30A-089 (4) BP-2022-1152
50 LIBERTY ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
30A-089-001 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-2022-1152 PERMISSIONISHEREBYGRANTED TO:
Project# ROOF Contractor: License:
Est. Cost: 12000 KAREN LAVERDIERE CSL055344
Const.Class: Exp.Date:08/29/2024
BERTINI ANDREA JOAN & DIANA LltNN
Use Group: Owner: SCWARTZ
Lot Size (sq.ft.)
Zoning: URB Applicant: KAREN LAVERDIERE
Applicant Address Phone: Insurance:
21 FAIRFIELD AVE (413)268-2080 6s62ub5n25195321
HAYDENVILLE, MA01039
ISSUED ON:09/14/2022
TO PERFORM THE FOLLO WING WORK:
STRIP AND RE-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: •
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: tty
wL cfr)
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
111111
RtZCE__�5
The Commonwealth of Massachu etts
Board of Building Regulations and S anda ds R
SEP 4 20 I IOPALITY
E Massachusetts State Building Code, 0 C R
_ _ SE
Building Permit Application To Construct,Repair, enovat� + n �¢ilitk cr ise Mar 2011
TON.MA 01060
One- or Two-Family Dwelling
This Section For Official Use Only _
Building Permit Number: 6 a- )-` !15.)_ Date Applied:
J���I►✓ ' i70ss /�i q_p1 2022
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: J 1.2 Vjsrs Map&Parcel Numbey,5a e a
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 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
-Di a n n f\T c._ ex- ,.,.1 )J 6 c 1 A-+ a.-,,.‘r, ,\ leV1 6-. 0 t 0 Cc. 0
Name(Print) SV+Prir.L City,State,ZIP
51) 14
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(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':
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 1 Zi o Do I. Building Permit Fee: $L`-p-= Indicate how fee is determined:
— ❑ Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ _ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Suppression) $ Total All Fees: $ (D m° u
Check No/ /2-Check Amount: y'D
6. Total Project Cost: S t/a/ 06 0 — 0 Paid in Full 0 Outstanding Balance Due:
Pr
City of Northampton
Massachusetts
r
DEPARTMENT OF BUILDING INSPECTIONS 4
212 Main Street • Municipal Building
Northampton, MA 01060
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS, ROOFS, RENOVATIONS, ROOF MOUNTED SOLAR, ETC.
1. 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. Construction Debris Affidavit filled out and signed by applicant.
4. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance.
6. Energy Conservation Compliance Certificate (new /replacement windows).
7. Home owner's License Exemption Form (if applicable).
8. Note any Special Permit requirements (if applicable).
9. Energy Code —all new construction (Gut/Rehab) requires a HERS Rater Affidavit
10. Please provide the appropriate fee in the form of a check made payable to: The City of
Northampton.
41.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) D cs 3 y y g )z' ) Zu
\{0�(mow is A�) et--A.:�t-t✓ CD? S 1— License Number Expiration Date 1
Name of CSL Holder
,II°e re v1 \, ` r�r \ ; List CSL Type(see below) (I__.
No.and Street V �L T e Description
Z` Alk i�f..k-PC.-1 1 /�"� U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
v, 1` ✓A A O ( p 3 I RC Roofing Covering
l WS Window and Siding
/ +� SF Solid Fuel Burning Appliances
1
( /3`- 5 3/- / 2 0 8 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration umber Expiration Date
H Company Name or HIC Registrant Name
No.and Street \—c...c G.h \a V 4 `t 0 Cif, 1 " Lo
Email address
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 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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 76: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.
y - . (...___._ e.....--\.; 9 I i y
Z.
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.iov/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 Commonlvealth of Massachusetts
(•P Department of Industrial Accidents
1r,d) 1 Congress Street, Suite 100
Boston,MA 02114-2017
wwicmass.govldia
VIOrkers' Compensation Insurance Aft-Ws%it:BuildersiContracturs/EleetriciansiPlumbers.
TO RE FILED WITH'I tit. PE10,11 ITING AUTHORITY.
Annlicant Information Please Print Leeibls'
Name tusubmorganizanori lngfr,duaIj
Address: j_ r- ; 1-1 v-e_
:
CityiStatelZip: v kikCIA Phone :I-.
err*mu an ciziptii heck thr appropriate trot: Type or project (required):
1.C3I am a erupt,"tar with employees',full:tutor part-hawk* 7. 0 New COnStrUCtiOn
20 I am a sole proprietor or partnership and hate no empltiyixt working for ruem K. 0 Remodeling
any capacity.iNta workers'ciamp insurance required)
9. El Demolition
31:3 I am a homeowner doing all work mytelf.[No Ve'ack.t.r."comp.inturamee requital]°
10 J Building addition
4.0I am a horrimvsner and will be raring coral-at:win to conduct all work on my property I LII
ensure that all,--cintractors either hose workers'cocripensation insurance or are sole 1 1 Electrical repairs or additions
proprietors with no employein,
12.0 Plumbing repairs or additions
50 I arn a iteneral contractor and I have hired the suts-contractors listed cin the:mulled diet!
I 3 eRoof repairs
the sub-contractors hove ernployees and have workert'comp.insurance)
14_ Other
61D we are a corporation and its officers have exercised their right of exeniption per MOI.c_
§lt 4 f.and we have no ermakiyees.[No workers comp.insurance required-I
"Any applicant that eltezks hot z I must also rill out the section below b1.1%ins:their iwrio_r..;:omperinaticiu policy infisrmation
Homeowners who Azimut tin ail-I./tilt man:Wing they art doing aft wank and then hue otwaide,:aittraetor a trutaa tubrnit a no affith,a indicating such.
:Contractors that cheek this box must attached an additional sheet showing the name of the iab-t.litaractocs and gate w holies or not thii e.imbue,has e
en!ploy ccs If the sult-c ontractora has niu,1 pnwide their workers'cumin.policy number
trill'an employer 1/to! provroria,;. u rke rs.compensation insurance,for my employees. Below L the policy and job Aire
lit fi -oltion.
Insurance Company Name: ( Pile- 04 i
C_&c-
Policy#or Self-ms. 9b 9-a-7"f 6 4 7-'A M5-74 2 3 'Expiration Date: (1 21.1
Job Site Address: 5 c- . Citv,StateiZip: oc
attach a ropy atilt workers'compen%ation policy declaration page(showing the policy number and expiraVion date).
Failure CO secure coverage as requirctl under MGL c. 152. §25A is a criminal %,iolation punishable by a fine up to SI.500.00
andOr 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 DR for insurance
co%triage verification.
I do hereby certify under the pains and penalties of perjany that the information provided above it true and correci.
Signature: \e----
DaW: I I Li
-2_
Phone 4: 1 I S-3 7 ' J 7 S
Official use only. Do nor write in thiA area.in be completed by city or town official
Cit) or Town: PermitILicense
Issuing Authority(circle one):
I. Board of Health 2. Building Department 3.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
'ontact Person: Phone 4:
•
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS �_ lk
11 ;,
212 Main Street • Municipal Building
^-� Northampton, MA 01060
oY 40
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: UrN.4
The debris will be transported by:
Name of Hauler: b' W\VItr'S 172Ard "Dv p S ��
Signature of Applicant: ate: ��
City of Northampton
Massachusetts
Wing:
DEPARTMENT OF BUILDING INSPECTIONS *
212 Main Street • Municipal Building IA,,
r, , Northampton, MA 01060
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, (insert full legal 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 780 CMR 110.R5.1.3.1, in connection with a project or
work on a parcel of land to which I hold legal title.
2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'
exemption, does not involve the field erection of manufactured buildings constructed in accordance with
780 CMR 110.R3.
3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2:
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
there is, or is intended to be, a one-or two-family dwelling, attached or detached structures
accessory to such use and/or farm structures. A person who constructs more than one home in
a two-year period shall not be considered a home owner.
4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I
qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of
the project or work on my parcel, I am not engaged in construction supervision in connection with any
project or work involving construction, reconstruction, alteration, repair, removal or demolition
involving any activity regulated by any provision of the Massachusetts State Building Code.
5. If I engage any other person or persons for hire in connection with the aforementioned project or work on
my parcel, I acknowledge that I am required to and will act as the supervisor for said project or work.
Signed under the pains and penalties of perjury on this day of , 20_.
(Signature)