25C-238 (2) BP-2021-2172
203 BRIDGE ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
25C-238-001 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-2021-2172 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF Contractor: License:
Est. Cost: 18750 R& H ROOFING LLP 114097
Const.Class: Exp.Date:02/12/2023
MALEK EUGIENIA H&THEODORE J OLEJNIK ET
Use Group: Owner: AL
Lot Size (sq.ft.)
Zoning: SC/URB Applicant: R& H ROOFING LLP
Applicant Address Phone: Insurance:
59 SOUTH ST 413-527-9378 6080835024
EASTHAMPTON, MA 01027
ISSUED ON:11/10/2021
TO PERFORM THE FOLLOWING WORK:
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:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
.52
Fees Paid: $40.00
•
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Buildine Commissioner
RECEiii
The Commonwealth of Massachus tts NOV 8 FO
Board of Building Regulations and St ndar 202 ICI ALITY
Ns
Wt. Massachusetts State Building Code, 7 0 C R U
Building Permit Application To Construct,Repair, enov ised ar 2011
One-or Two-Family Dwelling RrH 4Mnrorv,nnA o 6__
This Section For Official Use Only
Building Permit Number: 40'6,1 1 - -21 7d- Date Applied:
KC-U10(Z5 I/70 )I_ID'7zj
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 203 Bridge Street 1.2 Assessors Map&Parcel Numbers
Northampton,MA 01060 a� �
1.1 a Is this an accepted street?yes X 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 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Ted Olejnik Northampton,MA 01060
Name(Print) City,State,ZIP
203 Bridge Street tedo48@yahoo.com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied a Repairs(s) ❑ Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: Re-Roof
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building (Roof) $ 18,750.00 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:", $ ,y
18,750.00 Check No,,'0 /Check Amount: �1* Cash Amount:
6.Total Project Cost: $ 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS-114097 02/12/2023
Timothy Hopkins License Number Expiration Date
Name of CSL Holder
59 South Street List CSL Type(see below) U
No.and Street Type Description
Easthampton,MA 01027 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
413-527-9378 rhroofingllp@gmail.com I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 105948 11/02/2022
R&H Roofing,LLP HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
59 South Street rhroofingllp@gmal.com
No.and Street 413-527-9378 Email address
Easthampton,MA 01027
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 dC No ❑
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 R&H Roofing,LLP
to act on my behalf,in all matters relative to work authorized by this building permit application.
Ted Olejnik 11/04/2021
Print Owner'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 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.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"
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton
r
, �� ,�r Sys °...S
Massachusetts �?? - ' c�G.� �, ;�DEPARTMENT OF BUILDING INSPECTIONS ,212 Main Street • Municipal Building yJs., ?lir
z P
!� Northampton, MA 01060 � `^Wj�'�0
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: TBD
The debris will be transported by:
Name of Hauler: Dave Wickles Trucking
Signature of Applicant: Date: 11/05/2021
°L\L The Commonwealth of Massachusetts
' Department of Industrial Accidents
ti l� 1 Congress Street,Suite 100
Boston,MA 02114-2017
.,,� _„� www:mass.gor/dia
ll utters'Compensation Insurance Affidss it:Builders/Contractorsineclricians/Plumbers.
10 IZE FILED N 1TII 11W PI.RMITtim;AtTTHOwTt.
Applicant Information Please Print I.eeiblk-
Name 4Business O ganimtiott ladisidual) R&H Roofing,LLP
Address: 59 South Street
City/State/Zip: Easthampton,MA 01027 phone#: 413-527-9378
Aar yea as aa.Player?(."lack the ypraprWr bin: Type of project(required):
1.01 am a ewploya with_ 12 employees(full aad'or pert-disc}• 7. 0 New construction
2.01 am a sot pupriepr or pnAsenhip and have no eopltoyee%working for me in 8. Q Remodeling
any capacity_[No%s rters'curttp.insurance rcyrrred.)
3O 1 am a homeowner dying all work myself.[No wo► mu as'comp_trsn's required.]" 9. ❑Demolition
10 0 Building addition
40 I am a htmicowner and wiU be hiring cvntrartors to conduct all work on my property. I will
unsure that all cortractun either tutic weaken'imapercaatian usiranee or are sole i I.p Electrical repairs or additions
proprietors with au employes.
12.0 Plumbing repairs or additions
501 am a gctreral coatroom and I fuse hued the sub-contractors listed on the attained sheet. 13.0 Roof repairs
These sub-contractors have employers and Inv*takers'camp.insurance,:
60 we an a corporation and officersci its officers hays exorcised then right of excmptiun per MGL c. 14. Ocher
1SI 1(4).and we have no employees.[No winters'camp.insurance required.)
•Any applicant that checks boa r=t most atso till out die section below showing their nutters'compensation policy infunnatwa..
$llonvwnem who submit the affidavit indicating they are doing all work and then hue outside contractors must submit a new affidavit irdicctmg such.
:Contractors that check this boa must attached an additional sheet showing the name of die sub-`amtractursand state whether or not those entities has.:
crnpduyses. if the sub-contractors lure employees.they must pnnik their %inters*cutup.pubs!,number.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy anti job site
information.
Insurance Company Name: CNA Insurance
Policy#or Self-ins.Lie.#: 6080835024 Expiration Date: May 26,2022
lob Site Address: 203 Bridge Street CityiState'Zip: Northampton,MA 01060
Attach a copy of the workers'compensation polio declaration page(showing the policy number and explradss date).
Failure to secure coverage as required under MGL c. 152,*25A is a criminal violation punishabtr by a fine up to SI.500.00
ardor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 Mader its and penalties of perjury that the information prarilldiave is true and correct.
Stt!nututc Date; 11/05/2021
Plume413-527-9378
i -
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.('it /Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: