17A-057 (5) BP-2023-1193
195 BRIDGE RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
17A-057-001 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-2023-1193 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF 2023 Contractor: License:
Est. Cost: 800
Const.Class: Exp.Date:
Use Group: Owner: ROLLINSON JOHN L&MARSHA S JANSON
Lot Size (sq.ft.)
Zoning: URB Applicant: ROLLINSON JOHN L&MARSHA S JANSON
Applicant Address Phone: Insurance:
195 BRIDGE RD
FLORENCE, MA 01062
ISSUED ON: 08/31/2023
TO PERFORM THE FOLLOWING WORK:
STRIP AND REROOF NORTH SLOPE OF HOUSE
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:g (0 • 1' . r'1 •
II
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
780 CMR: STATE BOARD OF BUILDING REGULATIONS AND... https://northamptonma.gov/DocumentCenter/View/15553/Resideatia...
ernit
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR MUNICIPALITY
USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This S t"on For Official Use Only
Wnn
Building Permit Number: c�'Ji�' /1 Date Applied:
Lts�a3 ar,5 8-311,07-3
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1.la 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:
VfA VA- 4M t ) SOtkI AufAi ti _ Rot2.6vr, YY k 0 L b 2—
Name(Print) City,State,ZIP
let /Late 2i V ?—c%/y 3'? jko/t; Cc4sJ
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) ❑ Addition 0
Demolition 0 Accessory Bldg.0 Number of Units Other Cl Specify:
Brief Description of Proposed Work2: 72e.Si?eryit AVOIIt�J( s>IO�� p7 -11 gsc_ ,ADO F _
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/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) Total All F s J�O
6.Total Project Cost: $ Check No.��� Check Amount:t " l
06 1 0 Paid in Full 0 Outstanding Balance Due:
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780 CMR: STATE BOARD OF BUILDING REGULATIONS AND... https://northamptonma.gov/DocumentCenter/View/15553/Residentia...
City of Northam-tor "`
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, � DEPARTMENT OF BUILDING IN- ECT+ONSAU a
+w+ 212 Main Street • Municipal Buii•.nq /� �'`�- 1,
Northampton, MA 01+4 2U ss
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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.
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780 CMR: STATE BOARD OF BUILDING REGULATIONS AND... https://northamptonma.gov/DocumentCenter/View/15553/Residentia...
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
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.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofmg 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 ❑
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 information
contained in this application is true and accurate to the best of my knowledge and understanding.
(off. Rrli vises f 3r 073
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.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 ofhalf/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"
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780 CMR: STATE BOARD OF BUILDING REGULATIONS AND... https://northamptonma.gov/DocumentCenterNiew/15553/Resideatia...
.. .s, The Commonwealth of Massachusetts
Y1-1 ,thi'=_ Altl Department of Industrial Accidents
1 Congress Street,Suite 101)
Boston,MA 02114-2017
, \ , , wwmntassgoridia
.
Workers'Compensation insurance Affidavit:Builders/ContractorsiElectricianstPlutnhers.
TO IIE FILED vill'11 THE PERMITI'ING Atl-HORITY,
Applicant Information Please Print Leeihis
Name(Buslraess:Organaztion,Individual):
Address:
City/State/Zip: Phone#:
. .
Are you tilt eistploire?['hick the apprimriiiit out: Type of project(required):
1.E3 I am a employe with , crisploysies(full anchor part-timet* 7. 0 New construction
2,0 I ant a side progneux or partnership and have no eumbrilyees workin# fin me in 8. 0 Remodeling
arty capacity_[No workers*corms.imartarme impriroll
9. 0 Demolition
3V1 ant a IIMOLVW116E7 doing all work myself[No wistliers"coup.insurance raprinextr
to ci Building addition
4.0 I ern a hurravawnei and will Sc hiring ecianurtors to conduct all work ein nry property. I will
ensure that all contractors either have tworimrs'conmenienion itorraram or am sole 1 LC]Electrical repaits or additions
prapriatims With no empluyte.,
12.r]Plumbing repairs or additions
30 I ant a general I:oral-actor and 1 hoe hired the sulicontractors listed on the amichod sheet
13 i A Roof repairs
These sub-contractom hose employees and have workers'ermip.isesurance.?'
14.EH Other
, 6.0 We ate a corporation and its officers have exercised iten right of main:mt.:ion per MGL c.
I.52.§10),and we have no employees.[No workers comp.insurance required"
*Any applicant that cheeks boa*I Iflii4 Atm.)fili out the section below showing their Wi../rien'conmensatio;policy informatien
4 thasneowneri who sultrier this affidavit indicating they are doing all work and then hire monde contracturi maw submit a new affidai it antieating teeb,
ternitiactors that cheek this boa tonal atrivitheil an additional ghee showing the name of de sintvetintractoes and date whether an not those entitim lune
employees: El the tub conhactors boy employees.they mast preside their workers'comp.policy number,
I an.an employer that is'travailing woilers'compensation%Matthaei'for my employees. Below is Ihe policy and job site
information,
Insurance Company Name: _
Policy#or Self-ins.Lie.4: Expiration Date:
Job Site Address: /lc ri .....g,,,,),,_,o.., ., .„ City/State:Zip: 1A4 Oltq,2_
Attach a copy of the workers'compen•,.)!..a policy'declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a tine up to$1,500.00
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 cer t-under the pal and altieS ofpedoly that the ittforntation provided a e is fr/c and correct
Signature: ----- e-( z,v-) -1.--s.
Date: / 02-
Phone g:
Official use wily. Do not write in this area.to be completed by city or town official.
City or Town: PermitiLicense#
Issuing Authority(circle one):
'! I.Board of ilealth 2.Building Department 3.City/Town Clerk 4.Electrkal Inspector 5. Plumbing inspector
6..Other
Contact Person: Phone#:
.. „
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- — - - ......—_----- - - ---- -
780 CMR: STATE BOARD OF BUILDING REGULATIONS AND... https://northamptonma.gov/DocumentCenterNiew/15553/Residentia...
City of NorthamptonS
Massachusetts 4•,� — {c'
y" DEPARTMENT OF BUILDING INSPECTIONS pc
212 Main Street • Municipal Building
�� ✓� Northampton, MA 01060
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: VA-((Lam`? IQe J J
The debris will be transported by:
Name of Hauler: mg 5C I Y
Signature of Applicant: (>1/. .-
'-/g/
Date:
5 of 6 8/16/2023, 9:02 AM
780 CMR:STATE BOARD OF BUILDING REGULATIONS AND... https://northamptonma.gov/DocumentCenterNiew/15553/Residentia...
�* .,r
City of Northampton
,a
airs Massachusetts .40 84 sl9f
11
5 . � DEPARTMENT OF BUILDING INSPECTIONS .Sk
212 Main Street • Municipal Building vi,., b.
Northampton, MA 01060 .i'm-, t'
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, I i /1 ;Rv1Ii ei.s-on 7 3 5'3 (insert MI legal name), born (insert
month, day, year), hereby depose and state t e foll ing:
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 31 day of ,20 2-3 ka
l't - A)6'-g ;)t-5-"-
(Sig ture
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