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11C-071 (6) 110 FLORENCE ST COMMONWEALTH OF MASSACHUSETTS BP-2021-1884 Map:Block:Lot: 11 C-071- 001 CITY OF NORTHAMPTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED'CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2021-1884 PERMISSION IS HEREBY GRANTED TO: Project# window doors Contractor: License: Est. Cost: 28000 RANDALL ROBERTS 042573 Const.Class: Exp.Date:08/25/2022 Use Group: Owner: SANGER KIRK&KARYN R NELSON Lot Size (sq.ft.) Zoning: URA Applicant: RANDALL ROBERTS Applicant Address Phone: Insurance: 41 HEMENWAY RD (413)530-2703 O WWC349926 LEVERETT, MA 01054 ISSUED ON:09/16/2021 TO PERFORM THE FOLLOWING WORK: 13 REPLACEMENT WINDOWS, 2 PATIO SLIDERS, 2 EXTERIOR DOORS 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. Signature: yQ '1 • II Fees Paid: $40.00 212 Main Street,Phone(413) 587-1240,Fax:(413)587-1272 Office of the Building Commissioner E' c Fi 1/ 1Z, The Commonwealth of Mass. husw Sep �� Board of Building Regulations d St• dards , OR V Massachusetts State Building *de, 9:1 o� ' USE _ • N © �Oc�1 Building Permit Application To Construct,Repair, ' - °• is 1 olish a R, ised Mar 2011 One- or Two-Family Dwelling n °4 Mq o� � Thiss Sf ct'on For Official Use Only $ Building Permit Number: 3 .Lt'C l 0 V Date Applied: 4., zs ./7z q- 15-ZOZ I Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Prope Address: 1.2 Assessors Map&Parcel Numbers I/O J/lorrn�e Rd) Leeds 1.1 a Ts this an accepted street?yes no Map Number 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 CI Municipal_ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP'/' 2.1te erliopRepand:etk -7 Gt� / I© `0 r.e." L a �� Name(Print) �.J City,State,ZIP L.G Cj 644 r IBC $ . e r @,0 me l No.and Street Telephone Email Address -•G0 14 SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 2" Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. ❑ Number of Units Other 0 Specify: Brief Description of Proposed Work2: Rem Remaly& /3 W, 5 I Q o SI fei -r ci car_5 Ktof esc.4er-r or VI.% g 0 ^ 114 L V b..26 r m b#Dole- ( - lief t es' . e i. 2.4$ 6i-k SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 2 S Oaot'8la$uilding Permit Fee: $ Indicate how fee is determined: 2.Electrical $ J CIStandard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) tal All Fe s: (,� eck No-V Check Amount: `° Cash Amount: 6.Total Project Cost: $2.,e3) ODD ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 042573 08/25/2022 Randall E Roberts License Number Expiration Date Name of CSL Holder List CSL Type(see below) U 41 Hemenway Rd No.and Street Type Description Leverett, MA 01054 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 413-530-2703 robertsgc@juno.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 104873 07/24/2022 Randall E Roberts General Contractor HE Registration Number Expiration Date HIC Company Name or HIC Registrant Name 41 Hemenway Rd robertsgc@juno.com No.and Street Email address Leverett,MA 01054 413-530-2703 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 Issuaance of the building permit. Signed Affidavit Attached? Yes ..........HI No 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMI I,as Owner of the subject property,hereby authorize It' 4 !!1bllLl74S' to act on behalf,in all matters relative to work authorized by this building permit application. l �IrK S,p���. //��/ Z'z/ Print er's N lectronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering i r• name below,I hereby attest under the pains and penalties of perjury that all of the information contained thi a• •lication is true and accurate to the best of my knowledge and understanding. 'a C' ! z Print( er's o • 1 i onzed Agen,Name(Electronic Signature) e NOTES: 1. ' n Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor of 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.) (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" _� The Commonwealth of Massachusetts I Department of Industrial Accidents 'VI. 1 Congress Street,Suite 100 I- _ 1f_ Boston,MA 02114-2017 _7. i www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Randall E Roberts DBA Window Works Address:321 Russell ST City/State/Zip:Hadley, MA 01035 Phone #:413-530-2703 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 6 employees(full and/or part-time).* 7. ✓❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ✓❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 9. El Demolition 10 0 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 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box#1 must also fill 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. 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 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:Wesco Insurance Company Policy#or Self-ins.Lic.#:WWC3492926 Expiration Date: 10/19/2021 Job Site Address: All Locations 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 verificati I do hereby c ' un r t gins and penalties of perjury that the information provided abov is true an correct Signature: Date: 15 Z/ Phone#: 41 -530-2703 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#: City of Northampton 4-%. Massachusetts a�NIS - �'<< i,!( i ,• ,` DEPARTMENT OF BUILDING INSPECTIONS S, a et l�.''4r, 46 212 Main Street • Municipal Building �ti Ca )ioy .-4 Northampton, MA 01060 'rsbyi; ‘^� CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, 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, S 150A. The debris will be disposed of in: Location of Facility: Qq-5 Barne* Rd) ahict toe MA' MA' The debris will be transported by: Name of Hauler: �eLLIAiC, 4)81\J ices 114/ 9l Z. )Si nature of Applicant: 1 Date: g pp Commonwealth o• Massachusetts Division of Pratesatonat Licensure Board of Sundwtg% utalwns and Standards t-tswit,n Suner.+sor. • CS-0425" Estprre . 08/2512022 RANDALL E ROBERTS • 41 HEMEMWAY ROADa LEVERETT MA 01084 t. Commissioner %LA f; • Construction Supervisor Unrestricted -Buildings of any use group which contain less than 35,000 cubic feet(901 cubic meters)of enclosed space• Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(61T)T27-3200 or visit www.mass.govfdpt This is an of Icial application of the Corrmonweaith of Massacnusetts _(htjp://www.mass.ggy.) Office of Corsumer Affairs&Business Regi.iatior (h o://www.-rass.go'tiocabr,`? ;•M; home Imp•sierrent Ccntlar_cr:rag ar- l L,H.../h..,............. .....,.1......t.. ..,.,v.....,,..—. ,,..3..d.. .....i w•......,.......7L........ ...,.................a ......a.n.. rt ,(http://mass,gov) My Registrations • Your company Registrations and/or Applications with their statuses are displayed in the list below. • To manage or view any Registration, click on the appropriate Task button. • To register a new company as a Home Improvement Contractor,click the Start New Application button. Start New Application (/HIC/Register/CheckList?contractorld=0&applicationld=0) Contractor HIC Registration Effective Expiration Application Application Create Task Name Number Status Date Date Type Status Date RANDALL E. 104873 Active 07/15/2020 07/14/2022 Renewal Registration 07/07/2020 Manage Regist ROBERTS Issued RANDALL E. 104873 Active 07/15/2018 07/14/2020 Renewal Registration 06/19/2018 Manage Regist ROBERTS Issued RANDALL E. 104873 Expired 07/15/2016 07/14/2018 Renewal Registration 07/14/2016 Manag Regist ROBERTS Issued RANDALL E. ROBERTS 104873 Expired 07/31/2014 07/30/2016 Renewal Registration 07/30/2014 Manage Regist ' GENERAL Issued CONTR RANDALL E. ROBERTS 104873 Expired 07/15/2012.07114/2014 Renewal Registration 07/14/2012 Manage Regist GENERAL Issued CONTR