17A-215 (7) BP-2022-0185
4NORTH MAPLE ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
17A-215-001 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-2022-0185 PERMISSIONISHEREBYGRANTED TO:
Project# 2021 ROOF Contractor: License:
Est. Cost: 13000 JAMES ROBERTS 099404
Const.Class: Exp.Date:01/21/2024
Use Group: Owner: PEZZINI LINDA A&ALISTAIR SALTUS
Lot Size (sq.ft.)
Zoning: URB Applicant: ROBERTS ROOFING
Applicant Address Phone: Insurance:
30 Edwards Rd 4134410350
WESTHAMPTON, MA 01027
ISSUED ON:03/01/2022
TO PERFORM THE FOLLOWING WORK:
STRIP SECTION AND RESHINGLE
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: , cg
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e, • • •
Fees Paid: $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
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The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
g y Massachusetts State Building Code, 780 CMR MUNICIPALITY
USE
m •Moulding Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
W .
11- One-or Two-Family Dwelling
- This Section For Official Use Only
Building Permit Number: BR2o2z-Olac Date Applied: 2/2022-
/4.;),...) ,1 /� 3-I-zoza
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
��G 1.1 Proggr Add f- 1.2 Assessors Map&Parcel Numbers
( 01 Ni // l?A —Z1 - ov 1
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
(ARl3 666 uces
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❑
SCTION 2: PROPERTY OWNERSHIP'
2.1 Own r',iuf cord ✓
4-4
271i
Name 'n� City,s State,ZIP
(.4/6 , V”,/{.( yr
( )
No.and tree 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) ❑ Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2:
xat-1--,
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Lao► and Materials)
1. Building $ ' e.O0,, I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ _/ 0 Standard City/Town Application Fee
0 Total Project Cost3(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees: $ 40 a c o
Check No2222. Check Amount: o.
6. Total Project Cost: $ a Paid in Full 0 Outstanding Balance Due:
City of Northampton
Massachusetts
v
DEPARTMENT OF BUILDING INSPECTIONS
L, 212 Main Street • Municipal Buildingoa
�.
Northampton, MA 01060 ssf.F4; '1‘~1
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
SECTION 5: CONSTRUCTION SERVICES
5.1 Constr ction Supervisor ' n e(CSL)
'&42/1)t
License Number Expiration Da e
Name of 1.'*
I i erf3 ,Jj�� - ,f?- J 0 List CSL Type(see below)
No.and Street �' .-----, / Type Description
f7i n, L~�/y�2w r G� U Unrestricted(Buildings up to 35,000 Cu.ft.)
City/Town,State,ZIPI/ ��)) R Restricted 1&2 Family Dwelling
�/0"? M Masonry
KO Roofing Covering
Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered H me Improvement Contractor(HIC)
qIC Regist tion Number Expiration Date
HIC Corn y N e or C e ' ran ame
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 ,F'
to act on my behalf,in all matters relative to work authorVd by this buil g permit application.dPrinf Owner's a e(Electronic re) 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.
Print Own 's or Authorized gen 's Name(Electronic Signature) Date
NOTES:
I. 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.uov;loca 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 a ,
TpheeiCiaorntitite Industrial of:V la Ass catclhduesnettsts
nun o mt wealth
1 Congress Street, Suite 100
Boston, MA 0114-2017
www.ntass.gov/dia
Waiters'Compensation Insurance Affidavit:Builders/ContractorsillectriciansiPlumbers.
TO BE FILED SS ITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name lausiness;Organizationilndividual):
Address: 3 (-4\I
City/State/Zip: 0 t ,;--1 Phone Ft: t• 1-74111
03,r-
Art yen on employer?Check the appropriate hot: Type or project(required):
1.0 t am a employer wilb etrapioyees intim pait-tiraet„• 7. CI New construction
2.12-4111 sok proprietor ur parmenhip arid have no employees winking for me in 8. 0 Remodeling
Any capacity [Nu wui-kr nip.insuranix revintreill
9. Demolition
31:1 am a homeowner doing all work myvelf.[NO workiss'comp.imanance Femur'ed..]
a fl Building addition
llen a homeowner and will be hiring aintraeton canduct all work on my property. I will
ensure that all contractors richer ha,r.c workers'compensation insurance tYT are vole i 13 Electrical repairs or additions
Pt ' with no employem,
12.0P1u inn repairs or Addition,
5 T-Ei I am a general contractor and I have hared the sub-contractors listed on the attached iheci
13 Root repairs
These stib-cuntrActorS have employetti Ind hove workers'comp.insurance)
14.0 Other
6.0 We ase a Celpotation and AA officers have exercised their right of exemption per?WA.c.
152,.0101_and we have no employtes.[No A,OrkkIS comp,insurance required.]
•Any applicant that ateu:ks bixt t1 mast also fill out the section tNIL/1/0 A14.3%in g thenviorkern.compensation policy information_
Homeowners,who subriut thus affidavit indicating they are doing all work and then hire otaidv.coritnactors mast submit a neNk affidat it Intlicntang micts.
ICuntrneturn that check this box must attached an additional sheet showing the name of the sab-cuittractors and state whether or nut those entthirs have
emplovecs. If the sub-contractors have empty..res.they must provide their workers'Lximp.pulley number
1 um an employer that is providing workers compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name.
Policy or Self-ins.Lie.#: Expiration Date:
Job Site Address: Citv'State Zip:
.tttach a coo of the workers'compensation yolk" declaration page(showing thr[sulk!, number and expiration date).
Failure to secure coverage a required under NIGL c. 152, §25A is a criMinal violation pult4iiibk by a fine up to$1,500.00
andor 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 tolator. A copy of this statement may be firwarded to the Office of Investigations of the DIA for insurance
co.erage verification.
I do hereby certify.under the pains and ties of perjury that the information provided above is true aiM ct.
Date: c=
Phone 4:
Official use only. Do not write in this area.to be completed try city or town official
City or Town: Permit/License it
Issuing Authority(circle one)
I. Board of Health 2. Building Department 3.City'Tovin Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
L1L ya' F�,.hl ti S
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Massachusetts � ;,
DEPARTMENT OF BUILDING INSPECTIONS `
e AZI 212 Main Street • Municipal Building tr
Northampton, MA 01060 4'N ``4'
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:
(.,__-2,_, . ,._.
Name of Hauler:
7
_ .,
Signature of Applicant: \) i' Date: c/ 7
City of Northampton
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Massachusetts _-
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DEPARTMENT OF BUILDING INSPECTIONS ''
212 Main Street • Municipal Building -,
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Northampton, MA 01060 iry* 1"�`'
7
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)