17C-201 (8) i
5 BRATTON CT BP-2020-0215
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map-Block: 17C-201CITY OF NORTHAMPTON
,
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2020-0215
Project# JS-2020-000358'
Est. Cost: $8000.00
Fee: $80.00 PERMISSION IS HEREBY GRANTTD TO:
Const.Class: Contractor: License:
Use Group: JAMES ROBERTS 99404
Lot Size(sq.ft.): 10367.28 Owner: PALUMBO LISA M&GREGORY ERAMO
Zoning: GB(100)/ Applicant: JAMES ROBERTS
AT. 5 BRATTON CT
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTON MAO 1027 ISSUED ON:8/28/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
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Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
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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 8/28%21019 0:00:00 $80.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
RECEIVED
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The Commonwealth ofh4assacl usett AUG 2
Board of Building Regulations and tand rds �I 2��9 F R
Massachusetts State Building Code, 780 MR LITY
M IC A.
' I U E
Butldrng Permit Applrcar tion To Construct Re air Reno �i�J i&lSaEC i �ggised far•2011
P � HAMPTON MAO 10 0
Orae- or Two-Family Dtvelling
This Section For Official Use Only -
Building Permit Number: I ~ Date Applied:
B ing Oficial(Print Name) Signature
SEC : SITE INFORMATION
1.1 Propert cess: I 1.2 Assessors Map&Parcel Numbers
i� r�_ X01
1.1 a Is-this an accepted street?yes no elz Map umber Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
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Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Pard
Required --Provided Required Provided Required Provided
1.6 Water SuPP 13 04.G.L c.40,1§554) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal 0 On site disposal system ❑
Public❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O�� err o f/Reco
szOO
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N (Pr.in City,State,ZIP
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No.and treet Telephone Email Address
SECTION 3�, DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repair•s(s) ❑ Aleration(s) ❑ Addition ❑
Demolition ❑ AccessoryBldg. ❑ Number of Units Other Specify :
Brief Description of Proposed Work2:
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SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Lab _ nd Materials)
1. Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
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5.Mechanical (Fire $ Total
All F
Suppression) N �
AmCheckCCash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 _Con truction Supervisor L' e se(CSL)
License Number Expiration Date
Name C L I lolde G
List CSL Type(see below)
No.and Street Type Description
1. U Unrest•ictedl(Buildings up to 35,000 cu,ft.)
_� R Restricted 1&2 FamilyDNvelling
City/Town, State,Z P Masonry
Roofing Coi'ering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation I
Tele honeEmail address D Demolition
1�25.2 r d Home Improven Contractor(HIC) •—c j�
IC Refiistrati6n Number Expiration Date
HI Com n Name or HIC Name. .
No.and Street Email address
City/Town, State,ZIP Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(R'I.G.L,c. 152.§ 25C(6))
Worlcers 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...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BU DING PERMIT
1,as Owner of the subject property,hereby authorize
to act on m behalf, in all i ers relative to work authori by this building permit application.
Print vner'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 perjury that all of the information
contained in this application is�true d accurate to the best of my knowledge and understanding.
Print Ow ei s or Authorized n s lame(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 not 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.) f (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"
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The City of Easthampton
Building Department
50 Payson Avenue
co9p�RA1En dU����' Easthampton, Massachusetts 01027
Phone (413) 529-1402
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Fax(413) 529-1433
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
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In accordance with the provisions of MGL c40, s54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed wasteldisposal facility as defined by MGL c 111,s150A!
The debris will be disposed of in:
Location of Facility
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The debris will be transported by:
Name of Hauler
nature of A licant', Date: �
Sig pP
¢ y
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The C6177111otrlvealth ofAlassachuseffs
Department of IndustrialAccidents
1 Catrgress Streef,Suite 100
Boston,JIM 02114-2017
i9ly mnass.govIdia
v�IVcirkers'Compensation Insurance Affidavit:Builders/Conti•actat•s/Electricians/Plumbers.
TO BE TILED A'1'ITH THE PERMITTIi\'G AL'TIIOR1Tv.
A>>licant Information, Please Print LeQihly
Name (Business/Organizatioiitlndividual):
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Address:
City/State/Zip: Phone#: r
Are you sin employer?Check t se appropriate box: Type of project(required):
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I.❑1 am a em foyer with employees(full and/or part-time).* 7. ❑New eonstt action
2. - I a sole proprietor or partnership and have no employees working far me in S. Remodeling
any capacity.[No workers'comp.linsurance required.] 9, ❑Demolition
3.O I am a homeowner doing all work!myself.[No workers'comp.insurance required.]t
l0�Building addition
4.❑I am a homewkner and will be hiring contractors to conduct all work on my property. I will I0 F1 Electrical repairs or additions
ensure that all contractors either have workers'compensation insurance or are sole
proprietors with no employees. 12.Q Plumbing repairs or additions
5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13, ]Roof repair's
These sub-contractors have employees and have workers'comp.insurance)
14.[:]Other
6.Q We are a corporation and its officers have exercised their right of exemption per MGL c.
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information.
I Homeo-,vmers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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-contractors have.eniployces,they must provide their workers'comp.policy number.
I ani an eniplgper that is providing workers'compensation insurance for ml�entpinl'ees. Beloit,is the policy and job site
inforination.
Insurance Company Name:
Policy 4 or Self-ins.Lic.#: \ Expiration Date:
Job Site Address: City/State/Zip:l
Attach a copy of the-ivorlcers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required wider MGL c. 152,§25A is a criminal violation punislia'Ule by a fine up to$1,SOO.OD
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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cel ' t under the parris and p Iti of erjrn;p t at the information provided ove is tr re and co Ilett.
Date:
Sianature:
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Phone#:
Official arse only. Do not invite in this area, to be completed by city or tonirl offrcial.
City or Town. Permit/License#
Issuing Authority((circle ow):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6. Other
Contact Person: Phone
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ti� l?T(tp., The City of Easthampton
Building Departinbilt
t �l hhii 50 Payson Avenue
��P�RAiEOJUUE1� Easthampton,Massachusetts 01027
Phone(413)529-1402
Fax(413)529-1433
HOMEOWNERS' EXEMPTION ELIGIBILITY AFFIDAVIT
I (fid]legal name),born
(rionth,day,year),hereby depose and state the following:
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1. I am seeking a building permit pursuant to the homeowners' exemption to the permit
requirements of tlpe Massachusetts State Building Code,codified at 780 CMR I IO.R5.1.3.1,in
connection with a project or work on a parcel of land to which I hold legal title.
2. I all,not engaged in, and the project or work for which I all,seeking the aforementioned
homeowners' exemption, does not involve the field erection of manufactured buildings
constructed in accordance with 780 CMR 110.83.
3. 1 qualify under the State Building Code's definition of"homeowner"asi defined at 780 CMR
I I O.R5.1.2:
Person(s)who owns 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 tw,o-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 b'e considered a home owner.
4. I do not hold a valid Massachusetts construction supervision license and,except to the extent that
I qualify for and will abide by the Massachusetts State Building Code's requirements for the
supervision of the project or work on my parcel,I am not engaged in construction supervision in
connection with any project or work involving construction,reconstrueltron,alteration,repair,
removal or demolition involving any activity regulated by any provision of the Massachusetts
State Building Code.
5. If I engage any other person or persons for hire in connection with the aforementioned project or
work on my parcel,I acknowledge that I am required to and will act as,the supervisor for said
project or work.
Signed under the paills arad penalties of perjury on this day of ,20_
(signature)