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24A-190 BP-2023-0566 29 JACKSON ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 24A-190-001 CITY OF NORTHAMPTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGI.TERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARA TY FUND (MGL c.142A) BUILDING PI RMIT Permit # BP-2023-0566 PERMISSIO IS HEREBY GRANTED TO: Project# ROOFING 2023 Contractor: License: Est. Cost: 7200 DAVE LALIBERTE 050099 Const.Class: Exp.Date: 04/02/202' Use Group: Owner: BER .TEIN CAROLYN J&JOSHUA A NEWMAN Lot Size (sq.ft.) Zoning: URB Applicant: LALIB RTE BUILDERS Applicant Address Phone: Insurance: 11 BERWIN ST (413)695-3578 SOUTH HADLEY, MA 01075 ISSUED ON: 05/04/2023 TO PERFORM THE FOLLOWING WORK: REPLACE ROOFING 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: 14 • j' Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner r- RECEIV ^ . The Commonwealth of Massac usetts MAY — 3 2023 OR Board of Building Regulations and Stan rds MUNIICIPALI CI' Massachusetts State Building Code 780 OAR __ DEPT.OP BUILDING INSPECTIO !USE Building Permit Application To Construct,Repair,.RenQv_ f&ID AD 1 lnlisknoso Revised Mar 2011 One-or Two-Family Dwelling �T This Section For Official Use Only Building Permit Number: NO• A -..,L(,tp_ Date Applied: 5-1 WO Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address• 1.2 Assessors Map& Parcel Numbers 1.1 a 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: 18 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 Illivnerl Qf s lr VUC Record: tU e,u ai \ ©'� �cA vv ,)*OVA. M, Name(Print) City,State,ZIP o�°I ci',,c, dv1 S Lid 1 - 5-7 S11 ©1 nr•ac,a ,MTh No.and Street Telephone Em A ss SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building❑ Owner-Occupied 0 Repairs(s)'l. Alteration(s) 0 Addition D Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': r p L o—C.-e o o A/N SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ "7 v U 1. 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: $ Check No.13(0I Check Amount: Cash Amount: 6.Total Project Cost: $ '(--"Do Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 71 eek, ���al� Licensebe Number Expiration Date Name of CSL Holder S I \ 4061:0 List CSL Type(see below) No.and Stree r�J� Type Description (�. 0 b s3 Unrestricted(Buildings up to 35,000 cu.ft.) u �J \ R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding aa2.—w'110 ], l SF Solid Fuel Burning Appliances L7U\ Q,{� I Insulation Telephone Email address yy�p�� � JC D Demolition 5.2 Re Iis red Home ImprovementConttraacctor C) /&�/' i't la3e " S y'— HIC Registration Number Expiration ate 1 l Company •2`C ame l�or Fist e 1 r 601'Alec � � >� U � 'I • o.an tree l ' Email address tree 0L075 13 6a S 35`1g 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 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 authorizeLA.,' I ' k ``1 t. 11.(`eiA3 (_ to act on my behalf,in all matters relative . wo k authorized by this building permit application. Joshua KIEwrw►�1 �+ :ivl S fz/2nz3 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 perjLry that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. 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 nvt 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" City of Northampton _ Massachusetts _ c',, ,( * � RI :41DEPARTMENT OF BUILDING INSPECTIONS �' 212 Main Street • Municipal Building � Northampton, MA 01060 'PS 3'` 0 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: The debris will be transported by: Name of Hauler: 4 r - /Lea 1 t-- Sd Li-)-00, Signature of Applicant: Date: 0 Lp��� The Commonwealth of Massachusetts ii.,,,- �. t Department of Industrial Accidents — i 1 Congress Street,Suite 100 '' _ Boston,MA 02114-2017 r, a't;♦k www masx.gov/dia 11 urkers'Compensation Insurance Affidavit:Builders Contractors/I cctricians/Plumb ers. -fu HE FILED WITH THt:rERMrrrIM:Al THORIT'f. AnDlicani Information ('� Please Print Let ihfv° Name tHostress"tln;antrattottilndtvidual): �.C�,l\ \emu k ,ok,)I S T'}'c Address: R C.. .-e\c- Sk E.,* City/State/ZipSVk"kR x71 iAA 0IC)7S Phone#: Lt l 3 CLS"3S7� Ate yea err empknrr"Cheek the appropriate bus: Type of project(required): i,g I am a employer with 3 employees(full minim part-tirnek+ 7. 0 New construction 20 i am a sole proprietor or partnership and have no cntpkwct-s working forme in 8. 0 Remodeling any capacity_[Nu workers'coop.insurance required.] 9. ❑ Demolition 30 h am a humans:l a doing all work myself.[No workers'Pomp.insurance refit in.-d. " 4.0 I ama dumrcownea and will be hiring to mraciursto conduct all work on my property. I will 10 0 Building addition ensure that all contractors either Lune workers'compensation insurance or am sole 110 Electrical repairs or additions pntprictarrs with no employees. 12.0 Plumbing repair or additions S.0I ant a general cemtractur and I have hired the sub-contractor,listed on the arched sheet. 13rWtoof repairs These sub-euntractort have employees and have workers'comp.insurance.: 6.0 We area corporation and its officers have excnciscd their right of exemption per ltleiL c. I4. Other 152.¢1(4),and we have no unployecs.[No workers'comp.insurance required.] *Any applicant that chocks bus;Ti must also fill out dr section below showing their w urkers'compensation policy information_ +Iluaw mwuers who submit this affidavit indicating they arc doing all work and then him outside contractors must submit a new affi lase it indicating such. teentr-actua that cheek this box must attached an additional sheet shownnn tlx namnc of doe sub-contractors and%talc whether or not loose entities have employees. tithe sub-contractors Imasc employ they must provide their workers'comp.policy number. l am an employer that is providing workers'compensation insurance for mom employees. Below is the policy and job site information. Insurance Company Name: i_ et S t w if`J t[..e p G j_ Policy#or Self-ins Lie.#: D OO l UJ , 1 Expiration Date: 5 1`'25 .L Job Site Address: .. 9 3 0.....C.k%0v1 St City/StatefZip:4) I -Q/ iZ i Illn' Attach a copy of the workers'compensation policy declaration page(showing the policy number and expire n date). Failure to secure coverage as required under MGL c. 152,(R5A is a criminal viplation punishable by a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine 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 coverage verification. l do hereby c - .under the pains and penalties of perjury that the information provided above is true and correct Signature: C4.���-f Ael)/ Date: S Phone#: Lf ii h 9 S J 5 e7 D Official use only. Do not write in this area,to be completed by city or town ofeiaL City or Town: PermitfLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Instructor 6.Other Contact Person: Phone#: