24A-054 (2) BP-2022-1237
95 JACKSON ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
24A-054-001 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-2022-1237 PERMISSION'S HEREBY GRANT l I TO:
Project# ROOF Contractor: License:
Est. Cost: 27000 TIMOTHY LUCE 100515
Const.Class: Exp.Date:07/15/2024
POLACHEK DANIEL W& TRACEY II CO-
Use Group: Owner: TRUSTEES
Lot Size (sq.ft.)
Zoning: URA Applicant: TIMOTHY LUCE
Applicant Address Phone: Insurance:
90 WOODBRIDGE ST (413)387-9800
SOUTH HADLEY, MA 01075
ISSUED ON:09/30/2022
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 VIO • TION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: I
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a 51-°'
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Fees Paid: $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
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The Commonwealth of Massachusetts C J
i Board of Building Regulations and Standards Far o( F aa
Massachusetts State Buildin Code, 780 CMR ���°'?7 icf n ICIPkLIT.
r1 g „i.<,,;by>m SE
Building Permit Application To Construct, Repair,Renovate Or Demolish a `' c0/ 0 11 �'
One-or Two-Family Dwelling °60 AT ;
This Section For Official Use Only
Buildin Permit Number: l I ..1� —
r � ,�j ),3-"j'7 Date A�p lied:
,/ q-361°ZZ
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Pr pe ty Address: 1.2 Assessors Map&Parcel Numbers
I.la Is this an accepted street?yes 67 no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq II) 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:
DAIU)t=L W. Po cal-cl-iEK US% floRrH4 Tbti mA. 010 60
Name(Print) City,State,ZIP
'75" clAcKSonl 57-. 413-50-3365 c yeci ,..) lachenkcoir
No.and Street Telephone EmailAddress
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': P .Ae_ c -4 I .jttue_ i.it- le York t e.,:44N-
vk¢,w a.rcAn; ch,,,,,l roof
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
(Labor and Materials)
1. Building $ �7 QOv 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑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.i)-44 Check Amount: ( Cash Amount:
6.Total Project Cost: $ 271V 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 005i 7^ 2
y
k.)o6 I3 i 1 vv,,cJ 7 L u License Number Expiration Date!
Name of CSL Holder
76W ( S 1 - List CSL Type(see below)
No.and Street Type Description
).\ 17.641,62,7 /� s/OK U Unrestricted(Buildings up to 35,000 ail ft.)
City/Town,State,ZIP r� LV R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding 1
SF Solid Fuel Burning Appliances I
) 7"/vG�P� ti�•Ce.'^' I Insulation
Telep o 9 t
one Email a ess D Demolition
5Registered Home Improvement Contractor(HIC) /aA �Tr 0�
I '4o w�— HIC Registration Number E,xpirat n ate
HIC Co y Name or HIC Registrant Name
0 (, 7/19CoZ( Q— ( • Cert.—
No.nil t ect 0 Emailaddress
k, , i 'M Om?)Old?) w3 3.Y7 700
tty/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 No ❑
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 1 3 Lx—--
to act on my behalf, in all matters relative to work authorized by thWbuilding permit application.
G CL-n,g)I w/'4-44 '%✓t Vie. g -2 V—20 Z 2_
Print Owner'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.
. (�t, 0-0022_
Print er'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 contradtor
(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"
City of Northampton
SS - . SC
•' Massachusetts •w <
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DEPARTMENT OF BUILDING INSPECTIONS
• w `` 212 Main Street • Municipal Building
Northampton, MA 01060 sS'111, 0,1�
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: Va I (,)/
The debris will be transported by:
Name of Hauler: A4'k i3 i /' .
Signature of Applicant: Date: PV2,40 Z Z.
t_ The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston, MA 02114-201?
www.masc.go►t/din
11 tit kers'('ompensetiou Insurance.1Rdas it:Builders.1('ontractors E'leetrician Plumbers.
tt)H!I11.t:1)NIlH I III.PIRs111'1ING At I110kl .
Applicant Information ) Please Print Legibly
Name 1 iiusancss.O rgantrallon, vl p 1 1
. Il
Address: PO G•
t-tt .-`Statc:.lZtp: • , 4aOs.) Phone •z.
3 E7
Are yea an slap. re?(hark tie appropriate bat: type of project(required):
l.o i am a employer with employees(irdt and en page-tetar).• 7. CI New construction
2.gba<rsok prupnrtut or pannership and have nu employees*Mu* for nee in S. 0 Remodeling
any capacity {`:Vo waders'comp.utstuanue tenoned"
.:!am a honumwrwr doom all work myself.{No workcx,`t unttp.mwtallet!re^4wm11
9. 0 Demolition
4.0 i am a lu x1 ewm mte,.wn,a and will be biting o,nitors to ltra Ali work on nt,property. I wet! 10 Q Building addition
.J ensure that all cunrrx.-4ars,*thee hate work,n."eatiltp natant tnatirane'e ie Are*Ole 11.Q Electrical repairs or additions
propnetors with no etttpinvca^s
12.0 Pio repairs or additions
5C3 1 am a general contractor and l lose hired the sub-.wtrm:rwr,listed an the sits.ted diem. I 3 Roof repairs
These wbvLmtraetots hate enipkryees and has*takers camp.insurance.,
6.�we ate a....corporation and its offseems have exercised then nght ctt exemption pet MCI_e_ lA. Other_
152. 1i4r.and we hate no einpluwes.(No*Laker,'cam.insurance requited.!
y appttcant that et wt:ka tux a►Must also fill out the seetton hekew showing then workers'eurapeniuium puta) orlonnatron
*Htmtt^ctwnet,who submit tin,atYtduvtt indicating they ate doing All work and than here outside e»nrraetnrs must 1.uhnut a new artidas it tndteatmg such.
t_urotwton that check this tat mutt attached an additional sheet showing the name of the wb•catemrtort and state whether or not dwtse entities hasv
ortpkioee-, lithe.uh-eutt1ritturalts arFle eeh.the}ttru,t pn.ttdethem nt,tker,.'comp potta cutrtts.t
�._... .
am an employer that is providing wordier,'compensation insurance fur my emplot ees. Below is the Holley and fa*site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City,Stair,Zip __._.. __._�
Attach a copy of the workers compensation policy declaration page(*bowing the policy number and expiration date).
Failure to secure coverage as required under r MGL c. 152.*25A is a criminal violation punishable by a fine up to SI 300.00
and/or one-year imprisonment,as well as cit'it penalties in the form of a STOP WORK ORDER and a fine 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 that the information provided above is true and correct.
Signature. ate: / 7
Phunc 71260
k a t
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permitlicense 1:
Issuing Authority(circle one):
I. Board of Health 2. Building Department 3.City 3011n Clerk 4.Electrical Inspector 5. Plumbing Inspector
G.Other
Contact Person: Phone 4:
Commonwealth of Massachusetts
It Division of Occupational Licensure
Board of Building Re ulations and Standards
ConstionTSrvisor
CS-100515 I tpires: 07/15/2024
TIMOTHY J LACE
90 WOODBRIDGE STREET
SOUTH HADLLLY MA 01075 , .
J
nvivinr J CVI.t
90 WOODBRIOGE STREET
SOUTH HADLEY MA 01075 i
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Commissioner V 1. v.�.';;i:,t.7�
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: Individual
TIMOTHY J LUCE Registration: 49288
;� Expiration: 05/24/2024
90 WOODBRIDGE STREET
SOUTH HADLEY, MA 01075 «.
t
no
14,1
Update Address and Return Card.
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the
HOME IMPROVEMENT CONTRACTOR expiration date. If found return to:
TYPE:Individual Office of Consumer Affairs and Business Regulation
Registration Expiration 1000 Washington Street -Suite 710
149288 05/24/2024 Boston,MA 02118
TIMOTHY J LUCE
TIMOTHY J.LUCE
90 WOODBRIDGE STREET .001..4( , ��—
SOUTH HADLEY,MA 01075 Undersecretary Not valid without signature