25C-059 (10) BP-2022-0715
19 LINCOLN AVE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
25C-059-001 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-2022-0715 PERMISSIONIS HEREBY GRANTED TO:
Project# roof Contractor: License:
Est. Cost: 7000 SHUMWAY SERVICES 105743
Const.Class: Exp.Date:01/14/2024
Use Group: Owner: M HEATH JEFFREY M& EDNA
Lot Size (sq.ft.)
Zoning: URB Applicant: SHUMWAY SERVICES
Applicant Address Phone: Insurance:
PO BOX 522 (413)549-4658 O WWC3509999
HADLEY, MA 01035
ISSUED ON:06/16/2022
TO PERFORM THE FOLLOWING WORK:
STRIP AND RE-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: >2 . TIT
Fees Paid: $50.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
/ RC /I/ ...h
The
of
ttd
U
ommonituseStanUN , ALrrY Massachusetts State Building Codb. 786
'in�T sUtinin, SE
Building Permit Application To Construct,Repair,Renovate , s1s evise Mar 2011
One-or Two-Family Dwelling A44°10so Ns
This Section For Official Use Only
Buildin Permit Number: ea- )a P7/6 Date Applied:
kluio 4.55 I
& L-/L-ZOzZ
BuildingOfficial Name Si Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbe�9,
(4PI CUII h 0)5-G
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:
Jeffrey M. Heath Northampton, Mass, 01060
Name(Print) City,State,ZIP
19 Lincoln Ave. (413)586-2730 jeffhea@gmail.com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) ❑ Alteration(s) 0 Addition 12
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2:
Replacement of roof section with 30 year architectural roof system.Ice and water shield,
synthetic felt.ridge vent and cap.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs. Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire H
Suppression) $ Total All Fees: ''^^/
Check tlavl J�Check Amount: , Cash Amount:
6.Total Project Cost: $ 7 K ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
105743 01/2024
Shumway Services License Number Expiration Date
Name of CSL Holder
P.O Box 522 List CSL Type(see below) U
0
No.and Street Type Description
Hadley MA 01035 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
413-687-9400 shumwayservices�rii;gmail.com 1 Insulation
T
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 178390 04/2024
Shumway Services HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
P.O Box 522 shumwayservices@gmail.com
No.and Street Email address
Hadley MA 01035 413-687-9400
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 MI 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 Shumway Services
to act on my behalf,in all matters relative to work authorized by this building permit application.i �
1 —
" ! r.l di
Print Owner's Name(Ele Signature) ! ate
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 info ation
contained in this lie on is true and accurate to the best of my knowledge and understanding.
I
Print Owner' r 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 lommonwetrIth of Massachusetts
Department of industrial Accidents
t'ongress Street.Suite 100
11:fre Boston, MA 02114-2017
www.mass.govidia
afters'Cotttprrisation Insurance Affidavit: Builder (,7ontractorsiEletriciansiPlumbers.
I NS tin i HE PERMUTING AUTHORITY.
Applicant Information Please Print legibly,
Philip Shumway Inc. DBA Shumway Services
Name I Business/Organization/1 odividual
P.O Box 522
CityiState/Zip: Hadley MA 01035 Phone#: 413-687-9400
Art WUan easpkryee Check tke appropriate tort: -1-„,pc of project(required):
EN 1 ant employer with _X employees(run imilen pattionek* 7. 't New construction
I Jiti It sole proprietor pertnennap and rai.:e V.1110.0)LC'S A'Ott:44 fir:me 0 Remodeling
ety LAtreacity.No*Mums'comp.insUritlia. itspured,)
9. El Demolition
31:1 I ant a homeowner sluing all work myself,[No workers'comp misname reunited 1'
I 0 El Building addition
.40 I ant a homeowner and will be hiring ouritruchns to eoriduct all work on toy property. I will
("MUM that all connacions either have workers'conspen-satson inikonince of art sole 1 LC] Electrical repairs or additions
propos:tors 15,ith no eniployees.
I 2.1:1 Plumbing repairs or additions
$C3 arri 4 general contractor and I lido e tined the Alb-contractor%listed an the anaehol sheer
I 3123 Roof repairs
Thew sub-contraciori.have employees and have workers'comp.insurance,:
E]We am a corporation and its officer%have exercised then'nett or exaription per hIGL c, 14..30ther
I Si, and wt has,e no employees.[No weaken eurnp.innuance required:I
Any.applicant that checks hart 41 must also flit out the wenn;below sherng their Workers'compensation policy information
Ilomeowners who solvitin this affidavit indscatang they arc Joon all work and then hire muridt contracteir*must solaria a new affirlas, medicating such.
:t"untractors that chest this box must attached an 4daltit,0141 sitet:t showing the name of the sub,cuninwtori.mad stoic whether in not Mote imoties!taw
clirlo:seci It!I..,,i3h,conhaLtors luv,e emplo,,ceN,they uuardelipfWelew workers'CiAttp,rttliCy 111.14i'ver.
1 am an employer that is providing rrorbers'compensadon insurance for my employees. Below is the policy and job site
information.
Insunince Company Name: WeSCO
Policy#or Self-ins.Lie.#: WWC7569281 Expinition Date 02/2023
Job Site Address: -
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MCA c. 152. §2,5A 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 line of up to S250.00 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 penalties of perjury tluu the information provided above is true and correct.
Signature!
Date'
Phone#: 413-687-9400
Official use only. Do not wile In this area.to be completed kr city or town official
lily or Town: Permitel.icenle
Issuing Authority(circle one):
I. Board of Health 2.Building department 3.Cityfrowu Clerk 4.Ekrtrical inspector S. Plumbing inspector
6.Other 3
Contact Person: Phone tt:
City of Northampton
Maszachusetts
(%1; r
41- DEPARTMENT OF BUILDING INSPECTIONS r
411%; 212 Main Street IP Municipal Building
„
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: Amherst Trucking or Private Dump Truck to Valley Recycling
The debris will be transported by:
Name of Hauler: Amherst Trucking or Private Dump Truck to Valley Recycling
Signature of Applicant:
Da • C,
The Commonwealth of Massachusetts
=Iv; Deportment of Industrial Accidents
7 1 Congress Street,Suite 100
1.-:*17-41111— Boston. MA 02114-2017
wwwmass.goWdia
fl token Compensation Insurance Affidas it:Builders/(ontractorsiElectriciantiPlumbers
TO BE FILED 111111 1 ItE PERNIFEIING Air!Ii()R11 1.
Annlkant Information Please Print Legibly
Name(Buiuc nuunlri8niduat : Philip Shumway Inc. DBA Shumway Services
Address: P.O Box 522
MA 01035
City/State/Zip: Hadley phone#: 413-687-9400
Are yrs ea mph»re Check the appropriate lorai
Type of project(required)
X
1 lair.a employer oith employee% ull wilco part.tunel 7 New Construction
I4171 u Froprictotor postrier.hip and litoeniensploynci working for me m c3 Remodeling
area saleastly.Nv*utters'vamp.Itftsuran retprirod
30 tarn a buns:ovine:%km'all iron.myself (No winters'comp insuronce too:raj' 0 Demolition
10 0 Building addition
40 lam a hom000.nor and humg sunhat:tors to veridu.A.all work on roy property. 1 van
noun that all contractors either he workers'1...XIINTLS.A7011 LlItttiftlaCe Elf hole sole 110 Electrical repairs or additions
propnciors a no:lapis/cr..
I 2,0 Plumbing repairs or additions
5.0 1 am a priori!contractor and I haa r bated the sub.corittoeicirs.hided on the anachol%heel
Thew%tab-contractor%base employees and haat*utters'eiarrp nisainmee.: 3.0 Roof repairs
2i60 We arc a corporation and its officvni hove est:a:lard[Iwo rtgla orictnptioti per MU e. 14 t ()titer _
152.4114).and sir have no employees,(No woricni`Win) ifnainifiCe requireill
"Any applicant that dirk box PI mz thy IrU out the wion brio*showing their winters'compeers:awn policy inform:hoe
Hotheowners who 61.161:114 this affitlasit inchcatang they arc doing all oink and then hire outwit contractor%now sutittui a nt At&IV%it inethating 1.1.101-
IContraeturs that cheek this hei must;eta.hied alekuunal sbiet%boo tag the name of the sub-suntractors arid state w hether or not those cantles haw
employixs If the euta-curitra.tora bait.cmplosets.they must provide their wortas'comp member
ea —
I am an employer that is providing workers'compensation insaronee far my employees. Below ii the;whew'and job site
Informatkut
Insurance Company Name: Wesco
Policy or Self-ins.Lk.#: WWC7569281 Expiration Date: 02/2023
Job Sitc Address: CityStaterlip:
Attach copy of the workers'compensation policy declaration page(shouing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, k25A is a criminal violation punishable by a fine up to$1,500,00
anctior one-year imprisomnent„as well as civil penalties in the form ors STOP WORK ORDER and a fuse of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Otitsv of Investigations of the DIA fur insurance
coverage verification.
I do hereby cent&under the pains and penalties of prrJary that the information provided above is true and correct.
Signature: 54411.44,7 ..5,7„2.4../...c.44...• Date:
Phone 0: 413-687-9400
Official use on Do not write in this area,to be completed by thy or town official.
City or Town: Permit/License N
Issuios Authority(circle one):
I.Board of Health 2.Building Department 3.(14 II ossn Clerk 4.Electrical Inspector 5. Plumbing Inspector
G.Other
Contact Person: Phone#: