24D-173-002 BP-2024-0555
204 STATE ST UNIT 2 COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
24D-173-002 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-2024-0555 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF 2024 Contractor: License:
Est.Cost: 26660 DL WEST ROOFING CONTRACTOR 106007
Const.Class: Exp.Date:07/08/2025
Use Group: Owner: TRUSTEE DANIELL, DEBORAH LEVIN
Lot Size(sq.ft.)
Zoning: URC Applicant:
Applicant Address Phone: Insurance:
ISSUED ON: 05/08/2024
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:
(:as: Fire Department Driveway Final: Fireplace/Chimne :
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: 77Z
Fees Paid: $187.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
it i•-- ,
The Commonwealth of Massachtsetts/Board of Building Regulations and StandIrds M AY i FOR
WMassachusetts State Building Code,4780 MR ` s 2024 MUNICIPALITY
Building Permit Application To Construct,Repair/RenrOVAe lish a ;Revised Mar 2011
One-or Two-Family Dwelling - - 'mvs;t -!Oti-.!
This Section For Official Use Only
Building ermit Number: 6PI.V 67"5-5 Date Applied: _
Eth/...) &.55
// 5-8-Zzq
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
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
I Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record
J0e9fr_h LQutY\ act.v►\C l l (lac'-4-I„c,wp i c(v\A, e,(0Le e
Name(Print) City,State,ZIP
?p`4 M de .S.-4- 61-5)AS'S-5(`t4 _
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 lac Specify: Y1eu. Ck0e4
Brief Description.of Proposed Work2: (kl�nkb t ecasis -5 sn 1e RI vy�eikc.s ecs�lc.t {c
_es Q Jl_ E P c NA. t b-ec- ca ,�•Q � .c. �tL `k. v\.t.-o mi to P(--C-T Pa
(2 t_.bb-er— rki50 R IMa c..havm C..e.,Lic a J(c.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ '14 (4.4.6, determined:
Building Permit Fee: $ Indicate how fee is
2.Electrical $ ❑Standard City/Town Application Fee
0 Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:
Check No. lii,NCheck Amount Cash Amount:
6.Total Project Cost: $24,Coe)• r 0 Paid in Full 0 Outstanding Bilance Due: -�O
iP1/4 4Iv11 pa `1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
C5(
NvAc tit J4 License Number Ex it tion Date
Name of CSL Holder
nl List CSL Type(see below) ,l
rC `-�IMO( G .
No.and Street Type Description
�� (�r� �� � Unrestricted(Buildings up to 35,000 Cu.ft.)
City/Town,State,ZIP R Restricted 1&2 Family Dwelling
M r-, Masonry
,I;/ Roofing Covering
WS Window and Siding
AG SF Solid Fuel Burning Appliances
CS"131( 41U4-41Z4'4145 C Q(1/ �l' (CAA I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor
(HIC)
t- U-5A—� c. `` (0 ki ` `r- HIC Registration Number x ration Date
HIC Company Name or HI Registrant Aldine
It �(� env. d(�c�tut.CC �5 ,(<co�
No. Street (,,,)� Email address
Street
o1re42 t C�. 43(
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 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 �.L. r\poKet(gxA
to act on my behalf,in all matters relative to work authorized by this building permi plication.
deb orc\ Lc§..Av. ta,t6_41
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.
,(..e- 1 ( LS& SISIZAttel
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. 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"
City of Northampton
SAS S,�
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building ��'
Northampton, MA 01060 ssj:h �'`�
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: Ue-,-N VItisca lAS, -frI,\-6-T
The debris will be transported by:
Name of Hauler: tk` "c‘S
Signature of Applicant: Date:
•
The Commonwealth of Massachusetts
Department of Industrial Accidents
i!►,= 1 Congress Street,Suite 100
`•St.ttg—
Boston, MA 0211 d-2017
yy www.mass.gov/dia
11urkers'Compensation Insurance Affidavit: BuilderslContractors/ElectrieianslPlunthers.
TO BE FILED WI I ll I IIE I'ERMtnTINC;AUTHORITtt`.
Applicant Information Please Print Leeibly
Name(Business%Organization/Individual): s
Address: \ Pls- il�QyC�rt�lr. C3.tQ
City/State/Zip: etrzel.itet V/1,4. a tS( 7_ Phone#: 6-i_l,))
rc,or an employer°Cheek the appropriate box:
Type of project(required):
:al am a employer with Z_,,,enrlriuyees(full arrd%or part-lunch.• 7. ❑ New construction
0 I am a sole proprietor or partnership and have no entptoye working for roe in 8. 0 Remodeling
any capacity.[No workers comp.mauranee required.]
30 I am a)10m0ow71C r doing all work myself.(No workers*comp.insurance required_]'
9. ❑ Demolition
4.0 I am a homeowner and will be hiring(anus-actors to conduct all work on my property. 1 will
t 0❑Building addition
ensure that all anrtraa tun either have workers,'cortrpensatio n insurance or are sole 114:1 Electrical repairs or addition
pruprietots with no employees..
12.0 Plumbing repairs or addition-s
S I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet.
10 These sub-contractors have employees and peeve workers`eump.insurance. 13 Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per Mt-c. 14_(Other VIA tl�
152,i 1(4).and we have no employees.[No workers'comp.insurance requited]
*Any applicant that cheeks box al must also fill out the section below showing their worker,'compensation policy information.
+Ltorneowners who submit this affidavit indicating they arc doing all work and then hire outride contractors roust submit a new affidav it indicating such.
tContractors that cheek this lxo.x must attached an additional sheet show ing the name of the sub-coruractors and state whether or not those entities have
employee' If the iub•cuntractors Ricci employee'.the) niu+l provide their v,orkcrs-comp.policy number.
I an:an employer that is providing workers'compensation insurance far my employees. Below is the policy and Job site
information.
Insurance Company Name: „sL a. z- r t� �. _
Policy tt or Self-ins.Lie.#: AWG ttao -enye-5intov.( 4 Expiration Date: 5 ( 1 ( Zak
Job Site Address: 1.-Pf1 b e c5�- City/State/Zip:X\cC' 0(1:5(Q0
Attach a copy of the workers'compensation policy declaration page(showing the policy number an expo don date).
Failure to secure coverage as required under MGL c. 152. 425A is a criminal violation punishable by a fine up to S1,500.00
aniVor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.0,0 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 err i•out t' pains and penalties of perjury that the Information provided above is true and correct
Signature: /t I)atc: € "Z`t'
Phone#: (
Official use only. Do not write in this area.to be completed by city or town ujjicial.
City or Town: PermitiLicense
Issuing Authority(circle one):
I. Board of health 2. Building Department 3.('it}``Tustin('led. 4.Electrical Inspector 5. Plumbing inspector
6.Other
• Contort Person: Phone#:
CONSTRUCTION CONTROL WAIVER
From: LL‘2_
(rc inA.6>c-*U\
To:
Building Commissioner
City of Northampton
212 Main Street
Northampton, MA 01060
The Massachusetts Building Code, section 107.1 allows for an exclusion from requirements for
construction control in certain situations. In accordance with code section 104.10, I request that you
grant a modification to waive the requirement for construction control of the project at
because the work is of a minor nature,will not affect structural elements, health, accessibility, life or fire
safety,and will be done in accordance with the prescriptive requirements of the code.
Thank you for your consideration.
Respectfully,
G •