24D-206 BP-2022-0776
228STATE ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
24D-206-001 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-2022-0776 PERMISSION IS HEREBY GRANTEI) TO:
Project# ROOF Contractor: License:
Est.Cost: 6000 JAMES ROBERTS 099404
Const.Class: Exp.Date:01/21/2024
Use Group: Owner: HIGGINS MARY CLARE
Lot Size (sq.ft.)
Zoning: URC Applicant: JAMES ROBERTS
Applicant Address Phone: Insurance:
30 Edwards Rd (413)527-6078
WESTHAMPTON, MA 01027
ISSUED ON:06/30/2022
TO PERFORM THE FOLLOWING WORK:
STRIP AND RE-SHINGLE
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 VIOL TION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
I • , l
•
f s
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
RECEIVED ,
v
�UN Z 9 2022 The Commonwealth of Massachusetts
*r ' Boa 7d of Building Regulations and Standards FOR
7 ,., ECT,oNas'achusetts State Building Code, 780 CMR MUNICIPALITY
a otioso USE
Build' pplication To Construct, Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
BuildingPermit Number: 22- 776 Date Applied:
/
AE:Vi..) �o5s i1� Z 6, 36'Zit
Building Official(Print Name) Signature Date
SECTION l:SITE INFORMATION
1.1 Proper fi,e_s_s_
: 1.2 ste$s5s Map&Parcel Numbeso /
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 Prodded
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 O erg Record: t �'
Name rint/&� ` City, tate,ZIP
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) 0 Alteration(s) ❑ Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
/49
Brief Description of Proposed Work':
,._1•47+
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item ( .. d Materials) Official Use Only
1. Building :l% ,.4;00 A 1. Building Permit Fee: $ Indicate how fee is determined:
❑ 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 $ Total All Fees: $
Suppression)
Check No. Z(I Q Check Amount:
6. Total Project Cost: $ 0 Paid in lull 0 Outstanding Balance Due:_
I
City of Northampton
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c?iyr "r ti �Sts ."�•` sic!
iP Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
'• . t 212 Main Street • Municillitpal Building V6.%
Northampton, MA 01060 sfr i‘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.
./
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor Li ense(CSL) erg e� f-/-.'�
License10/ e`Number Expiration Date
Name of der
List CSL Type(see below)
No.an Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
City/Town,State,ZIP R Restricted l&2 Family Dwelling
Masonry
A., Roofing Covering
Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /�� _ _
HiC Regtstratton umber xpiration Date
HIC Com Name C Registrant me
No.and Stre 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 S ) ,-?'kle e....-er/
6(fr ,
to act on my behalf,in all matters relative to work authorized by this building permit application.
i-� / . •
_,,,,j7,7 ._
Print Owner's ame Sg a titre Date
(Electronicgn � )
SECTION 7b: O WNER1 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.
. - L-s ____L,...,2q.. .__,:„...,,,,i_
Print Owner's or Authorized Agent's ame(E ectromc ign-ature) 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.govidps
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"
• .
(At\dai6r-
The Commonwealth of Massachusetts
1,0 _, ;sz;• Department of Industrial Accidents
- -, 1 Congress Street,Suite 100
Boston,MA 0 2114-2017
\•_-„..- - '-' www.ma.ss.gov/dia
1Vorker.' Compensation Insurance A frida%it: Buildersit'ontractorsfEketriciansiPlumbers.
It)tit. 1:114,1)%1 I I II I Ilk l'i.liAll I !INC AI IIIORI1V.
Applicant Information Please Print Legibly
Name iflusiness,Organizatiorvinclividual):
City Stato7ip: /(2 Phone#: 4'/3_, ---
Are.ruu an eiriplir‘ell Check the appropriate box: -r, pe of project(required):
4:17 1.0 1.z.in. cmplo!.er xvith ezEipio)tcs full aniec pan-time I* 7_ 0 New construction
I AM a ink propnetin or Annacrlitip and have/10 employees wodting. forme in K. 0 Rezmxlelmg
any carrseiry.[No workers'comp.insurance irqtnrei]
_ El30 l am a hurrsoowner doing all work mjAclf.No worterik*curry.irettarance required.)• 9 Demolition
10 0 Building addition
4.0 I am a homeowner and will Se hems contractors St.)conduct all work on my property. twill
ensure that all Contactors either have workeni•compcn,at am inr.m...r or we sole 11.0 Electrical repairs or additions
V.0"a
prop' with no employetnt.
12.E:I Plumbing repairs or additions
5 am general cordrachar and I have hired the culs-euntrackirs listed on the=oiliest Alert
These sub-cootractors have employees sod Isisve workers'comp.Insurance,: 13 1:111.--7-Trepairs
14.
6.Q We are a corporation and 1L3 officers have exercised their right of e,cerription per MGL c:. CO Other
152,41141.and we il.l'oe no employees.[No workers'camp.insurmcc required.]
*Any applicant that checks boa.al MUSS also fill out the seezio it i's.:losc,show me their worker. cornpen,ation polwy information_
t Fiumeowners who surbnut thus affidavit mkt:ow:1g the are doing all work and:bets lure outside contractors must submit a new Affidavit indicating such.
IContractors that check this box must attached an ahlitional sheet showing the name of the sols-contractors and state whether or not those entities have
s-mployees. It'the sub-contracturs have employees.they most provide their workers"'isimp.policy number
I am an employer that is provid.ing worAers'compensation insurance for my employees. Below is the policy and job site
informatiofi.
Insurance Company Name:
„.... .
Policy or Self-ins.Lic.#: Expiration Date: 4
Job Site Address: 1/2--) gP---(-( .-jr City:State:Zip:
Attach a copy of the workers' c,shnpenation po icy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under NIGL c. 152, §25A is a criminal violation punishable by a tine up to S1,500.00
andior one-year imprisonment,as well as civil penalties in the form°fa STOP WORK ORDER and a fine of up to 5250.00 a
day against the viohitor.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage ventication,
I do hereby certify under the pains and pent, - of perjury that the information provided above is true and correct
SiLmature: Date: 6--,. g
Phonc:7:! L?/1 —14 C4/"-- , 3.5- .!--
Official Use only. Do nor write in this area, fir be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
I. Board of Health 2. Building Department 3.CitytTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _ P hone#:
0.__ i I _,.,
City of Northampton
Massachusetts
. j
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, 554, 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:
4r;—&/
The debris will be transported by:
Name of Hauler: L-421—'(7-----
Signature of Applicant: l! i Date: 6/79111- --
1
City of Northampton
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-i�'rT,'tiY>� 5.,. ++... ..,
Massachusetts }'' *9-ee
S, 1t DEPARTMENT OF BUILDING INSPECTIONS ;
°,_ :(ILL
- „it 212 Main Street • Municipal Building �J� 'Ir
'° Northampton, MA 01060 At soV'1�'
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)