41-022 (7) BP-2024-1475
1095 WESTHAMPTON COMMONWEALTH OF MASSACHUSETTS
RD
Map:Block:Lot: CITY OF NORTHAMPTON
41-022-001
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2024-1475 PERMISSION IS HEREBY GRANTED TO:
Project# SIDING REPAIRS 2024 Contractor: License:
Est. Cost: 4200 JAMES ROBERTS 099404
Const.Class: Exp.Date:01/21/2026
Use Group: Owner: TANUDJAJA COWAN,DAVID M&AMBER L
Lot Size(sq.ft.)
Zoning: WSP Applicant: JAMES ROBERTS
Applicant Address Phone: Insurance:
30 Edwards Rd (413)527-6078
WESTHAMPTON, MA 01027
ISSUED ON:11/04/2024
TO PERFORM THE FOLLOWING WORK:
REPLACE SIDING ON CHICKEN COOP
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:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: I:70
Fees Paid: $220.00
•
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
PHECEI v Ei
f
NOV — Q 2024 fBoaofBuilding
Commonwealth of MassachusettsFOR
Regulations and Standards MUNICIPALITY
Massachusetts State Building Code, 780 CMR
�1 :�•--�'N.a I,;rR!,6�' tiiit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
_ �►1� 1��c�'�� 11P eP
One-or Two-Family Dwelling t
This Section For Official Use Only
Building Permit Number:011,0W- /L Date Applied:
5,7E teiclicep //'V
Building Official(Print Name) azure Date
SECTION 1:SITE INFORMATION
1.1 Property Addr_ss: ' h- n`/h Th,,..- 1.2 Assessors Map& Parcel Numbers
Li a Is this an accepted street?yes f 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 CI Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 07,r'of Record: eze,
17,4•t_ 7/(/P -Name(Print) ( City,State,ZIP d�/
I� 7,5- , ,(4,7„'--- ��No.and Stree 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 0 Specify:
Brief Description of Proposed Work2:
_ervitz?,v,...(7e
SECTION 4:ESTI ATED CONSTRUCTION COST
Item Estimated Costs: Official Use Only
(Labor nd Materials)
1. Building S 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 66 2. Other Fees: S
4. Mechanical (HVAC) S ! List:
5. Mechanical (Fire
Suppression) S Total All Fees ��:
Check No. ,�jMheck Amount:
6.Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
$)/
(Lj
City of Northampton
Massachusetts
�r G
! � i ! DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
` Northampton, MA 01060
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 L' e(CSL) a Pf q (�o q /—2/i G
License Number Expiration Date
Name of Holder /el
List CSL Type(see below)
No.and"Street Type Description
U Unrestricted(Buildings up to 35,000 Cu.ft.)
ZIP 1 R Restricted I&2 Family Dwelling
City/Town
M Masonry
Roofing Covering
Window and Siding
}/d 2 ^441
4/ ` /13 5� Solid Fuel Burning Appliances
-Zi7 `� I Insulation
Telep ne /
" Email address D Demolition
5.2 Registered Ho e Improvement Contractor(HIC) /r7/4.3-y
HIC Registration Number xpiration Date
HIC Company ,me or HIC gistrant Name
tn
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 ❑ 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 authori d by this building emit application.
� � cereeproy64..._ /._-g
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.
' ,ti,,,,ye f1Liy9q
Print Owne or Authorized A enName(Electronic Signature) Date
g
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"
t
The Commonwealth of Massachusetts
w�° Department of Industrial Accidents
MI-. 1=r 1 Congress Street,Suite 100
_:, =. Boston,MA 02114-2017
www.mass.gov/dia
VI inkers' Compensation Insurance Affida%it:Builders/Contractors/ElectriciansfPlumhers.
TO 11L FILED WITH THE Pk:l0l1'TI INC AtITHO IT%.
Applicant Information Please Print Leiihh
ionic(BissinessiOrgantuttionilndividwiti:
Address: O ��
CityfState/Zip: k7ert.) 4r Phone#: 6/(,3-'4-{4-( -- 0 3,5`-S
Are yam an onpltryte Check the appropriate twit; Type of project(required):
la I am a employer with _ employes(full andeor part-time)-* 7. 0 New construction
la am a sole proprietor or partnership and have no entploytxs working for me in 8. 0 Remodeling
any eapseity.(No worker'coup.ut3ura11ee nvunil.)
30 I ant a homeowner doing all work myself. Idowatios'comp.nrwrancc minima r
9. [ Demolition
4.0 I am a homeowner and will he hump centracitlrs to l.undtteu all work o n my property. I will r�
10 0 Bwldtng addition
ensure that all contractors either have workers'compensation rJttturince or are sole I I.LJ Electrical repairs or additions
pruprorturs with no etnpluyetac 12.0 Plumbing repairs or additions
S0 I am a general contractor and 1 have hinvl the sub-contractors Listed on the attached sheet 13 Q Roof repairs
These sub-contractors h ve employees and have workers'comp,insurance;
6.0 We ate a corporation and its officers have exercised their rr right of exemption !4_ then _---
3Kg per MCA.c.
152.*I(4).and we have no rnaplu:fees.y[No workers'comp.insurance required.'
*Ant,applicant that checks box ni most also till out the idect oit below showing their workers'contperraation puttey oifonnth4xt_
r Iletrteownets who submit this aftidav it uuficatrrag they an doing all work and then hire outside c'urttracte:rs must submit a new at€'ulavit indicating such.
=Cilium:tors that check this bon must an:wised or additional shut showing the name of the ill b-evagmettsci and state whether or not those.:entities have
employees. If use sub-contractors base employees.they most provide their a miters`conlp.policy number.
I am an employer that Ls providing woriters'competes Ion insurance for my employees. Below is the police'and job site
information.
Insurance Company Name:
Policy g or Self-ins.Lie.*: Expiration Date:
Job Site Address: City/StateeZip:
Attach a copy of the workers'compensation policy declaration page(showing the policy nun er al expiration date).
Failure to secure coverage as require under MGL c. 152.§,25A is a criminal violation punishable by a line up to 51,500.0(1
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK.ORDER and a fine of up to 5 300.00 a
day against the t,iolator.A copy of this statement may be forwarded to the Office of Investigations of the D:IA for insurance
coverage verification.
I do hereby certify under the pains a nobles of perjuty that the information provided above is true and correct.
Signature: Date: . " e-
Phone#: C4. .`3 --Oct( f--03 7)
Official use only. Do not write in this area.to he completed by city or town official
City or Town: Penult/License
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.CIty'iTown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone 4:
City of Northampton
•
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS `
212 Main Street • Municipal Building ,
Northampton, MA 01060 :11';Y
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: r,j704—
The debris will be transported by:
Name of Hauler:
Signature of Applicant: Date: // `ff
City of Northampton
� =�' ', Massachusetts �4t?s'
4
4DEPARTMENT OF BUILDING INSPECTIONS 7i
7.0. 'ti`.yr' 212 Main Street • Municipal Building v�•, P�
'{,o Northampton, MA 01060 'rio., ...-'"';
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, (insert full legal name), born_(insert
month, day, year), hereby depose and state the following:
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 day of J 20 .
(Signature)