23D-130 (7) BP-2023-0995
20 WINSLOW AVE COMMONWEALTH OF ASSACHUSETTS
Map:Block:Lot:
23D-130-001 CITY OF NORTH MPTON
Permit: Exterior Res
PERSONS CONTRACTING WITH UNREG STERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUA NTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2023-0995 PERMISSION IS HEREBY GRANTED TO:
.Project# roof 2023 Contractor: License:
Est. Cost: 6000
Const.Class: Fxp. J)atc:
Use Group: Owner PO RS GLADYS &M GULLEY D POWERS ET AL
Lot Size (sq.ft.)
Zoning: URB Applicant: PO :RS GLADYS &M GULLEY D POWERS ET AL
Applicant Address Phone: Insurance:
132 SOUTH MAIN ST
BROCKPORT, NY 14420
' ISSUED ON: 07/28/2023
TO PERFORM THE FOLLOWING WORK:
STRIP AND REROOF
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 NO THAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
At
I
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax (413)587-1272
Office of the Building Commissis ner
I RECEIVED
The Commonwealth of Massachusetts
W Board of Building Regulations and S'anda.tds FOR
Massachusetts State Building Code, 7\30 CMR JUL 9 7 9.023 MVNIC ALTTY
U E
Building Permit Application To Construct,Repair,Renovate Or Demolish RPi1ised ar 2011
One-or Two-Family Dwelling DEPNT OgFTNW Tn BUILDING INSP01ECT160IONS
This Section For Official Use Only
Building Permit Number: 9fl' >3- 99.E Date Applied:
v,x1 Kos ���/ I 7-Z 7-Zla3
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: i 1.2 Assessors Map&Parcel Numbers
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 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owne Record:bml114 ataCr� Zp M/i J �/•(c Av-e I / '#"Ree /1,54
Name(Print) City,State,ZIP Q/0' ,2 .
'1/3-a-51) hkCIP lute !a?-eo)ilr4'%llody
No.and Street Telephone ` 'Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building e. Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition ❑
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Descript' n of Proposed Wor 2:
{
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:
❑ Standard City/To 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: $
Check No. Ch k Amount:— 0
6.Total Project Cost: $ 61. G,90 a 0 Paid in Full 0 Outstanding Balance Due:
City of Northampton
.L l� .7 0..,
Massachusetts
4' 4k DEPARTMENT OF BUILDING INSPECTIONS
` 212 Main Street • Municipal Building
"i"
* ., Northampton, MA 01060 4
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)
License umber 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.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
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 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 b6LU( P
0 u a e r
to act on my behalf,in all matters relative to work authorized by this building permit application.
7)etv( Gr S�fvu-Pr--5 772407202.
Print Owner's Name lectronic Signature) Dat
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.
7)01 U I P5 �p 44/.471- 1- Z�/Z o
Print Owner s or Autho ized 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"
The Commonwealth of Alassaehusetts
011)'.11 .1 Department of Industrial Aeci,dents
I Congress Street.Suite 100
'waltz= 10
- Boston, ALA 02114-2017
www.ntass.gotVdia
‘Vorters'Compensation Insurance Affidavit:BuildertsContractorsAlectriciansirlumbers.
11) f 1 BID WITH Tilt;PERMITtING AETHOBI
I oho-ma tion Please Print Legibls
Name lliumnicarr'Organizat taw
Address:
City/State/Zip: Phone 4:
Are you an employ erlt Cheek thie appropriate box: Type of project(required):
1,0 1 aura a employer with employee%CM main part-tian,!L" 7. New in struction D
20 I am a Ullc propnetor 4meihp and have no employee%yi oaring rot me m8, Remodebrig
any impacity.No written"comp.insurance required"
9., E] Demolition
Ira aini huntoovnet doing all wade myself No warktaii"camp, me rix[tiated.)
ID9 Building addition
4,C11 an a innansawner and vall be taring contractora to conchal all work ore aty property. 1 will
mauve-that all emanation either have%linkers'cattementiationnaitaneame tole a Electrical repairs or additions
ittoprietott.with no etiploycm,
PIttrablittl mpoirs or additioth
area igeriterai contractor wal I have hued the Mib-contraat,Th tinned an the attached sheet.
I 30 Root repairs
These subiamtractorsi haw employees,and lathe workers'camp.atiorarice.:
14.0 Other
it,E]we are a oorporation and officer%hate exercised their tight of eamagnion per
151.§,114,1.,and we have no employees.[No worker.'comp.insurance roomed,/
*Any applicant that efaxtica boa#1 mina At...80 fill mu the ritiction below showing that workers"comperwation policy titforimatanti
lionneowilen tieho submit th affidaidt ruthenium they are&ring all WfIck and then brie outside cotaractaint matt submit a new Affkile,it iratienarag swab.
:Contractor%that cheek this box most attached an additional sheet%bow inj the name of the talwoontracton and%tate whether or not those entitle.
einployed. If the imbhiontraerum bane employ ets,they mita provide thei tta:,"comp.policy number
I am an employer that is providing workers compensation insurance for my employees. Below is the police and Job site
information
insurance Company Name:
Policy#or Self-ins,Lic.#: Expiration Date:
kb Site Address: City!State.'Zip,_
Attach a copy of the workers'cum riensatitio policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under:AGE c. 152,§25A is to criminal violation punishable by a fine up to SI.500.00
andlor 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 a the pains and penal perjury that the information provided above is true and correct.
Signature: eizot Date:Phone#:#: tit/3—
Official use only. Da not write in this area,to he completed by city or town official
(ili or Town: PermitiLicense#
Issuing,Authority (circle one):
I. Board of Health 2.Building Department 3.Fit Tnn Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone 4:
- City of Northampton
r am ''v _,i f%,
Massachusetts mow- /,
DEPARTMENT OF BUILDING INSPECTIONS tf zz
n
212 Main Street • Municipal Building ',w
'e,,,.+ Northampton, MA 01060 s, h a.-,1"\"�`
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: //(-1/ V /<� ''7 - Nei-4a61, Q
The debris will be transported by:
Name of Hauler: 1)(ihIhr , raw'
Signature of Applicant: ae s,"7 .Date: ; U Z1.?