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13-066 (2)
BP-2023-0343 18 LAUREL LANE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 13-066-001 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-2023-0343 PERMISSION IS HEREBY GRANTED TO: Project# ROOF 2023 Contractor: License: Est. Cost: 14950 THOMAS ROBERTS 100333 Const.Class: Exp.Date: 07/03/2024 Use Group: Owner: CRUZ DEBRA Lot Size (sq.ft.) Zoning: RI/RR/SR/WP Applicant: ROBERTS ROOFS CO INC Applicant Address Phone: Insurance: P O BOX 1312 (413)283-4395 2008W6216 BONDSVILLE, MA 01009 ISSUED ON: 03/20/2023 TO PERFORM THE FOLLOWING 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: I . 9 (V. . .. I M , J t Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner DocuSign Envelope ID:26D7C201-F419-411B-AA98-F28F87B3D7BC The Commonwealth of Massachusetts 7 J Avi Board of Building Regulations and Standards z:V FOR Massachusetts State Building Code, 78©cC,MR MUNICIPALITY USE Building Permit Application To Construct,Repair, Renovate O tnalish a Revised Mar 2011 One-or Two-Family Dwelling ° � ` '' This Section For Official Use Only Building Permit Number: 61x 3.. 343 D to Ap•lied: IZZ.5. J 3 20-70�3 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 18 Laurel Lane 1.1 a 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❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Debra Cruz Northampton,MA 01060 Name(Print) City, State,ZIP 18 Laurel Lane 570-6090 cruzalina@verizon.net No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ 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 Work2:Remove&replace shingle roofing complete with all associated flashing details 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 $ 0 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 Nola! Check Amoun : Cash Amount: 6.Total Project Cost: $14,950.00 0 Paid in Full 0 Outstanding Balance Due: DocuSign Envelope ID:26D7C201-F419-411 B-AA98-F28F87B3D7BC SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 100333 7/3/24 Thomas R Roberts, -11 License Number Expiration Date Name of CSL Holde7:5 List CSL Type(see below) RC 400 Franklin Street No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) Belchertown,MA 01007 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry Sn P. t a RC Roofing Covering -�e•J� WS Window and Siding SF Solid Fuel Burning Appliances 413-283-4395 info@robertsroofsinc.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 128264 3/16/25 Roberts Roofs Co.,Inc. HIC Registration Number Expiration Date HIC Company Name or HIC Registrant.Name PO Box'1312 info@robertsroofsinc.com No.and Street Email address Bondsville,MA 01009 413-283-4395 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 B 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 Roberts Roofs Co.,Inc. to act on my behalf,in all matters relative to work authorized by this building permit application. DoeuSigned by: Lptigt 2/21/2023 rigbQ a(Electronic Signature) Date SECTION 7b:OWNER1 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. alai P ' wner's>3 Authorized Agen a(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 '`� BiS 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" DocuSign Envelope ID:26D7C201-F419-411B-AA98-F28F87B3D7BC City of Northampton M_r1Mp0 •5 .:. SA Massachusetts � 5 c,� I/ C DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building v_ warr+% Northampton, MA 01060 Jt'tn 3 IN�``\ 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. ?t111:, irit:,`:;191iJ ►HT J .x:11v!w9:Re firt;J•; : ii'(ui 1~1O T: 3r)1, .' A ) The debris will be disposed of in: Location of Facility: O SA tiG��i�• R2cyc`I f - CA k(\ The debris will be transported by: Name of Hauler: ()ON \ \c.ak c )cin Signature of Applicant: i Date: ,} v r .. --1 Commonwealth of Massachusetts lit Division of Occupational Licensure Board of Building Regulations and Standards C'7 I t ConstructiQupers"Qr Specialty i CSSL- 100333 EX : ' :'s : 07/03/2024 THOMAS R FpBERTS, JR 400 FRANKLiN STREET BELCHERTOVe: MA 01007 . il i� \leo 1' lip Iloe Commiss:crocr ditaif - ' L - - THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration t Z � - W � till �,� Type: Corporation e ist ation: 128264 ROBERTS ROOFS CO. INC. �v �lie = E e.tion: 03/16/2025 PO BOX 1312 = • BONDSVILLE, MA 01009 .+ 1sIlir ©� W� in. Pi 7'' f I.11 Ai 0 0 Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE: Corporation Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 128264 03/16/2025 Boston,MA 02118 ROBERTS ROOFS CO. INC. -"- ' t 1 THOMAS R. ROBERTS JR•:. �/` � ^�, tei.a.400 FRANKLIN ST ��u ,e ,x, a. y,k s �► BELCHERTOWN, MA 01007 ..01, Undersecretary Not valid without signature DocuSign Envelope ID:26D7C201-F419-411 B-AA98-F28F87B3D7BC The Commonwealth of Massachusetts y - Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia 11uskers'Compensation Insurance Affidavit:BuUders/ContractorvElectriciau s.Plunthers. TO BE FILED WITH THE PERMITTING At'I Iloki 11. Applicant Information Please Print Le/_ihis Name 4 Business O gantzationrindnidual): Roberts Roofs Co.,Inc. Address: PO Box 1312 City/State/Zip: Bondsville,MA 01009 . phone #: 413-283-4395 Are you an employer!Cheek the appropriate box: 1\pe of project(required) 141 am a employer with 2 employ, (full and Or part-time)_• 7• ❑ Noss r - � construction 2171 I am a sok peopnetor or puflnaahrp and ease nu employed workm :or nn m S. � Rt:rnuJchnc any capacity.[No m ur►era'comp.uuuranot requiem!J y- ❑ Demolition 30 l am a homeowner doing all work myself.[No wrik.'r>'cunt 1r:,uran�,required j Building addition 4.0 I am a humeoa u-r and will be hiring tuntrattur, l.rnJtut a:l...Ink on rorert_, I+.111 1 f)❑ ensure that all eontraetUrs either hase workers'Ion ' nsal:un rum-runic or ar.soli I 1,0 Lk:el :al repairs or additions proprietors with nu employees. 1 2.0 Plumbing repair.or additions 50 I am a general contractor and I hose hired the sub-contractors listed on the anac(resI sheet 13.181 Rout repairs These sub-contractors hose employees and hose worker,'comp.insurance.: 60 We an a corporation and its officers base cxer ised their nghu of exemption per hlteL. I4.❑Other 152,j II j1.and we ease no employees.[No mufflers'comp.insurance required.] •Any applicant that check,but al must also fill out the section below.showing their workers'compensation ts.11 l,} int.-rnlatr.•n r homeowners mho submit this atlulasrt uulxatmg they are doing all murk and then hue outside contractors ntu t,uhnlrt a rc,+at:1J..,rt rni lacing such. :Contractors that check this hot must attached an additional sheet showing the name of the sub-cuetractura and,cat.+s Ii i er w not(hlu,c still,tres have employees. If the sub-contractors Fuse employees.they oust pros tde their workers'lump.pulley number. I am an employer that is providing workers'compensation insurance for my employees. Below Is the policy and job site information. Insurance Company Name: Farm Family Casualty Insurance Co. Policy#ur Self-ins. Lic. #: 2008W6216 Expiration Date: - 1111Pr till 7 I?3 Job Site Address: (h Lc-uvt\ t v• City/State/Zip: )J e r' ova )4 A- 1O(..c Attach a copy of the workers'compensation policy declaration page(showing the policy number and a vr iration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to SI,500.00 and+or 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: 1 Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official ('its or Fos,n: Permit/License# Issuing Authority (circle one): I. Board of Health 2. Building Department 3.City fTossn Clerk 4. Hectrical Inspector 5. Plumbint Inspector G.Other (contact Person: Phone u: