38C-048 BP- 022-1195
42 SOUTH PARK TERR COMMONWEALTH OF'MASSACHUSETTS
Map:Block:Lot:
38C-048-001 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-2022-1195 PERMISSIONIS HEREBY GRANTE TO:
Project# ROOF Contractor: License:
Est. Cost: 3000 JAMES ROBERTS 099404
Const.Class: Exp.Date:01/21/2024
Use Group: Owner: WALTON LYNNE A
Lot Size (sq.ft.)
Zoning: URB Applicant: JAMES ROBERTS
Applicant Address Phone: Insurance:
30 Edwards Rd (413)527-6078
WESTHAMPTON, MA 01027
ISSUED ON:09/23/2022
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 VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
II . ', 55-1,
ll
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
RECEIVED
14, The Commonwealth of Massachusetts
Board of Building Regulations and Ste ndards SEP 21 2022 IR-.
Massachusetts State Building Code, 780 CMR M PALITY
t` '�% E
Building Permit Application To Construct,Repair,Renov/Fa ', PE ''sefar 2011
One-or Two-Family Dwelling l__ NORTHAMaTON.MA 0106 _ ,
This Section For Official Use Only
Building Permit Number$P 2- ' 1 q 5 Date Applied:
141 %, // 9-zz- zz
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Adc ss•�y �-- 1.2 Assessors Map& Parcel Numbers
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 Ow r'of Record:
Name(Pri City,State,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) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work': .J 'ilv 1 `c!,,,t
SECTION 4:ESTIMATED CONSTRUCT ON COSTS
Item Estimated Costs: Official Use Only
(Lr and Materials)
1. Building $ ?�C) 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $
`l ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: $
Suppression)
Check No.RA I Check Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
City of Northampton
(-,'
LS Yr\ s,
Massachusetts �y?� �k{
i ,14. DEPARTMENT OF BUILDING INSPECTIONS S
,'xwi
�ar +' 212 Main Street • Municipal Building L
Northampton, MA 01060 t4
•
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 Cons uction Supervisor • ense(CSL) e-cir
9 404< ,,)-i-(
License Number Expiration Date
Name o S Ho der
List CSL Type(see below)
36)
No.and Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP Masonry
ii �^/O�� Roofing Covering
!/ Window and Siding
F Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 3; -3( �p
HIt,Registra)ion Number Expiration Date
HIC Company or Regis ant ame / /7 i 1
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
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authoriz by this building permit application.
Prim 's Name(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.
/4nise?-,ge4 5 q-,- -.
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 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.go*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 itlassachusetts
Ira Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.govidia
Workers' Compensation Insurance Affidavit:Builders/C2ontractorsiElectricians/Plumbers.
TO BE FILED%tin THE PERMITTING Atl'HORITY.
Applicant Information Please Print Legibly'
Name(Business;Organization/Individual):
Address: 3
City/State/Zip:
Phone #: /7(ZAL-0,93?Y
Are you an employer?Check the appropriate butt Type of project(required I.
1.0 I am a employer with employees ft&andior part-Limit.* 7. 0 New construction
2.17t1<----in a.sok proprietor or pittmership and h;ase no employees working for me in 8. J Remodeling
any capacity.[No wallets camp.insurance iv-toured.]
Ej30 lam a homeowner doing all wort myself.{No workers'comp.imitirancre required.r 9. Demolition
4.0 I am a homeowner and will be hiring mat:rat:tors to coodibet alt wars.on my pro 100Building addition
will
CThiltre that all contraiturs either have workers'compensation insurance or are sole II.0 Electrical repairs or additions
proprietors yr ith nientployem,
I 2.111.Plumbi its or additions
Sacirri a ireneral contractor:Arid I base hind the sub-cutatractors listed on the attached sheo.
Li oof repairs
These sub-contractors have employees and base workers'comp.insurance.; 13
14.0Other
6.0 we arc a cuiporzaion and its officers have est:nixed their right of cienattion per hiltSL c.
152.;111.0.and wti ha,oe no etirloyees.[No workers'conip.insurance required.]
Any applicant that checks h. i ruLA Aku till out the section below showing thetr workers'conicaLltsation policy information_
*Homeowners who subltut this affidakit milk:aim they are doing all work and thin hire outside contractors must submit a new affidavit indicating such.
:Contractors that deck this bus must attached an additional sheet showing the name of the sols-contractors and state whether or not those entities hate
employees. If the sub-curiractors hate employees.they must prce.ide their workers"eump policy number.
I am an employer that is providing workers'compensotion insurance for My employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-iris.Lie. #: Expiration Date: /1",.2/ —67?
Job Site Address: CityStateZip: --
Attack a copy of the workers'compensation polic declaration page(showing the policy number and capitation date).
Failure to secure coverage as required under NIGE c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00
andior one-year imprisormvent,as well as civil penalties in the for of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
co%eruge verification.
do hereby certify under the ins and penalties of perjury that the information provided above is true and correct.
Date:
Phone 4: 4-1-(3 I-1 I
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3.City/Town Ckrk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
City of Northampton
,P,,. Massachusetts
is
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 'i
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number _ is that all debris resulting from this work shall be disposed of
in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: ii--;------'
The debris will be transported by:
Name of Hauler: ,---'11-K--
Signature of Applicant: Date: �e5)
City of Northampton
�,0� 32.1 r� s$ -- ,sib
Massachusetts ��,•� . _ 't.
DEPARTMENT OF BUILDING INSPECTIONS = II
y`
frj,, +` 212 Main Street • Municipal Building r� y' Cb.
�- Northampton, MA 01060 'rJf (\
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, (insert fill! legal name), born (insert
month, day, year), hereby depose and state the following:
III 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.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)