23C-035 (3) BP-2022-0695
638 RIVERSIDE DR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
23C-035-001 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-2022-0695 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF Contractor: License:
Est. Cost:
Const.Class: Exp.Date:
Use Group: Owner: SHAW CHRISTINE M&JUSTIN L T WENTWORTH
Lot Size (sq.ft.)
Zoning: GI/WP Applicant: SHAW CHRISTINE M &JUSTIN L T WENTWORTH
Applicant Address Phone: Insurance:
638 RIVERSIDE DR
FLORNCE, MA 01062
ISSUED ON:06/13/2022
•
TO PERFORM THE FOLLO WING WORK:
NEW 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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: Q
' I
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
/
S , The Commonwealth of Massachusetts
,;(1) Board of Building Regulations and Standar, , O i FO
Massachusetts State Building Code, 780 C, R N 3 M ICI ALITY
(20&1 U E
Building Permit Application To Construct,Repair,Yteno$ ' t! ! - olish a '. ise Mar 2011
One-or Two-Family Dwelling '' °`?TNgMnT�r iNsp
This Section For Official Use Only '"44 o os71oNs
Building P it Number: I ,P- ?.1.- Le 015 Date Applied:
l .....1` �b5'S /C ! 1-I3-ZOz2
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
:_ ' 1.2 Ass ssors Map&Parcel Numbers
. ," r`ttt s; d - `orenCe . 5C 035
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❑ On site disposal system 0
Check if yes❑
2.1 Owner'of Record:
C lie.-1 ST1 NF S i'A vJ k T1/4.15TI N WtitfrW042AW rW geA)Ce ► MA- Q/O- -
Name(Print) City,State,ZIP
(3`6 R►vG-x.Sive OiQtv6 1113- S48-S % swtv.)•crie)5 1 .m CsMAJt..(oAA
No.and Street Telephone Email Address
New Construction 0 Existing Building❑ Owner-Occupied 0 Repairs(s)..8' Alteration(s) 0 Addition ❑
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: f'i p e ic;51-J „► « S'I u..4-e,5 Zn 5-1-41 l Act.)
, 1/ Stvt S 4 C f,J Sil.,'w t e—S , ft?t..) c GIS.
4111111111
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ y/ U6 71. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ I ❑ 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: $ ]�
yCheck No. Check Amount: (�
6.Total Project Cost: $ t / ❑Paid in Full 0 Outstanding Balance Due:
cvtdi-f Colgi
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
XNo.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&.2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant 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
msi 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.
Print Owner's Name(Electronic Signature) Date
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.
)44/nt
Print Owns or Authorized nt'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
X 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"
City of Northampton
,µ t
Massachusetts ? ; s'c!`�c
o . - 1 DEPARTMENT OF BUILDING INSPECTIONS �o
212 Main Street • Municipal Building �Jy �
Northampton, MA 01060 s'fr 41°0
z►311,s
I, C1�p5s1,k MAR 1E 5ttAw' (insert full legal name), born (insert
month, day, year), hereby depose and state the following:
1. 1 am seeking a building permit pursuant to the homeowners'exemption to the permit requirements of the
Massachusetts State Building Code, codified at 780 CMR 110.16.1.3.1, 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
mu parcel,I acknowledge that I am required to and will act as the supervisor for said project or work.
City of Northampton
•
NA
17'" Massachusetts
I.
R 1 ` DEPARTMENT OF BUILDING INSPECTIONS VA, g'
' 212 Main Street • Municipal Building �'• C��
" 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: Sv-1 `� ( r� C T
The debris will be transported by:
Name of Hauler: V W-(, rr1 w X Ctlfk511Aie 5 Av✓
Signature of Applicant: 114'1 Date: (pi 1-3)�-�-
The Commonwealth of Massachusetts
1• oat mar
:�,= t Department of Industrial Accidents
1 Congress Street,Suite 100
. _ �1. Boston. MA 02114-2017
,wY'. 'r+R4 wsw mass.gov/din
1ltaken: (•tuulsrnsallou tn.urance AIrd*+it:Bander%/(ontractors/Electrici*n.Plumber',
It) It FII.F:I)11iiii 11111rcumiI:TIr(.At MORI!I.
Aa*licaat laformwtiun Please Print Lettib1+
Name tItusines3E(kgantzatio ltulc+,duuil. CIA e. Si 1/l, 5-1A o -i- ju,Tt✓✓ ,vEECvvoiem
Address: (o?)iS 21 ver2-S 10 a 1Z ►vC
City/State/Zip: N,ogtivcft, 1,iviA 0104,- Phone#: Li J-5- 5-jFs - 53g6
Are yen en c plo er?t'beck►for appropriate bus Type of project(required):
I.EI 1 am a employer with crnpdaycs:a{hull wane pa rNimel-e 7. 0 New construction
20 l am u auk proprietor or partnership and have no employers working fur roc in II. 0 Remodeling
egicapawty.[No workers'rump.cnaaninic wooded"
9.
a humrwwner doing all work myself.[Nu workers'aurrrp-pburanec tenured.]' ❑Demolition
l0 Building addition
1111101 a homeowner and will be hiring cool mitsn to conduct all work on my property. 1 will
mane feud all ctmtra Curs tither ba+e workers'ae usatrun tnsuranY or are sole 11.0 Electrical repairs or additions
proprietors with no ernpluyees.
12.0 Plumbing repairs or additions
S0lam a general cuntracwr and 1 have bided the sub-contractors listed on for awrefnrd shim_ 1 �'�QOI n a[rs
These sub-contractors have employees and love workers'comp.insurance.'
6.0 we arc a corporation and its officers have exery sed their night of exemption per M(iL c. 14.0 Other
151[;(tat.and we has.:nu anpluvees.[Nu workers'comp.insurance requirat.J
*Any applicant that checks bur ni must also fill out die facvhou below shins mg their workers'cutnpertsntiun policy information.
r Homeowners who aubrnt this affidavit animation they are doing all wink and then hire outiidr ctantravturs mart subnut a new aflWdarit indicating such.
:Contractors that check this lea must attacbed un additional sheet show mg the name of die wnlpcamtra:turs and Ante w het er or not dWae attrtites ha++e
etrtployers. It the sub-contractors hale cirgoluyees.they must pros isle their workers-camp.pubes nwnber
s- s. ----in
i am an employer that is proriding worker.+'compensation insurance for my emplor'ee.+. Below i.+ the policy and job.+ire
information.
Insurance Company Nance: —
2 Policy#or Self-ins.Lie.#: Expiration Dace:
Job Site Address: City:Statc.Zip:
Attach a copy of the workers'COMpensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required wider MGL c. 152.4525A 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 fine of up to S250.00 a
day against the violator.A copy of this statement may be forwarded to the Otike of investigations of the DMA for insurance
coverage vet fieation.
I do hereby certify under the pains and penalties of perjury that the information provided shove is More and correct.
kftrifiNaiiiiiitallifir/111.1101111/111/111011111P1 "' 113). . .-
Phottu 4:
Official use only. Do not write in llri.s urru. to be completed hs'cite or town official
( its or !own; rernrit:'t.ictan+c A
Issuing.‘u1huril} teircle one):
I. Board of Health 2. Building Department 3.City/Town( let{. -I. Iarctrical Inspector S. Plumbing Inspector
G.Other
( union Person: Phone 4:
77
Signed under the pains and penalties of perjury on this I . day of 1 U"6 , 20 2 2-
(Signature
City of Northampton
..•
Massachusetts w, :..I
a ' �. 4 N =
DEPARTMENT OF BUILDING INSPECTIONS
G°
-�' 212 Main Street • Municipal Building JF C.
�� ° Lam` Northampton, MA 01060 sI, go%1a
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 specification 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. Homeowner's License Exemption Form(if applicable).
S. Note any Special Permit requirements(if applicable).
9. Energy Code—all new construction(Gut/Rehab)requires an HERS Rater Affidavit.
Your Confirmation number is 202206131453692
Date of Confirmation: 6/13/2022
NOTE: When paying by ACH (Checking) it will take two business days for the payment to be debited from your bank account.
Your account number is not verified until this payment is presented to your bank. They have the right to return this payment if
unable to process this transaction against your account.
Your request for payment(s)of$42.50 has been received and is subject to approval by your financial institution. No email
was entered so a confirmation was not sent.
Account Information Payment Information
Name: CHRISTINE M SHAW Payment Type: Credit Card
Note: QUICK PAY TRANSACTION Payer Name: CHRISTINE M SHAW
Card Number: **************4617
Transaction Information
Transaction Quantity Amount Fee Payment Type
City of Northampton - Building 1 $40.00 $2.50 Credit Card
Department
Misc. QP
Permit Option: Building-Zoning-Sheet
Metal Permits
Full Name: CHRISTINE SHAW
Phone: 413-548-5396
Property Address: 638 RIVERSIDE
DR
Notes: ROOF
Total: $42.50