10B-035 (2) 7 UPLAND RD BP-2017-0586
G15#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block: 10B-035 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2017-0586
Project# JS-2017-000949
Est. Cost: $7680.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Grouo: BOB THIBODO ROOFING & SIDING 065699
Lot Sizc(sq. ft.): 30448.44 Owner: ROCKETT THOMAS K&ELLEN E
Zoning: URA(100)/ Applicant: BOB THIBODO ROOFING & SIDING
AT: 7 UPLAND RD
Applicant Address: Phone: Insurance:
P O BOX 201 (413) 527-7663 0 WC
NORTHAMPTONMA01061 ISSUED ON:10/27/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE MAIN HOUSE ROOF, RESHINGLE
WITH NEW
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: O1: 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:
FeeTvpe: Date Paid: Amount:
Building 10/27/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Deoartnen.use only-
i -----T—Crhj of Northampton sta;c=of Perrot _
cul dlf g D ails Eli Curb CU Druef y Permit
i WI 26 212 Mar Street Sewern plc vaT Dill,
°C Room 100 WaterWeil Availability
/41h m+ton MA 01060m0S forutua Pans
,° PTi6tTsfia3-55Fax 413-587-1272 Plot/Site Plan
Oto t_Sc sT v
APPLICATION TOCONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO. FAMILY DWELLING
SECTION 1 -SITE INFORMATION 6v— 17 fj- 6—S76,
1.1 Prooemr Address. t ms section to be completed by office
^` ' ,,^, Mop - Lo: Unit
t up 1G,N'r�\� -Zone Overlay District
-Elm St D st ct - CS Distract
SECTION 2-PROPERTY OWNERSMP]AUTHORIZED AGENT
2.1 Owner of Record:
Name(P IOt Current Neal Log Address =1
St0
eegbane
Signature
2.2 Authorized A t:
Name(Print) Current Man no Address.
S1 S Ic1 (, l
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item I Estimated Cost(Dollars)to be Official Use Only
completed by permit aooiicant
1. Building j (a) Suilding Permit Fee
2. Electrical I (b) Estimated Tota!Cost of F
Construction from (6)
3. Plumbing I Building Permit Fee
4. Mechanical(HVAC)
5. Eire Protection
E Total=(1 +2+3+4+5) I 7.E1 I,Check Number /13Y #::(0) This Section For Official Use Only
Date
Buildino Permit Number Issued:
Signatura: ///,i%%�%j .��� �� -a���
Building Commis inner/Inspector of Buildings Dale
&rnai/ de
Section 4. ZONING I AU Information Must Be Completedgerm t Gar Be De-Ted Due Tc Incomplete Information
Existing I Proposed I Required by Zoning
tis column to be tined in by
1 I Building Deparmer..r
Lot Size .._,...,. ,
Frontage _. __. _ __I:.— .
Setbacks Front _>__.,
Side
Rear _ -
BuildingHeight _. "— '_._>
Bldg. Square Footage I m — w .�_•
•_.._.
Optin Space Footage
FYe 1 parkin )
area rocs bid er
&pay
Of Parking Spaces
I
(College&Locaoci �'..._ _.< L...... . ...... �. >... ,. >'�
Has a Specia Permit/Variance/Finding ever been issued for/on the site?
rb
NO DONT KNOW 0 YES 0
IF YES, date issued:. -
IF YES: Was the permit recorded at the Registry of Deeds? I
NO 0 DON'T KNOW 0 YES 0 _ -
IF YES: en'er Book — _ Page . and/or Document I
B. Does the site contain a brook, body of water or wetland=_? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES CD NO Q
P YES, describe size, type and location:
D. Are there any proposed Ganges to or additions of signs intended for the property? YES 0 ' NO 0
IF YES, describe size, type and Location:
Will the construction activity disturb(clearing, grading excavation, or fillip )over 1 acre.orr is it pati of a common plan
that will disturb over 1 acre? YES 0 NO O
IF YES,then a Northampton Storm Water Management Permit tram the DPW is required.
•
it I
SECTION!G-DESCRIPTIOP OF PROPOSED WORK(check all agpiicable)
New House ❑ Addition J Replacement Windows Altlratic.fa) f Roofing
Or Doors r
Accessory Eidg. ❑ Demolition E New Signs fo3 Decks !CI Siding WI Other ICI
Brief ley�,G[iptionofProposed
Work. \"'Zin )vie( alp YXNh\w 1,1 \T-P rh \ \K 5 —^-�` 'LS \
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement .,,,_Yes „__No
Plans.Attached Rad -Sheet
self New house and or addition to exisftna housna„ comafete the tonow na:
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 hwtage of new construction, Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each F
S Energy Conservation Compliance, M^asscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 P. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
I. Depth of basement or cellar floor below finished grade
k. Wlllbuilding conform to the Building and Zoning regulations? Yes No .
