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12C-092 (3) SECTI�ONB� CONSTRUCTION SERVICES' r 8 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : — License Number Address Expiration Date Signature Telephone Not Applicable ❑ 128264 — Company Name Registration Number Roberts Roofs Inc. 3/17/2003 Address Expiration Date 3090 Palmer Rd. Bondsville MA 283-4395 01 009 Telephone SECTION I0-WORk.bS',GOMPENSATION 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....... ❑x No...... ❑ The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person(s)who own 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 homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature ....... ., tr Q�tPTO =moo Grx -� laf &NartilalI ptaii Z 9 � B 6 �aaachnsctta' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 B'ORDER'S COMPENSATION INSURANCE AFFIDAVIT I, Thomas Roberts (licenste/permittee) with a principal place of business/residence at: 3090 Palmer Rd. Bondsville, MA 01009 (phone#) 413-283-4395 (Street city/stalr/ap) do hereby certify, under the pains and penalties of perjury, that: ( I am an employer providing the following workers compensation coverage for my employees working on this job: CR Wilson 6S59UB-898x689-3-02 6127/03 (Insurance Company) (Policy Number) (Expiration Date) ( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following worker's compensation policies: (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Comparry/Poky Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (aaach add?=oml sbtet if neocnxry to include information pertaining to all ooatrncrnrs) O I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:please be aware that whilo homcowom who employ per a=to do m i ,,,,�cmstluzioo or repair work on a dwelling of not more than three units=n which the homeowner m=ats or oa the grounds appurtenant iherdo are not generally com=datd to be c mployrrs under the wozieu`s bat=on Act(GL152,ss 1(5)),application by a homeowner for a 6ccase or permit may cvidcnoo the legal status of an amp loyoc under the Workeet C.ompomatioa Act_ I undentrud that a copy of this etatccacnt may be foawnrded to the Departaxa2 of Industrial Aceid.&Oflioo of Ln5tx nee for the covaage VM cation and ttut fail=to azure coverage undcr Seaton 25A of MOL 152 can=cad to the imposition of criminal penalties ooasisiiag of a fine of up to S1,500.00 andlor imp=iso�of up to one year and civil pernit=a is the form of a Stop Work Ordtr and a fine of 5100.00..aaday tgainst tm. For depatm�use o°ly Permit Number Lot# p#---- Ma Signature of LicenseeJPermiU= ' S 3fl C TMI`K O Ni-,iN++DES �PTr �H 1O )5# 2+Y=r+ n hTit JAMaAS i',_"WS licable PRDOSEDIO P � a �iWf�. td.` �+!Y� y -0P "Y'�� 3��id�l�Fn �� :• - 3 New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: Remove existing shingles and rep] ac P wi Lh VO yr architectural shingles . Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet o If New ho lie a d�oradditiotJ to ezistifiRming, comptebeIt�ie�al—OMin : a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. _ Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Mascheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? .Yes No. Is construction within 100 yr. floodplain Yes__No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION'7a OWNERAUTHORIZATI.ON, TO'BECOMPLETED, WHEN OWNERS AGEN' YO CONI RACTOR APPLIES;FOR BUILDING PERMIT I< r , n c�/1�1 S �� _ as Owner of the subject property hereby authorize Roberts Roofs Tn _ to act on eha , in all mar rs relative to work authorized by this building permit application. ---- o n S n ure of Owner Date Thomas Roberts as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Thomas Roberts Print Name 10122/02 Signature of Owner/Agent Date vnn.ranw'aa.a.,.,...r.r,..;... .. ... .. :....... .. .:. .R.✓'MwfiT+Fi,`4✓r�uY!.Wre4Psee 'M'nT%?y4':.n._. Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW _ YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Date Issued: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property?YES _ No IF'YES, describe size, type and location: ` y t l ` Northampton Buljgi'hg Department �24,2 ain Street R om 100 Northam ton, MA 01060 w r v ptio3. 40 Fax 413-587-1272le a APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by'offtce , 1.1 Property Address: ' E F v✓ '9 v 5, .,✓� 7 Mary Jane Lane Map Loup Florence, MA 01060 -ZoneOverlayDistnct ,b Elm St. District CB District '. SECTION;2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: John and Diane Richardson _ see Name(Print) Current Mailing Address: Telephone Signature 586-6585 2.2 Authorized Agent: Roberts Roofs Inc 3090 Palmer Ed Rnndsvije --MA-0 eq Name(Print) Current Mailing Address: 413-283-4395 — Signature Telephone SECTION.'3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official Use Only completed by ermit applicant 1. Building (a)°Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5)— Check Number > This Section For Official Use Only Building Permit Number: Date Issued: Signature: Date Building Commissioner/inspector of Buildings BP-2003-0407 GIS#:r" ""5 COMMONWEALTH OF MASSACHUSETTS ap:$ :k CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:_ BUILDING PERMIT Permit# BP-2003-0407 Project# JS-2003-0692 Est. Cost: $4500.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROBERTS ROOFS INC 128264 Lot Size(sa. ft.): 10018.80 Owner: RICHARDSON JOHN W&DIANE M Zoning:URA Applicant: ROBERTS ROOFS INC AT. 7 MARY JANE LANE Applicant Address: Phone: Insurance: 3090 PALMER RD (413) 2 3-4395 Workers Compensation BONDSVILLEMA01009 ISSUED ON:10122102 0:00:00 TO PERFORM THE FOLLOWING WORK:STR I P & SHINGLE 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: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 10/22/02 0:00:00 2919 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo