36-160 (3) BP-2024-1248
1104 HURTS PIT RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
36-160-001 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-2024-1248 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF 2024 Contractor: License:
Est.Cost: 5000
Const.Class: Exp.Date:
Use Group: Owner: DEARBORN SANDRA M
Lot Size(sq.ft.)
Zoning: WSP Applicant: DEARBORN SANDRA M
Applicant Address Phone: Insurance:
11 CAMINO DEL RIO
PORT ST LUCIE,FL 34952
ISSUED ON: 09/27/2024
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:
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: 72.
Fees Paid: S60.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
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City of Northampton
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Massachusetts
-• , DEPARTMENT OF BUILDING INSPECTIONS pi':
212 Main Street • Municipal Building
E � 1.:♦ '� �O ��
Northampton, MA 01060 L �
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS,ROOFS,RENOVATIONS,ROOF MOUNTED SOLAR, ETC.
f
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.
- CE/V
SEp The ommonwealth of Massachusetts
2 0211 and f Building Regulations and Standards FOR
assa husetts State Building Code,780 CMR MUNICIPALITY
USE
'°NTHq • Ap ication To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
Mq ofpZONS One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: 8/9- ay-/a t rr Date Applied:
4-v10 3 ��— q 27-Zo21
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address* 1.2 Assessors Map&Parcel Numbers
110Y PIS 0, R oki Nva1Nu►v46,11',(J 10
1.1 a Is this an accepted street?yes no TWV 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❑ On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own r'of Record: �� �"� �� M 1
Sc� e cl 4r N I I Ott 3Or li Q.4- Rc I)cr� 1l i&1
Name(Print) City,State,ZIP DO(,4g-
jtit $.ads 434
No.and Street �r')')a"!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 ❑
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Br f Description of Proposed Work2: ' S4-r. ,tl f'o . &S rGP . I.UG�er 11. J
Nor. Iva your t ��,Pr
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
Check No. ' Check Amount:
6. Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
r
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 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 Namc 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
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.
tU, qlrg-01C.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date 6
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"
1
= The Commonwealth of Massachusetts
�;j; Department of Industrial Accidents
;l 1 Congress Street,Suite 100
,_„. Boston, MA 02114-2017
;` www.mass.gov/dia
11u1kers' Compensation Insurance Affidavit:Builders/Contractors!Electricians/Plungers.
fU RE FILED 11 fill tilE PEIt111TIINC AUTHORITY.
Applicant Information `v �._`J Please Print Leeibly
Name 1 Business Organization Individual l: S e...1 d(I - a LA0)/3
Address: 1 I 0li B auks 61- R o
City/State/Zip: )ci4 O/0662 Phone #: I - 770 - (, 1166
.,re you an employer?('heck the appropriate box: Type of project(required):
I 0 1 am a employer with_W__ __emaployecs(Pull:oboe part-time).* 7. 0 New construction
-i__i lam a sole proprietor or partnership and have nu employa.-a working fur me in K. O Remodeling
any cify.[Nu wot{ters'carry.rntiarancY required.]
a humi.uw MY doing all worts myself.[No wot1 cs'comp,insuran lu ce retiucd.j
9. El Demolition
4.0 dam a homeowner and will be hiring contractors to cundtut all work on my property. 1 will
10 0 Building additioncontractors
ensure that all contractors either have workers'comperosatron ouanance or use sole 11.0 Electrical repairs or additions
proprietors with no cmpluyeut_
12.0 Plumbing repairs or additions
50 1 am a general contractor and I have hind the sub-contractors listed on the attached sheet
Theme sub-contractors tnvc employee and have workers'comp.insurance; 13 Roof repairs
60 We an:a curperatton and its officers have exercised their nght of exemption per Wit.c. 1 4. Other
152.'i 114I.and w c have no anpluyees.[No workers'comp.mummer required.]
'Any applicant that Cheeks box fir!mutt also till out the section below showing then sour►era cuntperrsativa puttA:y mt icination_
t tit/Mt:0w'neri who submit that affidavit indicating they are durng all work and then here outside cunttractora must submit a new affidavit indicating such.
!Contractors that check this box must attached an additional ahe et showing the name of the seb•cuattractcn and state whether to not dome satiates lisye
.npL.,cc. lithe mob-contra tea,base t,r5 ' ee .they, nww.t pros ids Bract aotkeim'cuznp.policy number.
I am an employer that Is providing workers'compensation insurance for my employees. Below is the policy and jab site
it firrvnalion.
lasurance:Company Name: _
Policy#or Self-ins.Lie.#: Expiration DatL
j 1 OLi e0 r15 1 ; -- RA cityistateZi,, i -1(4.1 tinA, 0/060)-
Attach a copy of the workers'
compensation policy declaration page(showing the policy number and LApiratton date).
FailurIlto secures coverage as required under 1 GL c. 152. g25A is a criminal violation punishable by a fine up to$1.500.00
and/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a tine 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 tint/pent/No of perjury that the information provided above A true and Correa.
Si •zm! -iww f. 202,e(
Phone::::
Official use only. Do not write in this urea.to be completed by ciii air toner of/ic cut
City or Town: I'crmii Licence#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.('ity;'town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
t'ont:iCt Person: Phone#:
a
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City of Northampton
f " Massachusetts ';
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DEPARTMENT OF BUILDING INSPECTIONS s; `;
/ 212 Main Street • Municipal Building f a
Northampton, MA 01060 Is ��-\"�
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: DCNA p5r-
Location of Facility: t GLfe_ LU 1L i Io,_ I rJc, 1.A _
The debris will be transported by:
Name of Hauler: W e tiNci 1.--
n1c..K i Lc
Signature of Applicant: Date: 1- 24, 24-72'1
R
City of Northampton _
= Massachusetts = ''.t,
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DEPARTMENT OF BUILDING INSPECTIONS �,j,°
Ktra
� y ." 212 Main Street • Municipal Building f'�
r
(y Northampton, MA 01060 "`- �'�0
HOMEOWNERS'EXEMPTIONELIGIBILITYAFFIDAVIT
1, �aNi all1' r )eCkel)0(10 i+ 69
I fI I'ILO (insert full legal name), born_(insert
month, day, year),hereby depose and state tde 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 swill act as the supervisor for said project or work.
Signed under the pains and penalties of perjury on this ol? day of 5eiy-k ,200g
r
Signature
1