29-433 (7) 19 ELLINGTON RD BP-2021-0009
GIS#: COMMONWEALTH OF MASSACHUSETTS
MW:Block:29-433 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categdry: KITCHEN RENO BUILDING PERMIT
Permit# BP-2021-0009
Project# JS-2021-000015
Est.Cost:$500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO.-
Const.
O:Const.Class: Contractor: License:
Use Group: KEVIN NETTO CONSTRUCTION INC 1317
Lot Size(sg.ft.): 10018.80 Owner: MOTAMEDI MATTHEW
Zoning: Applicant: KEVIN NETTO CONSTRUCTION INC
AT. 19 ELLINGTON RD
Applicant Address: Phone: Insurance:
90 Southampton Rd. (413) 527-3168 Workers Compensation
WESTHAMPTONMA01027 ISSUED ON.71212020 0:00:00
. TO PERFORM THE FOLLOWING WORK.-open kitchen wall
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:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department 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.
Certificate of Occupancy Signature:
FeeType: Date 1'a6d: Amount:
Building 7/2/2020 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
GDepartment use only
m � City of Northampton Status of Permit:
' Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
� 7 Room 100 Water/Well Availability
"_`:0 Northampton, MA 01060 Two Sets of Structural Plans
D G `�;�.► one 413-587-1240 Fax 413-587-1272 Plot/Site Plans
'3 CD Other Specify
Tt UTt APPLICAT O CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
W
RMATION
1.1 Property Address: This section to be completed by office
` J
Map ( Lot `1 3 Unit
19 Ellington Road
Zone Overlay District
Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Matt Motamedi 64 Prospect Ave., Northampton, MA. 01060
Name(Print)) Current Mailing Address: 413-219-8281
r
r I�14 ` �-}ci! t Telephone
Signature
2.2 Authorized Agent:
Kevin C. Netto Construction, Inc. Kevin C. Netto Construction, Inc.
Name(Print) Current Mailing Address
C Kevin C. Netto Construction, Inc.
Signatur Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed--by permit applicant
1. Building lJ v (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 +2 + 3+4+ 5) Check Number pl-
This Section For Official Use Only
Building Permit Number: i5 l Date
Issued:
Signature: r
ou
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) a✓ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [[--3] Other[17J
Brief Description Of Proposed Open kitchen Ncall to living room,add 2-9"LUL10 foot opening
Work:
X
Alteration of existing bedroom Yes No Adding new bedroom Yes X
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, V�i \� \ , as Owner of the subject
property
Kevin C. Netto Construction, Inc.
hereby authorize
t91 act on my behalf, in all matters relative to work authorized by this building pe rit ap lication.
1LdRr_ /"I, ,a 0�
'Z . 4
�-
&6'hitM of Owner Da e
I, as Owner/Authorized
Aq_ent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my—Knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Sign ture of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Kevin C. Netto
Name of License Holder
License Number
90 Southampton Road 001317
Address Expiration Date
Westhampton, MA. 01027 10-02-21
Signature Telephone 413-527-3168
9. Registered Home Improvement Contractor: Not Applicable ❑
verC.Ne'6�:,
Company Name Registration Number
103945
Address / Expiration Date
6 , 'Z� TeIephoney�-b 07-09-20
SECTION 10-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...... ❑
t: Massachusetts
�f
r
— �{y DEPARTMENT OF BUILDING INSPECTIONS
r -- > 212 Main Street •Municipal Building
: 7
Northampton, MA 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
(Please print "se se number and street name)
Is to be disposed of at-.
Q '�
(P ase prinf name a location of facile y)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
A'/'- C ( - v -LO
ignature of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The Commonwealth of Massachusetts
Department of IndustrialAccidents
a 1 Congress Street,Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual):Kevin C. Netto Construction, Inc.
Address:90 Southampton Road
City/State/Zip:Westhampton, MA. 01027 Phone#:413-527-3168
Are you an employer?Check the appropriate box:
Type of project(required):
1.[E)1 am a employer with 3 employees(full and/or part-time).* 7. ❑New construction
2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. ✓❑ Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]+
10E]Building addition
4.[:]l am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.[]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[]Roof repairs
These sub-contractors have employees and have workers'comp.insurance?
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box It 1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
AIM Mutual Insurance Company
Insurance Company Name:
Policy#or Self-ins.Lie.#:WCC-500-5008057 Expiration Date:03-01-2021
Job Site Address:19 Ellington Road City/State/Zip:Florence, MA. 01062
Attach a copy of the workers'compensation 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 fine 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$250.00 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.
1 do hereby ceerrtiffy under the pains and penalties of perjury that the information provided above is true and correct.
Signature: 1� C Date: (O 3 U
Phone#:
413-527-3168
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: