11C-007 (5) BP- 022-1193
8 HEFFERNAN ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot: -
11 C-007-001 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-2022-1193 PERMISSION IS HEREBY GRANTE TO:
Project# ROOF Contractor: License:
Est. Cost: 12000 Jack Morse CSSL 1041' I
Const.Class: Exp.Date:09/29/2023
Use Group: Owner: JAKE WOOD
Lot Size (sq.ft.)
Zoning: URA Applicant: JAKE WOODJACK MORSE
Applicant Address Phone: Insurance:
8 HEFFERNAN ST
LEEDS, MA 01053
2 LILAC AVE (413)374-9064
CUMMINGTON, MA 01032
ISSUED ON:09/23/2022
TO PERFORM THE FOLLOWING WORK:
STRIP AND INSTALL METAL 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 VIOL• TION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
1 I
III � * •
•
' I
Fees Paid: $40.00
•
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
RECOV----------
The Commonwealth of Massachu•efts ■
Board of Building Regulations and St:nda •s F R
Massachusetts State Building Code, 7:0 C I R SEP 2 1 2022 I.,PEALITY
Building Permit Application To Construct,Repair, t eno ate Or Demolish ai
ise' ar 2011
One-or Two-Family Dwelli g °EPT of But , ,
This Section For Official Use I ' A"'TON.MA 0108iON$
Building 'ermit Number: 4' #-? )_.. f(q3 Date Applied:
(MA.) l 6ss 772 Cr,4
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
‘-‘ e f-NiAtj v Legs I��— c)01
1.la Is this an accepted street?yes v 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 Pro 'ded
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal Syste i
Public 0 Private 0 Zone: Outside Flood Zone?
— Municipal 0 On site disposal s tern 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
3--Pr cc wv�n t - e_C 1S Vet`
Name(Print) City,State ZIP
14C c-t..d.� LRa Q- 7%o' (337-7154
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
• New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. ❑ Number of Units Other 0 Specify: e0 c Replet,t,.....A
Brief Description of Proposed Work2: S-v C i o as S ee 54- owes), k n) 'vA 0 S
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost3(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $ 4��
Check No.O I Check Amount:
6.Total Project Cost: $ , 2 0 0 6 0 Paid in Full 0 Outstanding Balance Due:
I
Irr e. .--....:4-
City of Northampton
Massachusetts .'
w . DEPARTMENT OF BUILDING INSPECTIONS ,�
212 Main Street • Municipal Building Ly c'1*
s� Northampton, MA 01060 j VD'tia
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.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) t 0 L) 19 ' q ) 2 ci-62 3
Ti-cJ< v1/4/\ o(Z._sr- License Number Expiration Date
Name of CSL Holder
\` List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
l.".M 1�x A li V\^P' 0\ 02 V? R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
R) Roofing Covering
WS Window and Siding
�( �j ` 1 - SF Solid Fuel Burning Appliances
`c, 379- 0V-i �i�o`\.��`P4 env_d '1 .'� I Insulation
Telephone Emai address ,wt.3 D Demolition
5.2 Registerede Home Improvement Contractor(HIC) 119 (014 Q h S /lo2
i3(„ V 0(LSE HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
Sl e"'''
No.and Street Email address
City/Town, State,ZIP Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit ust be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of th ssuance 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 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 informati.
contained in this application is true accurate to the best of my knowledge and understanding.
1P—C� w --s.— q II
Print Owner's or Authorized Agent's Name ec is 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 arbitra ion
program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can •e 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 leorch)
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" ' -2— G 0 6
The Commonwealth of Massachusetts
Department of Industrial Accidents
' mr.111W
--• , ,ti
ii I Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.govidia
Workers' Compensation Insurance,lffidavit:BuildersiContractorsiElectricianstPlumbers.
It)BE FILED N1IIII I HI PERMITTING AUTHORITV.
Applicant Information Please Print Lezibii,
Name(Business'Organization Individual I: ---S-cN,k- --- V\/\0 Y1—
AAAAc., N.,..4....e_ .. . ., . . _
City/StateiZip: ,,,,Ky.(t' i fa---Ft,n,„. 1-.‘"P-- Phone 0: (-i 1 3 -3'71-1
Arr yea mai employer?Cheek Me apprepriate box: Ty pe of project(required):
101 d a eiick.-tri wok ... erripiiiytes(fun main parttimel.'im 7. 0 New construction
2 I am a sake proprietor or partneraJbm and have nu troployem working for Inc in K. 0 Remodeling
any Cartitelry (Nu winters'comp insuranix required]
9. 0 Demolition
30 I am a hurricow MT doing all*mi.myielf.[No,...uritt.1-$'comp_insurance required]
l 0 0 Building addition
4.01 am a humeorancr and will bc hiring commeturs zu conduct all work on thy property. 1 will
ensure that all contractors either have worircrs coinprmation insiur.rice or are sole II a Electrical repairs or additions
,
proprietors with no ensployont,
12.Q Pjsnning repairs or additions
50 1 am a ecneral contractor and I lam e hired the yub-contrachns listed on the&nailed sheet
13 'frepairs
These yob-contractors have employees and ha Y c workers'corny.insur.uice.:
14.c3 Other
6.C]Vie are a corporation and mu officers have exercised their right of exemption per Mk:A.,.
151.§114i.and sic have no allpiO}Vini.[NU A orit.ry',:ortrp.Insurance required.]
An apphcant that chcalis boa al mini abu flia Old Umt ,Ct.::ix:It/scion showing their worker,'.,:ompcmariun ix)th:y inkTruntwo
'flonnaiwtstri who submit this affidavit nuheating they are doing ail work and then hire curanle contractors must submit a new affidav a indicoung such.
:•Colaractott that check this boa must attached an additional sheet shownis the name of the sub-contractors and state w/tether or nut those antrues}Lase
erriplyfActs. If the ilit,COntrIcitrx have employers they must provide their workers'ce rip.poil,::, nLitilwr
1 am at/ employer that is providing workers"compensation insurance far my enrpiovoc.N. Below i.s the polity and lob site
information.
Insurance Company Name: —
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: 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 NIGL c. 152. §25A is a criminal violation punishable by a fine up to$1500.00
and or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a line 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
L.:xc' verification.
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I rho hereby certi fj,u er the pains and opol t i ilArl f perjury that the information provided above is true and correct.Sn.znature: Date: q / 2
Phone::`,.. 3 71 — 90 6 "4
i
Official use only.. Do not write in thi.s area.to be completed by thy or town official
('its or Town: Permit/License#
Issuing Authority (circle one):
I.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
' ,
City of Northampton
Massachusetts .71
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 nFy. .iC`��
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: v� `�� a_"`
The debris will be transported by:
Name of Hauler:Signature of Applicant: Date: c, 12k I z 3
City of Northampton
Massachusetts 4� �. %,,
.# DEPARTMENT OF BUILDING INSPECTIONS �, a
212 Main Street • Municipal Building I0,
Northampton, MA 01060 �``"µsrs
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, (insert full legal name), born_ (insert
month, day, year), hereby depose and state the following:
1. 1 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)