42-159 BP-2022-1241
41 WOODLAND DR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
42-159-001 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-2022-1241 PERMISSION IS HEREBY GRANTE'I TO:
Project# ROOF Contractor: License:
Est. Cost: 8000 ROBERT THIBODO 65699
• Const.Class: Exp.Date:06/22/2023
Use Group: Owner: L DOUCETT GARY V& SANDRA
Lot Size (sq.ft.)
Zoning: WSP Applicant: BOB THIBODO ROOFING AND SIDIN1
Applicant Address Phone: Insurance:
P O Box 201 (413)586-0391 UB0250N144
NORTHAMPTON, MA 01061
ISSUED ON:09/30/2022
TO PERFORM THE FOLLOWING WORK:
STRIP AND RE-ROOF
POST THIS CARD SOP' 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:
1 �
� i •• )2 T '� .
Fees Paid: $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
The Commonwealth of Massachu •tts C /
Board of Building Regulations and anda t fr . FOR
k,zt) Massachusetts State Building Code 780 I, R6ep ICIPALITY
Building Permit Application To Construct,Repa. R&D,: - Or Denlol a ' • ised ar 2011
One-or Two-Family Dwellin_ tio,°Ty,ouizo
This Section For Official Use Only a"'n(4,,
�.
BuildingPermit Number: l )"' (a � Date Applied: 41'4 o c
rn�i �
Lit—) (re", ,/'/. ei 30-ZQZZ
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Pr rty AdC s:o 0 Q' 6r 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 ❑ Private 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 er' Recor �
���t of /Cam P -0 (Yr t'\iN C'•
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(checkall that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) B Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
f Description of Proposed Work':
,tzr
-\J S ,,C, c\-k S `\<;A(Ns.c _\ {,,--r v-v-. \c,,.LAvv,."k c -\-*
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees: $1 t j�
Check No.4�/'� heck Amount: t�U
6.Total Project Cost: $ Chi �� 0 o Paid in Full 0 Outstanding Balance Due:
City of Northampton
s s
Massachusetts
ilsy. '
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building ��t
'. Northampton, MA 01060 tSfrkY .v �•�0
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 License(CSL) -4G --(=i9°\ (0-\ License Number Expiration Date
Name"Sf alder
1~�
e3a £Z A'f �oQ\k List CSL Type(see below)
No.and Street Type Description
�. \_ - U Unrestricted(Buildings up to 35,000 Cu.ft.)
C ��"` '� R Restricted1&2FamilyDwelling
City/Town,State,ZIP M Masonry
r 1��-Z'-�C� RC Roofing Covering
1 WS Window and Siding
SF Solid Fuel Burning Appliances
S 13 161 -\ I Insulation
Telephone Email address D Demolition
5.2 Re istered Home Impro ement Contractor(HIC)
♦ HIC Registration Number Expiration Date
HIC-Company Name or HIC Registrant Nam
-N3-S'.' ��N 2 ik
�:.?u �� ��\ \ S'n I CI G-1 Thsw Email address
City/Town,State, IP 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 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(•>> � Z)- e) 6.2)
to act on mybehalf,in all matters relative to work authorized by his buildingpermit application.
PP
Gr C- Da'S.1-1CR W �CA dNC1 1
Print Owner's N�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.
5-- ----Tjg\\7 0 1k0 (-- k 19 VI,
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.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!: / Congress Street, Suite 100
---„, .--ta= ...si
17 iii9ftfilli.i Boston,MA 02114-2017
''';•;7w:." • www.mass.gor/dia
Wolters'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibili
Name iiiiiiinics.Orktrazotwn,individual):r-S3 C.C3 \ INN4Z:l 0 •
Address:_1L_EA.S- _S_ ____________.___________
City StateiZip:__S \-\\ C) "- --r--\01% Phone#: 5-1-5 I Ct (.--i
....-•----„A c....,
,HottwAre s uv,menisci rnwittoptity,Ltheetnt(t'utuhrekarthrtear avpttpradtruperailinnteilmnt the:). are doing an wort,and then lure echade...vnctriairts,taiti tei,T97i7g14.320,ibp,....0000p,,e7: otothNREED3rriotiodeunepruiwi:lir iei,cadto..,ocajrieinie.triipgoiititigctnsdzt3taoniingacre:indit;isrsionki_nAreuoirdgaadydd:txl.cikititi_:rs 111\Api:
, L I am a employer with .-7ernipioyees(fait aristor part-tiniel..*
; 20 I am a sole proprietor or partnership and have ni..,employeini working for me in
any 4:4IFIAC1Py (No worker-1'comp.insur.nas niquaredl
• 31:11am a horrieowmi doing all work.myself[No workers'comp..insurance required ;
410 I am a horlICOV•tirt and will be hiring airmail:bars to usithset all work on my propoly, I
ensure that all contractors either ha ye workers'convert:swim insur.uaiar or are sole
proprreton with no employees.
30 I am a general contractor and I has c hired the suli-contractorA listed on the attasted iheet.
These sub-cuntractors hate ettlpluyo, and have workers'comp.insurance.:
6.0 We are a corporation and its officers have exacised their right of exemption per?vkil..e.
Li 2.,.. I i 4 1..and we have.no CITVILI)ONV.,[NO workers'comp.insurance required.]
i .
'Any applicant Mat JrceLs hes.=1 naot also till out the section'below A/wising their-workers'eompernatiori policy unktinatIon
:Contractors that cheek tins box must attached an additional sheet shots-mg the name of the suts-conrans....tors and cute whether or not those snit:tn.-a have
ernploNees. it ,u1,eontractors bate emisk,CI:N.they must provide their workers'oultir.po!ie:.number
I um an employer that is providing workers'compensation insurance/Or my employees. Below is the policy and job site
information.
In.surance Company Namer-------Ke' .\' Cis se*" V
Policy#or Self-ins.Lie.#: V)tc3) (3 4,5 o "i\l \ Li (4
/ Expiration Date: 3 )....--1 3-.7),,
Job Site Address: LI 1 t-A.)t 0 ci \A'',N \)-r—
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 violation punishable by a fine up to SI.500.00
and/or one-year imprisonment as well as civil penalties in the form 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 for arded 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 ohove is true and correct.
,--.
Signature:\S,Z4— \57-4,---cy-
k
Phone it: UI 1 r- S-1.3 N9 (4—\
.. .
Official use only. Do not write in this area.to be completed by thy or town official
. Cih or Town: Permit/License n
Issuing Authority(circle one):
• I. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other •.:
Contact Person: Phone 4:
"..
City of Northampton
Massachusetts
- s DEPARTMENT OF BUILDING INSPECTIONS 1
212 Main Street • Municipal Building
Northampton, MA 01060 r'A 1,,,v
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: 1
Location of Facility:
The debris will be transported by:
Name of Hauler: ) o 1\
Signature of Applicant: Date: c d-,
City of Northampton
Massachusetts x°•.f�
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building c.`
Northampton, MA 01060 4 ' ^ {10
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, (insert full legal name), born _ (insert
month, day, year), hereby depose and state the following:
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)