42-001 (2) BP-2022-0122
245 WEST FARMS RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
42-001-001 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-2022-0122 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF Contractor: License:
Est. Cost: 3000 JAMES ROBERTS 099404
Const.Class: Exp.Date:01/21/2024
Use Group: Owner: OMASTA JOHN P OMASTA
Lot Size (sq.ft.)
Zoning: WP/WSP Applicant: JAMES ROBERTS
Applicant Address Phone: Insurance:
30 Edwards Rd (413)527-6078
WESTHAMPTON, MA 01027
ISSUED ON:02/08/2022
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:
Gas: Final: Final: Rough Frame:
Rough: Fire Department Driveway Final: Fireplace/Chimney:
Final: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: I
)2 - cikiF
Fees Paid: $40.00
2l2Main Street, Phone(413) 587-1240,Fax:(413)587-1272
Office of the Building Commissioner
The Commonwealth of Massachusetts
Board of Building Regulations and Standa ds F EB ~ a �0ZZ OR Massachusetts State Building Code, 780 C R MUNI IPALJTY
wstoEc.T1 §E t
Building Permit Application To Construct,Repair,Renov to Or--D ,' N tlrtad M_ar D11
r�oF� ----
One-or Two-Family Dwelling -----
This Section For Official Use Only
Building Permit Number: ' ".Z I ZZ- Date Applied:
Building Official(Print Name) Signature ! ate
SECTION 1: SITE INFORMATION
1.1 Property Address: / 1.2 Assessors Map&Parcel Numbers
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 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:
t
Name(Print) City,State,ZIP
,34/.5---1/1/ 40
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 Work': .,144,//1
-- on- - _
SECTION 4:ESTIMATED CONSTR TION COSTS
Estimated Costs:
Item ( or and Materials) Official Use Only
1. Building ,1,b ja0 d 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $
❑Total Project Cost3(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: /Il
Check No.66' Check Amount: v
6. Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
I
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City of Northampton
r
Massachusetts `�'�� _ J``,,
: t' 4 1
DEPARTMENT OF BUILDING INSPECTIONS
.„
, et, 212 Main Street • Municipal Building y, �i
'.7 Northampton, MA 01060 `h
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.
J
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor Li e(CSL) O q(i-0 /. /
License Number Expiration Date
Name of CS older
36 ' List CSL Type(see below)
W.No.and Stre Type Description
iti7%� 1Y1 � / Gs) U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RCS Roofing Covering
Window and Siding
Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Improvement Contractor(HIC) / 7 . 3-3/ e,1--
HIC Registration Number Expiration Date
HIC Comp y Name HIC gistr t
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 I
to act on my behalf,in all matters relative to work authorized this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 76:OWNER1 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.
D/Pb aF:ers
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"
•
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
. ..,
- —12 --
1.‘
Boston, MA 02114-2017
www.ntass.govidia
'Workers'Compensation Insurance Affidavit: BuildersiContractors/ElectriciansiPlumbers.
TO RE FILED'Sinn THE PERNIITTING All'HORITN.
Applicant Inform atiO rt Please Print Legibls
Name i Husincs,s Organization,itli.i1V'dual 0: Xr1P-r17.
Address: 3
City/StateiZip: g/7:—(44..)--- -2pqr 0 fojq Phone #: c413 -4-7' q/ -(), 3--a
Art you an employ erlfr Cheek the appropriate box: Type of project(required):
1.0 I am a employer with employees(full atutor part-ternet..* 7. J New construction
proprietor or inirtnerslim Ind have no employees working for we in 8. D Remodeling
any capircit'v.[No*oilers'c.omp.insurance required.]
9. 0 Demolition
30 lam a homeowner doing all work myself.[No workers'conal.insurance requinal I'
i 0 0 Building addition
.1.0 lam a lumwowncr and will he hams oantracturs to conduct all Work on my property. I will
ensure that all contractors either hare workers comwristition insurance or are sole 111-3 Electrical repairs or additions
propnetars with no employers_
12.11 Plumbing repairs or Additions
5 I :Krnmerid contractor and I have hired the.ub-cunenietors fisted on the aitaithod sheet
WO '
These sub-contrackirs have employees and have workers'comp.mstirance. 13 I repairs
14.n—Other
6.0 we are a corporation and its officers have exennsed their right of exemption per?AU_C.
152,§..101.and'NO 11.1Se no eniployees.[No workers'crarels.insurance required.1
*Any applicant that checks box 41 mint alms all ant Elle section below A Lurk ing their workers'coraisecisation policy inksmatien
+Homeowners who itstrrint this affidavit indwaturg they are doing all work and then hire outside contracters must subrart a dew arlidik it it:the:4ms such.
ICormactors that check this box must attached an additional sheet showing the name of the sub-contractoes and state whether or nut those mimes have
emplovecs lithe iob-conaraeturs base smplo...ecs.they mum pros ide thce *orkers'amp.policy number.
I ant an employer that is providing IvorAer.$*compenNarion insurance for my employee.14 Below is the',olicr. rind it,)1,.Nite
information. 6 .e../i6"..4‘,.
Insurance Company Name: . 7 /..- I..._23
Policy#or Self-ins.Lie.#: Expiration Datetit
Job Site Address: CityState.`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 S1,500.00
and or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a
day against the violator.A copy of this statement may be forwarded to the OtTke of Investigations of the DR for insurance
co...7,1.2:2 ..e tl tication.
I da hereby certify under die ins and penalties of perjury that the information provided above is true and correct.
jr nal :
q / --- 6) 3-e-
Official list'way. Do not write in this area, iv be Lotnpleted by city or town official
City or Town: PermitiLicense 4
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
('ontact Person: Phone 4:
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City of Northampton
.. "
Massachusetts Z w ;
DEPARTMENT OF BUILDING INSPECTIONS ' l i
'','a► ; ` 212 Main Street • Municipal Building �1.. 4.-
. �,>w! Northampton, MA 01060 srF.,� ,�.\'�}\
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: 9r)
z , -"�l�
The debris will be transported by:
Name of Hauler: f` L� C lit) ,
Ntri
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Signature of Applicant: [ Date: ri "
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City of Northampton
?) Massachusetts
F f k M1
DEPARTMENT OF BUILDING INSPECTIONS
1 -
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)