23D-199 (2) 59 NONOTUCK ST BP-2016-1538
GB COMMONWEALTH OF MASSACHUSETTS
Mgp:Block:23D- 199 CITY OF NORTHAMPTON
Lot:-00 I
Permit: Building
Cdteuorv; ROOF BUILDING PERMIT
Permit# BP-2016-1538
Protect JS-2016-002619
Est. Cost:56640.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: BOB THIBODO ROOFING & SIDING_
Lot Size(sq. ft.): 12022.56 Owner: CLARK DAVID M
Zoning,: LIRB(100)/ Applicant: BOB THIBODO ROOFING &SIDING
AT: 59 NONOTUCK ST
Applicant Address: Phone: Insurance:
P 0 BOX 201 (413) 527-7663 O
N O RT NAM PTO N MA01061 ISSUED ON:6/27/2016 0:00:00
TO PERFORM THE FOLLOWING WORIK:Strip roof on house and garage then install asphalt
shingles
POST THIS CARD SO rr IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.N. 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: FeeType:
Date Paid: Amount:
Building 6/27/20160:00:00 $4000
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck-Building Commissioner
Department use only
City of Northampton Status of Permit
Building Department Curb Cut/Driveway Permit
212 Main Street SewerfSecUcAvaiabtiity
Room 100 WaterM+ell Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 PIottSrte Plans
(Other Speofy
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 •SITE INFORMATION
it Property Address. This section to be completed by office
Map Lot Unit
59 Nor\ c K s--t-
Znne Overlay District
Elm St.District - CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
\OsAC \ Prreccl 1Lc�vst
Name(Po.' \ Current Mailing Address: c 'c 4.3L('-,
X v Telephone
Signatur •
2.2 Authorized Aaent:
a U \ '\ +o b 'r .. .p\ -}-1/4a 1 Nur-\-\a - k u--
Name(Phot) Current Malang Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Emanated Cost(Otters/to be Official Use Only
completed by permit apoiicent
1. Buliding (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee L/
... ...... -t °
4. Mechanical(HVAC)
5. Fire Protection t
5. Total=(i +2+3+A+5) Vk� 1L.-?Le 0 ,Check Number /7,5
7_ This Section For Official Use Only
te
Building Permit Number Issu
�/�/� ISSU2d. / a�^7 �/�(''
Signature: d r- y) -5 %U
Building Commissioner/Inspector of Buildings Date
Y
Section 4. ZONING All Information Must Be Completed, Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filed in by
Building Department
Idol Size
Frontage
Setbacks From
Side
Rear .. _..
Building Heigh[
Bldg.Square Footage
Open Space Footage 96 —.
(Lot area - us bldg&pa'ved _
nankin
P of Paridna Spaces -_. __.. ._.
"otmi &cooarioni
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Re`�gistry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document#
E. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW a YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained (9 , Date Issued:
..... .. _ .. ..... .....
C, Do any signs exist on the property? YES a No p
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and tocation:
E. Will:he construction activity disturb(creating, grading, excavation, or rating)over t acre or it part of a common plan
that will disturb over 1 acre? YES fl NO 0
IF YES,then a Northampton Storm Water Management Perrot from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Windows Altoraiicns) Roofing
Or Doors 1:1)
Accessory Bldg. ❑ Demolition ❑ New Signs 101 Decks I[] Siding[0] Other ID]
Brief D cription of Proposed C
Work. -CNnahJ-C Em" Nta1. Sssrmsc ac w. %c un -'�' G YQ{i�C tilt'�
Alteration of existing bedroom Yes No Adding ne bedroom Yes No q"< S\t'x
Attached Narrative Renovating unfinished basement Yes
Plans Attached Roll -Sheet
Ba. if New house and or addition to existino hous€na,complete the following:
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?
t. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck 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 Fear 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 -OWNER AUTHORIZATION-TO SE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, ew'� \Pe`�\+. ,as Owner of the subject
property r�
hereby authorize Owl? b 6
to act onm`half,fn all matters r
ICo work authorised by this building permit application-
. � . 4
Signature 0s_...r Date .^.
l � Q }
nv rl nye „ as Owner/Authorisedmyknowledge
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.
