and will be hiring contractors to conduct all work on my property_ 1 will 10❑Building addition
ensure that all contractors either have inciters'compensation insurance or are soh- I 1.0 Electrical repairs or additions
proprietors with no employees.
12.Q Plumbing repairs or additions
5.111 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs
These contractors have employees and have workers'comp_msmaooe:
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c.
14_Q Other
152,§1(4),and we have no employees.[No workers'comp-insurance required.)
*Any applicant that checks box#1 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 this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees_ If the sub-contractors have Lmphry.,,,s,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. 1 A
Insurance Company Name: L St/7 y IL1 Gil--L
Policy#or Self-ins.Lic.#: 1.‘"C -C 3 IS C 2 3 IC 2 0 10 Expiration Date: 10' 1 q- 22-
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,§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 do hereby certify under the pains and nalties of perjury that the information provided above is true and correct.
Signature: !Uliy C'r7i/" Date: r L- 7 U
Phone#: I �j�?i.Fi S/Q 6
F
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: #
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#:
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spJepueiS asmnassunayaoie sleuossa toi douasl+WP susern�oraaebu!P
aMU0InW9uiw010 P JeOBild'
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: Individual
ANTHONY ROBITAILLE Registration: 169957
D/B/A"LOCAL"BUILDING AND REMODELING Expiration: 08/22J2023
P.O. BOX 892
THORNDIKE,MA 01079
Update Address and Return Card.
.i smEiharme b iS on
HOME IMPROVEMENT CONTRACTOR
TYPE:Individual Registration valid for individual use only
Registration Expiration before the expiration date. If found return to:
169957 08/22/2023 Office of Consumer Affairs and Business Regulation
ANTHONY ROBITAIi t F 1000 Washington Street -Suite 710
D/B/A'LOCAL"BUILDING AND REMODELING Boston,MA 02118
ANTHONY ROBITAILLE. - ,
4212 CHURCH ST .� -
THORNDIKE,MA 01079 Not valid without signature
Undersecretary
City of Northampton
•'' 'Massachusetts i-_
I
,4 , G.
DEPARTMENT OF BUILDING INSPECTIONS
s 212 Main Street • Municipal Building � ha
'"� � Northampton, MA 01060 Fh 3 D8
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.
IV — ropF /3/4-N STR,Trfec
AIvc t K Co(i1RA cTGK , I-104r 0&itft-2 SArd
The debris will be disposed of in: 74H, HA U A U VCti P TR�4Ju�
Location of Facility:
The debris will be transported by:
Name of Hauler:
Signature of Applicant: a ,� � Date: (2-26-1 t
1