29-454 (6) BP-2022-1013
56 CRESTVIEW DR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
29-454-001 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-2022-1013 PERMISSIONIS HEREBY GRANTE I TO:
Project# ROOF Contractor: License:
Est. Cost: 6000 ROBERT THIBODO 65699
Const.Class: Exp.Date:06/22/2023
Use Group: Owner: YAO WU
Lot Size (sq.ft.)
Zoning: WSP Applicant: ROBERT THIBODO
Applicant Address Phone: Insurance:
P O Box 201 (413)586-0391 UB0250N144
NORTHAMPTON, MA 01061
ISSUED ON:08/18/2022
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:
- CP*
1 ,
Fees Paid: $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
/ ' 7 /1
The Commonwealth of Massach etts
l•�/'� i '~
Board of Building Regulations and tand. ds '4 o � `9 FO
E Massachusetts State Building Cod 780�,t. R 18 �0942 M ICSE LITY
Building Permit Application To Construct, Repair, riot `-molish a evise Mar 2011
One- or Two-Family Dwelling 4'144 p''iNSp
This Section For Official Use Only Mq of 6,0% /
Building Permit Number: i7Q` aa-- l_V 1. Date Applied: __
KkulL (75s .//� 8-ie-zozz
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Pro erty Address: k t 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes no Map Num er Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use i 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 ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O ner'of Record:
Name(Pnt) City, State,ZIP
No.fi 'reetec- 1rJ `r S l
S Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'-(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
jarief Description of Pro osed Work'-:( ,,, -..c.,c\-\:-..--,A0-;x\ 1,w -ik 1 '
15\
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ 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)
Q Check No. Check Amount:
6. Total Project Cost: 0 Paid in Full 0 Outstanding Balance Due:
p�,� City of Northampton
c(
j °-- , Massachusetts . _ ��;.
».11: .'G,' � ti* � t
DEPARTMENT OF BUILDING INSPECTIONS .
\ ,�� 212 Main Street • Municipal Building ,,i. b`'
�. 4'allorthampton, MA 01060 10'1a
56cr-es ►e
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS, ROOFS,RENOVATIONS, ROOF MOUNTED SOLAR, ETC.
a
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)
c 3 1 Kb( cg, ics�9 -GI,-
License Number Expiration Date
Name of CSL Holder
3 a. .ASN' `M }gyp)k S�" List CSL Type(see below)
No.and Street Type Description
^�. U Unrestricted(Buildings up to 35,000 Cu. ft.)
V'� ���^ R Restricted l&2 Family Dwelling
City/Town,State,ZIP M Masonry
.e 1ti 1 --a9rtrcilAZ
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Sn S ) Gn I Insulation
Telephone Email address D Demolition
5.2 Registered Home mprovement Contractor(HIC) S �
AL\43_
-03_. HIC Registration Number irion Date
HIC Company Name or HIC t Name
3 L A4�' .`p -t
No. arem S�S /9 6`� Email address
s''C�A �'a�
City 1 own, 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 o provide
this affidavit will result in the denial of the Issu ce of the building permit.
Signed Affidavit Attached? Yes 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 P----\2- 1 d 44c)
to act on my behalf,in all matters relative to work authorized by this building permit application.
(ao .).-)0 , • 17 ' 2--- -,
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER1 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.
C Y1 1‘b 0'k0 r?-- y- • ) 3 . - -)-
Print Owner's or Authorized 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 unregisterec 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
Department of Industrial Accidents
I Congress Street, Suite 100
- Tatati---7 41 Boston,MA 02114-2017
•a ",
WWW.mass.goviitia
S-Vorkers' Compensation Insurance Affidavit:BuildersiContractors/ElectricianstPlumbers.
TO lik,FILED%Rill IIE PI:101ITTES C.',AUTHORITY.
ileplk.lint Information Please Print Legiv
Name i ausinessanaluzatiorandivittual): 1- 0 C—R.12.____
Address: 33 , E e.34- IN\c..kci5 -1Z, S A--
CityState/Zip: 5 )-1 ,. , Phone .Art!pnu an empkry er,Cheek the appropriate hot:
Type of project(required):
, Lai=a employer with ---. employees(lull amine partdirn4* 7. 0 New cunstructum
20 lam a sok proprietor Or partrierahrp and have nu employee%working fen me in S. 0 Remodeling
any capaciry,[No woricri"comp.insuraniv mpiired,]
9. 0 Demolition
30 I zni:1 IIMMELVWfter tiorne all work myself,[No workers'cramp_insurance required]
ia 0 Building,addition
4.0 lam a homeowner and will be hiring cmsniracidri to conduit all work on my propty. 1 will
CMUM that all contractors either have workers compensation insurance or are sole 1 110 Electrical repairs or additions
proprietor%with no employees-,
12.0 mbing reimirs or additions
SCJ I am a general cuntmetor and I have hired the sub-euntractors listed on the attached sheet.
Thele sub-euistrattors base employees and hat e workera'comp.nenarance. I 3 Roof repairs„.:
1 i 4.r:1 Other
6.E3 We are a corporation and its officers have exervised their right of ex:ern/Men per NICiL c.
1.12.§1(4),and we have no employees,.[No workers'eon*.insurante required.}
'Any applicant that checks but 41 Mad also fill out the section below showing their workers''compensation policy information.
Homeowners who sulinut this affidavit indicating they are doing all work and theta hire outside contractors Mad till:VI:TM a new affidavit intheating such.
au .
that cheektho boa mod attached an additional sheet showing the name of the sub-contractoca and date whether or nut dlaNtt initities hate
employers_ If the sub-eurits4Cti3T%base mipluyers.they most provide their workers'.,.-0117r.p.i hey nomber.
I am an employer that is prowiding woriers'compenudion inNorutice fur my employeeN. Below is the polka'and job site
information.
Insurance Company Name:
.._._A-- \)Ckle)- CO Ne —
Policy#or Self-ins.Lie. #: L '. 7\-"-S CD'..)..„5 ()1•1
—\---Y-gs_ Expiration Date:_3 '''.. ---.1
Job Site Address: 5(e, C:rf-SW-1-e k..,...) 'DI' city,StateZip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal viiAation punishable by a fine up to$1,500.00
anikor one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a tine 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 penaltieA aperitif).*that the information prey i, • e above ...s true and correct.
Si nue! '--------gkjs—c,—IL DiftiL k \c- cl.
phon ,__9_.(, ,___________ _______
Weld use ottly. Do not write in this area,to be completed by city or town official
',-
City or Town: Permit/License#
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.Cityrtown Clerk 4. Electrical Inspector S. Plumbing Inspector 6.Other
Contact Person: , Phone 4:
City of Northampton
��` Massachusettsw
# DEPARTMENT OF BUILDING INSPECTIONS
212 •
Main Street • Municipal Building ��1,.
Northampton, MA 01060 ��Sk ,,
a
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.
')') -) c)
The debris will be disposed of in: (\--- V
Location of Facility: "N/6 r-�)1,,eo,
The debris will be transported by:
Name of Hauler: c,. . (D 0
Signature of Applicant: (-- Z J ,s-croZSD Date: 1.41-)---
City of Northampton
t
Massachusetts 4, . _ �'
F * A
DEPARTMENT OF BUILDING INSPECTIONS ` ;
212 Main Street • Municipal Building �...
Northampton, MA 01060 Pp Ai i1:N.
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)