I. Septic Tank_ City Sewer Private well City water Supply
SECTION is•OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, A IVY cV-ti ,as Owner of the subject
proPeriy �_
hereby authorize r 7u ) n k()
to act on my behalf, i. -II aders relative to work authorized by this building per -t applicatio i.
Z...ji ' A a, . k 'o
Signal.e of Owner Date
1, - ' ,R 11V\Ob V7 ,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.
Sig der th sins and e cities cif ped iry.
a _I' 'b U
?tin e
IL \ I�, v C' `Xv 10
Signature of Own. /Agent Dat
SECTION 6-CONSTRUCTION SERVICES t
8.5 Licansea Constmation lluneralsors it,tt0Applcable £/'
License Number
/ �� -� \
Arc ress p,rat, Gare
S.nature Telephone
9. Registered Horne lmurovement Contractor Not Applicable E
Com.apv Name
1 Re'Ix;rot Number
Address Expiration Dat_
-..- = — _— Telephone - e
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
W orlers Compensation Insurance affidavit must be completed and submittedapplication.
� e 8 with th�sa lic2fion. Failure to provide this affidavit will result
in the
enia
o
the issuance
V
I—Signed Affidavit Attached Yes
th be iidina permitNo ^
11. — biome Owner Exemption
The curent exemption for"homeowners"was extended to include Owner-occupied Dwellinas of one(I) or two(2)families
and to allow such homeowter to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor,CNLR 780. Sixth Edition Section 108 3.5,L
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 he considered a homeowner.
Such'homeowner"shall submit to the Building Official,on a form acceptable to the Building Official.that he/she shall h,e
responsible for all such work performed under the boldin?Hermit
As acting Construction Supervisor your presence on the job.site will be required tom 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 injnnes notresulting in Beath)of the Massachusetts General Laws Annotated,you may he 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 Sate Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
Tine Co smon—we: r of ✓'c'.ssw e' e-.,,
DepanMeNt3a w y.., x,.sAcc..: e s
- 660 Washixgton Street
? Boson,, to r•A 62..;.i.
0.
Workers Compersa:TCYt limmeramie c cdaatu,. Emii4ersi oto mtea t iEiece.ixlam /ri mthers
Annfca5t Information ation 'Please Print Taegu
Name (Business/Orga;izationnhddiijviduaf: C^`ti� t ?ita )
Address: v
e--
Ci /State/Zip: Phone 4: s crJ
Ar- you an employer? Cheek the appropriate box: Type of project(required):
1. V` I am a employer with k 4. I am a gen:ral contractor and I iNto
6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
2._) I trio a sole proprietor or partner- listed on the attached sheet, 7. 0Remodeling
ship and have no employees These sub-contractors have S. [ Demolition
working for me in any capacity. employees and have workers' 9. — Building addition
[No workers' comp. insurance comp. insurance. —
required] 5. d We are a corporation and its 10.0 Electrical repairs or additions
3._ I am a homeowner doing all work officers have exercised their I l.F Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MOL 12.[ Roof repairs
insurance required.] i c. 152, §1(4), and we have no
employees. [No workers' 13.H Other
comp.insurance required.]
*Any applicam Nat checks box bl must also fill out the section below showing their workers compensation policy information.
°Ho
meowners who submit this aftdavit vdioating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached en 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'camp.policy number.
.1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: p e \\ es • t♦Zl
Policy#or Self-ins. Lie.4: h )yy yn733 Z?„}s7G Tt `-4 C‘ Expiration Date 17-1k f cc
Job Site Address: ��
' V +}*\ A e���� City/state/Zip: � e-E'Xs IN J
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,c. 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 fee
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 DLA for insurance coverage verification.
1 do hereby cerh5 under the •sins and penalties of perjury that the information provided 'bine is ir.e and correct.
SiLmature: _♦ .A. ' • ,,, Date: •
Phone#: -..._ S . l • G
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):
7. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone 6:
h -qr . . CCS
212 Main
.r
Street 0 MuH ng�
Northampton, 012e2
1NSPECTON
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOW OWNER FXFDUTION 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 dwell/no, 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
foundationlfootines (before backfill. sonotube holes (before Dour). a rough building inspection I
(before work is concealed). insulation inspection (if required) and a final buiidino 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
its of Northampt.o*_. 212 Main Streets Norfinfrapron, MA 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 150,-'f.
Address of the work: f ti� c�
The debris will be transported by: ` o3 \ bo kro
The debris will be received by:V q\Ve tfr,\ eC,V�. v1n
r
Building perit number: _ 1
Name of Permit Applicant Z „)\,,s3 "
vo\a- 1\1e
Date Signature of Permit Applicant