11C-008 (5) BP-2022-0379
11 BERNACHE ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
I 1 C-008-001 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-2022-0379 PERMISSIONISHEREBYGRANTED TO:
Project# roof Contractor: License:
Est. Cost: 6000 SHUMWAY SERVICES 105743
Const.Class: Exp.Date:01/14/2024
MENDEZ, GUADALIPE D. & ELIZABETH C
Use Group: Owner: KAMERER
Lot Size (sq.ft.)
Zoning: URA Applicant: SHUMWAY SERVICES
Applicant Address Phone: Insurance:
PO BOX 522 (413)549-4658() WWC3509999
HADLEY, MA 01035
ISSUED ON:04/12/2022
TO PERFORM THE FOLLOWING WORK:
REPLACE ROOF SECTION
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:
Roue: Rough: House # Foundation:
• �
as: Final: Final: Rough Frame:
Rough: Fire Department Driveway Final: Fireplace/Chimney:
Final: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: i Ts
• in 'Ii
_ I l �
Fees Paid: $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
_� The Commonwealth of Massachusetts l
1� Board of Building Regulations and Standards APR 1 2 2) FOR
Massachusetts` / Massachusetts State Building Code, 780 CMR . MtJN>CIPALITY
.�JSE
Building Permit Application To Construct,Repair, Renovate or Now:;`; ,iryi.The- c $Mar 2011
One-or Two-Family Dwelling : r r•. 1 , r,0
This Section For Official Use Only
Build' g Permit Number: 3a a -s`',.5`7 9 Datee Applied: _
cot...) eo5.3 1// y-iz-Zo2L
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Properly Add ss G(0_, 1.2 Assessors Map& Parcel Nuns
1.1a Is 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 0 Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Guadalup Mendez&Elizabeth Kamerer Leeds,MA,01053
Name(Print) City,State,ZIP
11 Bernache St 503-866-8480 liz.kamerer@gmail.com
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work':
Replacement of roof section with 30 year architectural roof system.Ice and water shield,
synthetic felt,ridge vent and cap.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(I.abor and Materials) Official Use Only
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
0 Total Project Costa (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire
Suppression) Total All Fees: $
Check No. AO Check Amount: l'q Cash Amount:
6. Total Project Cost: $ 6
f 6\o0 0 Paid in Full 0 Outstanding Balance Due:
City of Northampton
Massachusetts 4�?� t�
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building v.
, Northampton, MA 01060 sNW 30 �5
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 !egal 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.
14 Please provide the appropriate fee in the form of a check made payable to The City of Northampton.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 105743 01/2024
Shumway Services License Number Expiration Date
Name of CSL Holder
P.O Box 522 List CSL Type(see below) U
No.and Street Type Description
Hadley MA 01035 Il Unrestricted(Buildings up to 35,000 cu.fi.)
City/Town, State,ZIP R . Restricted 1&2 Family Dwelling
M Masonry
• .. . .. RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
413-687-9400 shumwayservices@gmail.com I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 178390 04/2024
Shumway Services HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
P.O Box 522 shumwayservices@gmail.com
No.and Street Email address
Hadley MA 01035 413-687-9400
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 ® No 0
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 Shumway Services
to act on my behalf,in all matters relative to work authorized by this building permit application.
Elizabeth Kamerer
3/25/2022
Print Owner's Name(Electronic Signature) I 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 acc to to the best of my knowledge and understanding.
Print Owner's or Authorize gent's Name(Electronic Signature) Date
NOTES:
I. 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,fmished 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
, ' Massachusetts � !��.,
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
';/* Northampton, MA 01060 pr ,.,, 1.h�
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: Amherst Trucking or Private Dump Truck to Valley Recycling
The debris will be transported by:
Name of Hauler: Amherst Trucking or Private Dump Truck to Valley Recycling
Signature of Applicant: Date:
== The Commonwealth of Massachusetts
=..11:1
1 Department of Industrial Accidents
I Congress Street,Suite 100
Boston. MA 02114-2017
www.mass.govidia
‘%(»kers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Pin tubers.
It)Bt.111.1..D VS rut THE ri.:RmrITIN( Al°111()It111.
Annlicant Information Please Print i-ciLibh
Philip Shumway Inc. DBA Shumway Services
Name I Husimssorganurvionfirldividum):
P.O Box 522
Address: .
City/StaterZip: HadleyMA 01035 Phone#: 413-687-9400
Are yen on einployer?Clark the appropriate heat Tape of project(required):
'0 I am a employer with X employees(full andior part-timet• 7. .i New construction
.:*.71 I arn u -oh:proprietor in par.rentup an.'Et4v.i ne eitiplo:ec' working for me in K. M RemodAing
any capacity INo workers comp utsusinace nun/reit)
Dk 0 I am a horneownia doing all work myself[No workers'comp,nouran 9. Demolitionce terauiro1 J"
10 CI Building addition
4.0 I am a hornotwrier and will be hittng contractors to conduct all*ark on my property. I will
ensure that all contractors either have workers'compensation insurance or am WIC I I 0 Electrical repairs or additions
proprietors with no employees.
12,0 Plumbing repairs or additions
5C]1 am a general contactor and I have hired the sub-coottactors listed on the attached sheet
1 30 Roof repairs
rhese sob-contractors haw employees and have workers'comp.insurance.;
14.010ther
6 0 We are a corporatton and its officers have exercised their right sticks:moron per Wit.c,
152.1,It 41,and we have no employers,[No workers'comp.insurance required.]
*Any applicant that elites:Ik%box 4 i must also till out the section below show in then workers's.otripensiation pokes information
+tiorneowners who submit this affolatit indicating they are doing all work and then hire outside contractors mud 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 in nut those entities have
employees It the sub,contractor%have employ on.they must mot ide their workers'comp.polies number
i ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Wesco _
Policy#or Self-ins.Lie.#: WWC7569281 Expiration Date: 02/2023
Job Site Address; City/StateiZip:_ ...
Attach a copy of the workers'compensation policy dedaratioa page(showing the policy number and expiration date).
Failure to secure etreraE.e as required under MG!. Q. 152.1-,2$,A ir.,a criminal violation punishabk Iv. a fine up to SI,500.00
andOr one-year unprtsorurlent,as well as civil penalties in the form of a STOP WORK ORDER and a tine 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 certift under the pains and penalties of perjury that the infOrmation provided above is true and correct.
, (5'e-44,4-4C.,24--'
Sianature: I)ate.
Phone x: 413-687-9400
,. .
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Perniitticense#
Issuing Authority(circle one):
I. Board of health 2.Building Department 3.Cityrlown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other _
l
Contact Person: Phone 0: