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17C-265 (6) 104 NORTH MAIN ST BP-2018-1175 G1S#: COMMONWEALTH OF MASSACHUSETTS Map.Block: 17C-265 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-2018-1175 Proiectk JS-2018-002106 Est.Cost:$12000.00 Fee $70.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: BOB THIBODO ROOFING & SIDING 065699 Lot Size(sa. R.): 15071.76 Owner: COE NORMAN A&3ACKLYN A Zoning:URB(100 Applicant, BOB THIBODO ROOFING & SIDING AT: 104 NORTH MAIN ST Applicant Address: Phone., Insurance: P O BOX 201 (413) 527-7663 O WC NORTHAMPTONMA01061 ISSUED ON:5/9/2018 0:00:00 TO PERFORM THE FOLLOWING WORK:REMOVE SLATE ROOF, PLWOOD, RESHINGLE 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: FeeTvne: Date Paid: Amount: Building 5/92018 0:00:00 $70.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner h Department use only City of Northampton Status Of Permit �. Building Department Curb Cut/Drive"Permit 212 Main Street Sewer/Septic Avallablity 1 • ')��� Room 100 WatertWell Availability Northampton, MA 01060 Two Sets of Structural Plans \;. phone 413-587-1240 Fax 413-587-1272 Plot/Ste Flans Other Speafy APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Prooertv Address'. This section to be completed by office Map- Lot �i a,,'5— Unit 1 O L ( 1�1 •-�A p 1 T. I � l _ Zone Overlay District OL— ( 1 '\ 1� 1` �" Elm SL District CB District SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Nam Pdn) cument Mailing A dress:5� S S Telephone �1 Signature 2.2 Authorized Agent: � ossok CA,24 Name(Pring Cument Mailing Address: 1 � U S-15 1Gtil Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by eermit 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 Oficial Use Only Date Building Permit Numb Issued { Signa re: J B Acting C issionecinspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 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 filled m by Bonding Department Lot Size Frontage Setbacks Front Side L: It U R Rear Building Height Bldg.Square Footage -" % - - Open Space Footage (Lot.vee minus bldg&pevN _.. rkin #of Parki ng S paces Fill: (volume&Lacetion) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained Q , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO O IF YES, describe size, type and location: E. Wil the construction activity disturb(clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. r SECTION 5-DESCRIPTION OF PROPOSED WORK Icheck all applicable) New House ❑ Addition ❑ Replacement Windows Ali lon(s) ❑ Rooting Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding[Ell Other IpJ Brief L�s�nption of Proposed \ ` O sl - Work- �l =oVC ] IA 6 �S�L. %0 eo d Air Alteration of existing bedroom_Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes -No Plans Attached Roll - Sheet Ba. If New house and or addition to existing housing, 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? J. Proposed Square footage of new construction. Dimensions e. Number of stories? f Method of heating? Fireplaces or Woodsloves Number of each g. Energy Conservallon Compliance. Masscheck Energy Compliance form attached? In. Type of construction i. Is construction within 100 R. 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-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize O to act o half, in alla relative to work authorized by this building permit applicatio . Signature of 04ner Date as Owner/Authorized Agent h reby d clave 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. Print Na e 5 � Signature of Owner/Agent Da 1 SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: C�\) ( •\! i 4r Cj 1LICen 2 N Address Expishoh Dale Signature Telephone S.Re istered Home Improveontractor, Not Applicable ❑ Company Name �l\ \ Registration Number A�e. t V� �-1D. N A,�"d�res�s ��(� Expna bn Da Ra l � Telephone5l S CI (e1 SECTION 70-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6() Workers Compensation Insurance affd vit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buil Ing permit. Signed Affidavit Attached Yes....... d No...... ❑ _ City of Northampton ( Massachusetts DEPARTMENT OF BUILDINGi INSPECTIONS St 212 nein reet eMun010 Building Northamptoo !A 010n, 60 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the`reconstruction, alteration, renovation,repair, modernization, conversion, improvement, removal, demolition, or construction otan addition to any pre-existing owner-occupied building containing at least one but not more than tour dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC, that entity must be registered. Type of Work: Est Cost: Address of Work: Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): —Job under S 1,000.00 _Owner obtaining own permit (explain): _Building not owner-occupied Other (specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton 4 Massachusetts �• s DEPMTMENT OF BUILDING INSPECTIONS 212 Bain _the • Mup 010 Building y CD NortAamp[on, MA 01060 Massachusetts Residential Building Code Section 110.R5.1.2 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. Section i 1025.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. 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. City of Northampton 6 Massachusetts ._A L I DEPARTMENT OF BUILDING INSPECTIONS 3 212 Main Street •Municipal Building n„ 4 Northampton, MA 01060 hiy �1 Debris 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. The debris from construction work being performed at: I bt-1 Irl �� S4' yor " (Please print house number and street name) Is to be disposed of at V A\1 - ) �cC� C�� (Please prini name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: . o-\� ) '1�: 10 a 1&, —Z- s�.4 w. wIx S)�" 6sf y (Company Name and Address) �..� 1 Signature of Permit Applicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. r� The Commonwealth ol"Massachusetts Department oflndustrial Accidents 1 Congress Street,Suite Boston,MA 02114-2017 www.mass.goeldia US- Workers'Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. 2 licant Information Please Print Leltibly Business/Organization Natal Address: -ND�ENS City/State/Zip: Phone#: y �� s1� f C7 6---N At u an employer?Check the appropr'ate box: Business Type(required): I.u I am a employer with employees(full and/ 5. ❑Retail or Part-time).* 6. QRestaurantBar�Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 71 ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] S. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right ofeeca ption per c. 152,$1(4),and we have 10.❑Manufacturing no employees. [No workers' comp.insurance required]*' 11.❑ Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers'comp. insurance req.] 12.❑Other "Any applicant that cheeks box#I most also fill can the section below showing Meir workercompensation policy Intortmtlore "Ifthe cotpomm officers have exempaN themselves,bat the conmmtion has othm employees,a workers'compensation policy is required and such an mgamvation should check box#1. I am an employer that is providing,-workers'compensation Tsurance far my employees Below is the policy immamofion. Insurance Company Name: ham( �p���` � OY(1U Insurer's Address: City/State,'Zip: Policy#or Self-ins. Lic. O U 1j), —0 a SO N ]y �Lf—I L Expiration DOlt ater �� Attach a copy of the workers' compensation policy declaration page(showing the policy number a d expir tion date). Failure to secure coverage as required under Section 25A ofMGL c. t52 can lead to the imposition of criminal penalties of a fine op to$1,500.00 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify,, under thepains and penalties u perjury that the information proval d above is true and correct Signatumd L=4_(-, Date: SA 9A\ Phone# LF 1"ll, S1S 1 CI L, ­,, 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): L Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www mass.goddla / Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written" An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership.association or other legal entity,employing employees. However,the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, constmetion or repair work on such dwelling house or an the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer" MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states`Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements ofthis chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply your insurance company's name,address and phone number along with a certificate of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom ofthe affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be are to fill in the permit license number which will be used as a reference number.In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 www.mass.gov/dia Form aevieed 02-13-15