25A-102 BP-2022-0698
11 SHERMAN AVE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
25A-102-001 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-2022-0698 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF Contractor: License:
Est. Cost: 12000 JAMES ROBERTS 099404
Const.Class: Exp.Date:01/21/2024
Use Group: Owner: LAMONTAGNE BARBARA ANN
Lot Size (sq.ft.)
Zoning: URB Applicant: JAMES ROBERTS
Applicant Address Phone: Insurance:
30 Edwards Rd (413)527-6078
WESTHAMPTON, MA 01027
ISSUED ON:06/13/2022
TO PERFORM THE FOLLOWING 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:
i .5
2 .
Fees Paid: $100.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
i
0 i
The Commonwealth of Mas,.cht • s ti
n Board of Building Regulations an t dsIv/ `n FOR
� Massachusetts State Building Code, 7 i' '•, o `COI ISPALITY
E
Building Permit Application To Construct,Repair,Renov. :-molish . R• red Mar 2011
One-or Two-Family Dwelling ' .ya'OFe,
This e tion For Official Use Only
Building Permit Number: 6/2- A�' t 4 Date Applied:
POJJ1-3(2S7 //' / 1 L-)3-ZOzz
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property A r ss: � 1.2 Ass5AgF ss Map&Parcel NumberaA
1.la Is this an accepted street?yes no Map Number Parcel 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 ❑ 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: �—__ il1)
Name(Print) L� City,State IP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building❑ Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition ❑
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: e�
Cr4-7-e..--
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Laid and Materials)
1. Building $Air � �� 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ �� 0 Standard City/Town Application Fee
0 Total Project Costa (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees: $
Suppression)
Check No.,7(e Sf Check Amount# I I/"'"
6. Total Project Cost: $ ❑Paid in Full 0 Outstanding Balance Due:
City of Northampton
/. Massachusetts
a ` DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
4
Northampton, MA 01060
•
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.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
4CSL.er
License Number Expiration Date
Name of CSL Ider
List CSL Type(see below)
No.and Street Type Description
'A � U Unrestricted(Buildings up to 35,000 cu.ft.)
Y� R Restricted 1&2 Family Dwelling
City/Town,State,ZIP xx M Masonry
C/.07 RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Re.' ome Improvement Contractor(HIC) /l l< 'J� o��
HIC Registration Number Expiration Date
HIC Coiany N•••e ,r I C Registrant Na
No.and Street /Of 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
to act on my behalf,in all matters relative to work authoriz by this bui ding permit application.
5ri �/ Ce-( -,�
Print Owner s ame(Electronic Signature) 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 Owner' or Auth zed gent's Name(Electronic Signature) Date
NOTES:
1. An Ownef'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
r- -- .___:_,,, ‘,,J.?' Department of Industrial Accidents
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a& MINIM II) I Congress Street,Suite 100
Boston, MA 02114-2017
most nt ass.govldia
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Workers'Compensation Insurance Affidavit:Builders/Contractors/ElectriciansiPlumbers.
TO BE FILED'V%ITH THE PERAIIMNG AUTHORITY.
Applicant Information Please Print l_effiblv
Name i Business Orgaruzation,[mirk Inial): -ee'7r-
Address:
City/State/Zip: Phone #: ctitey-- OJS-Cil
Art yen an employee Ckerk appropriate but: 1.11}e of project(required):
1.0 lam a employer wail employees lflill arator purt-timet..* 7. j New construction
201irri a sole proprietor or partnership and hake nu encloyets working for me in 8. 0 Remodeling
any capacity [No workers'comp.insuranix aapuredi
9. 0 Demolition
30 l am a homeowner doing all work myself.[No wirrkers'curry.Mini:owe required.]'
la 0 Building addition
4.C3 1 am ri hurneowner and will be hiring contra:lupin)conduct all work on my propory, I will
ensure that all contractors eitber hare workers'conmemation oisurankx or are wile 110 Electrical repairs or additions
proprietors with no employ
-cm.
rill PI i.ing repairs or Additions
50 I in a ttV. 31 contractor and I base hired the sub-contractors hazed on the attained sheet
13 (2 Roof repairs
These sob-contractors/woe employck and has c workers'comp.maw:ince.:
14.0 Other
6.0 w,are a corporation and ita officers hair exercised their right of exemption per NAGL c.
I'..§li 4 t,=dot have ma employees.[No workers comp.insurance required.[
'Any applicant that check%boa:41 rranut 360 fill out the section below show ing their work...Ts'--oinpetisat ion policy information_
Homeowners who submit this affickakit Endwatutg they are domg all work and then hire outside colitracters muse subnut a oink atfidav it indicating sui.:h.
:Contractors that check thei boa must attached an additional sheet showing the name of the aub-contractors and state whether or sot those entities have
einployeew. If the sub--contractora bast clue .thcy must pros ide their w orkers'comp.polic:. ra.arilicr
fans an employer that is providing ovorAers'compensation insurance,(rr my employees. Below is the policy and jab site
information. r"--
Insurance Company Name: _
Policy St or Self-ins.Lie.#: Expiration Date:
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 NtGL 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 violator. A copy of this statement may be forw w,..cd to the Office of Investigations of the DI.A for insurance
coverage verification.
Ida hereby certify der the ' s and penalties of perjury that the information provided above is true and correct
Signature: k r all- r/v --- Date:
Phoned: 4 (4/ — . 5 3 3 0
(With!'IiNt.only. Do not write in this area,to be completed by city or town Official €
City or Town: Permit/License#
Issuing Authority I circle one):
I. Board of Health 2. Building Dtpartnirnt 3.Cityanun Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
A g i At iCity of Northampton
Massachusetts
�' -,:- i -
,,) DEPARTMENT DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
rf a 4
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:
:.,_.4w._---...‘)
Location of Facility:
The debris will be transported by:
Name of Hauler:
Signature of Applicant: v Date: .4. --/AZ576 ----
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411111111
City of Northampton
rMassachusettsP��� ,,E f��DEPARTMENT OF BUILDING INSPECTIONS Di Et ,
t 0ir 2,,: `� 212 Main Street • Municipal Building �ti36%
Northampton, MA 01060 r ' �t ~
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:
N
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)