0m \90 Azb
Print Name
Lcia
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8A Licensed Constructiontionsor
Supervisor: Not Applliicable(' b£( p
Name of License Holder's \- p$ \ Y�\�'t b (1 b_�L 1 C\
License Number
S CeeLQ. .1 (‘ (ug\' )1' SIGN \ s—v.. t'M (e ''.-3 k`1
Address xplration Date
10, i _: 5n5' .1Cjto~
Signature Telephone
9:Registered Home Improvement Contractor. _. . Not Applicants £
CP7 ""'CC\")k a \lc+ ... ASS' xi—n-.
Company Name Registration Number
`
Address Expi ntDate
_�y (�,.�-�('� �T Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c.152, §25C(61)
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 Ye r Ne...... £
H. Home Owner Exemption
The current exemption for"homeowners'was extended to include Owner-occupied Dwellings of one(I) or twe(2) flimilies
and to allow such homeowner to engage an otdividual 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,oris intended to be,a one or two family dwelling,attached or detached structures accessory,to such use and/or faros
structures.A person who constructs mare than one home in a two-year period shall not he 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 buildinu 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. F
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,xnu 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,
The Camenerwealeh ofMasswk se is
I'._-.-.. sts
Depa' ee:1 rl kedheleid Acei:ier s
J Y Office affnt estigaiions
PiNeee, '"-; 600 Washington 53reel
12esteh, MA 02111
--t;�% twee waelesr,.gevtdia
Workers' Compensation Emmen-mice Afildavft: N minders/Contractors/El t e:sns/Plrm"cers
Atnnnncant Infornnatdors �--�� Please Pr;nt Iregnbh
Name(Business/Organizatiotrjndicidual): yY a} (� y� d\$J
Address: `3).EFS1Cy k`r Q\e- Sk
p
City/State/Zi : r'a5 '< vCW k % v ' Phone#: J S (<71
Are ou an employer?Check the appropriate box:
Type of project (required):
1. I am a employer with
4. I am a general contractor and I
employees (full and/or part-time)." have hired the sub-contractors (' New construction
2._i I am a.sole proprietor or partner- listed on the attached sheet. 7. 11 Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers'
comp. insuranee.t S. ❑ Building addition
[No workers' comp. insurance
required.] 5. D We are a corporation and its 10. Electrical repairs or additions
3.n I am a homeowner doing all work officers have exercised their 19 lumbing repairs or additions
myself No workers' comp. right of exemption per MGL 12 [Roof t 152, 1s4) repairs
insurance required.] §c, ,and we have no
employees. [No workers' 13.] Other
comp.insurance required,]
"Any applicant that checks box e l must also fill out the section below showing their workers'compensation policy information.
tklo meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contactors have employees,they must provide their workers'comp.policy number.
lain an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. \
Insurance Company NameTTtr \-}a.rY�r ,4__
Policy#orSelfins.Lie. #:(DSC.b•-)9) Oa S ON I ti Cl Expiration Date: 3
S
Job Site Address: 5 Il o'tlL
_a v c IS. R,�- City/state/Zip: ha��s'- ir.
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 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, Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cern)"under the pains and penalties of perjury that the information provided above is true and correct
Signature: C . �#+^+1.7-inN Date: C-rico
Phone#: Sfl S t C1,-1
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 Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
r
City of Northartton
7:5qk JII;
Massachusetts S<
DE2-nalrCNT. of avizziNG IDIS7ECTZ2111.5 1/41>: )
212 M Street n Municipal Buil 'am .
a th MA 0116D h.
INSPECTOR
Louis Hasbrouck Chuck Miter
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. The state defines "Homeowner"as, " Person(s) who owns a parcel on which
he/she resides or intends 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."
The building department for the City of Northampton wants any person(s) who seek to use the home
owner exemption, to act as their own construction supervisor,to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages, which include
foundation/footinas (before backfill), sonotube holes (before pour), a rough building inspection
(before work is concealed). insulation inspection (if reauired) and a final buildina inspection.
The building department requires these inspections before the work is concealed, failure to secure
these inspections can result in failure to obtain a certificate of occupancy until the work can be
inspected. •
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspections are made
understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
City of Northampton 212 Main Street, Northampton, :NIA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: S S ono+u c \c c N u rk-lbwe thr
The debris will be transported by: 01; g,\) a
The debris will be received by: AI c,,A\CL,\ 9 Gw\ (.\j rPry0Th
-e-
Building permit number:
Sfi, � k
Name of Permit Applicant a 1 l l D a
Date Signature of Permit Applicant