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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#: