17A-123 (11) 330 BRIDGE RD BP-2021-1171
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A- 123 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-2021-1171
Project# JS-2021-001969
Est.Cost:$10000.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: BRUCE DUBRULE JR 069157
Lot Size(sq.ft.): 9713.88 Owner: TUCKER JONATHAN
Zoning: RI(100)/URA(100)/ Applicant: BRUCE DUBRULE JR
AT: 330 BRIDGE RD
Applicant Address: Phone: Insurance:
21 EAST BUCKLAND RD (413) 834-3331 WC
SHELBURNE FALLSMA01370ISSUED ON:4/14/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & 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:
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THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signatu �: , ' ! t
•
FeeTvpe: Date Paid: Amount:
Building 4/14/2021 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
City of Northampton
(1, ' Massachusetts
G
i x DEPARTMENT OF BUILDING INSPECTIONS yt
t 212 Main Street • Municipal Building
Northampton, MA 01060 Y....
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR NEW
1 &2 FAMILY DWELLING, ADDITIONS, POOLS, DECKS, ACCESSORY STRUCTURES,
FENCES, GROUND MOUNTED SOLAR, ETC.
I. Building Permit Application signed by legal owner and filled out by owner or authorized agent.
2. One set of plans and specifications of proposed work. (Digital and hard copy)
3. Site plan with location of proposed structure(s) and set backs.
4. Construction Debris Affidavit filled out and signed by applicant. .
5.Worker's Compensation Insurance Affidavit filled out and signed by applicant.
6. Contractors must supply a copy of CS License, HIC Registration and proof of Liability Insurance.
7. Energy Conservation Compliance Certificate (new/ replacement windows).
8. Home Owner's License Exemption Form filled out and signed by Homeowner(if applicable).
9. Note any Conservation and/or special permit requirements(if applicable).
10. Driveway Permit(if applicable).
11. Proof of Water and Sewer entry fees paid (if applicable).
12. Trench Permit-public land by DPW/private land by Building Dept.
13. Stretch Energy Code -all new construction will require a HERS Rater Affidavit to be submitted with
permit application before issuance of permit.
` .L
RECEIVE
The Commonwealth of Massachusetts
AP6 Board of Building Regulations and Standards FOR
2021 Massachusetts State Building Code,780 CMR MUNICIPALITY
USE
L -Builtiing.Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
DEPT.OF fUII DING,INSPECTIONU-
NORfH4MP1ON,tAA moho One- or Two-Family Dwelling
This Section For Official Use Only
Buildinn Permit
Number: 402-. "I( 7/
.u � er, D to A ied:
J� y-1'-1-20Z I
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address:�`_ s� 1.2 Asses,oAs lylap&Parcel Numbers'
1.1 a Is this an accepted street?yes V no Map Number /3- Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: Outside Flood Zone?
— Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP1
2.1 Owner;of Record:
JoNA-1,1loA, 7`ucktct 1=ld Ace cc it t - Ui GG)-.
Name{Print) City,State,ZIP
f l 0 6 n;4c. .sf- 415 2 3 0 to`f To N t,,c )CaA(4-5t, t-
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) 0 Addition ❑
Demolition 0 Accessory Bldg. ❑ Number of Units Other fX Specify:
Brief Description of Proposed Work': e,i p ' 17 f, I'l
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No.tal Z Check Amount Cash Amount:
6.Total Project Cost: $ /p(ODa. 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
,Q .e 44 e, License Number Expiration bate
Name of CSL Holder (.2
4- Eiv 4 /!� List CSL Type(see below)
No.and Street �- ( mi ae
Fv-1 Type Description
i� ,/L( ,o l 3)c U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 182 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
`i13 yY3) / ✓K F✓Ji`C 9-?Y9&/ 4t ) I Insulation
Telephone Email address i CO iy D Demolition
5.2 Registered Home Improvement Contractor(HIC)
1AG9-77 (// ?1a ,
(C tiS H1C Registration Number Expiration Date
Co
mpany om any Name or IiIC Registrant Name
41 6, Ac/ckttyil4j1 AE Jc 9 &tia4 ,44rl 4/
No.andStreet Email address
s /3(At& f+/( /144 0/)2e7 %/, 8'3V )
City/Town,State,ZIP Telephone
SECTION 6:WORKERS' COMPENSATION 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 0 No Nrr-
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
2-411
Print Owner's Name(Electronic Signature) Date
SECTION 7b:O Rt 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 and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(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_aovioca Information on the Construction Supervisor License can be found at www.mass.nov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (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"
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION
IKE RYARD
SIDE 'ARD Sf_E•;':,c[i
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FRONT:£IBACK
FRONTAGE
YDICATE LOCATION AND DI ME NSI ONS OF 11 OLS E GARAGE.ADDITIONS OR ACCESSORY BUILDING. 11E
SURE TO INCLUDE FRONTAGE AND LOT SIZE(SQUARE FEET OR ACRIZS)
•
t
The Commonwealth of Massachusetts
.l Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name(Business/Organization/Individual): VL 6 CEO,i/✓�S VL�T�or✓
Address: Lii-jf- 6 v o'Cf- Eve
City/State/Zip: '24? vJ2,ek i'-f 6- sue-°t 5 PPhone#: (1'j, �,3 (-/- 3)3(
Are you an employer?Check the appropriate box:
Type of project(required):
1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.piI am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.(No workers'comp.insurance required.]
9. ❑Demolition
3.01.ant a homeowner doing all work myself.[No workers'comp.insurance required.]'
10❑Building addition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 ElectricaI repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet I3.�j{Z oof repairs
These sub-contractors have employees and have workers'comp.insurance.: L�3�
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§I(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also 511 out the section below showing their workers'compensation policy information.
t Homeowners 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-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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 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 certify under the pains and penalties of perjury that the information provided above is true and
correct.
Signature: Date:
Phone#: t.) Q Y / 3-3 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#:
44 The City of Northampton
SI.or Building Department
212 Main Street
9PORATED No-‘,, Northampton, Massachusetts 01060
Phone (413) 587-1240
Fax (413) 587-1272
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVAT ION PROJECTS)
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 waste disposal facility as defined by MGL c 111, s150A.
c� �
The debris will be disposed of in: (J i¢1 r � Yy
Location of Facility
The debris will be transported by:
Name of Hauler S ' Ce",s 7
Signature of Applicant: A Date: Vl3101---(
City of Northampton
foQK�°'�rr�
�y'' Massachusetts
g 41 *
{ ` DEPARTMENT OF BUILDING INSPECTIONS a t ro
fl 212 Main Street • Municipal Building
Northampton, MA 01060 �siyyl^DO
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
•
I, (insert full Iegal name), born _ (insert
month, day,year),hereby depose and state the following:
1. I am seeking a building permit pursuant to the homeowners'exemption to the permit requirements of the
Massachusetts State Building Code, codified at 80 CMR 110.R5.1.3.1, in connection with a project or
work on a parcel of land to which I hold legal tit •.
2. I am not engaged in, and the project or work or which I am se- g the aforementioned homeowners'
exemption, does not involve the field erection • manufactured . ilh'ngs constructed in accordance with
780 CMR 110.R3.
3. I qualifij under the Sta Buz ding Code's def nitz rn of"ho owner" 's defined at 780 CMR 110.R5.1.2:
Persons) who o a p- ,cel of land on w c - ' •- resid-s or inten• o reside, on which
there is, or is intr., ded t• be, a one-or tw• -. ' dwellin• - •- -• or detached structures
accessory to suc se and or farm •tructures A p•rson who constructs more than one home in
a two-year perio shall not be cons dered a he• e ,.wner.
4. I do not hold a 'alid Massa.husett• construction ,.ervision license and, except to the extent that I
qualify for and ill abide by t • Ma sachusetts Sta • uilding Code's requirements for the supervision of
the project or ork on my pa el, /am not engage i, construction supervision in connection with any
project or w• k involving • ction, recons tion, alteration, repair, removal or demolition
involving any ►ctivity regulate' • any provision o !I • Massachusetts State Building Code.
5. If I engage a ,L. other person or persons for hire in co ection with the aforementioned project or work on
my parcel,I a knowledge that I am required to and wi act as the supervisor for said project or work.
Signed under the pains and penalties of perjury on this day of , 20 .
(Signature)