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29-241 (6) 7 GOLDEN DR BP-2021-0089 GIS#: COMMONWEALTH OF MASSACHUSETTS Map.-Block:29-241 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation BUILDING PERMIT Permit# BP-2021-0089 Proiect# JS-2021-000139 Est.Cost: $15000.00 Fee: $98.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: - Contractor: License: Use Group: TOSHI KASHIMA 060134 Lot Size(sg. ft.): 10497.96 Owner: YANLONG GUO zoninpz: Applicant: TOSHI KASHIMA AT: 7 GOLDEN DR Applicant Address: Phone: Insurance: 15 UNION ST (413) 774-5402 _ WC GREEN FIELDMA01301 ISSUED ON.712312020 0:00:00 TO PERFORM THE FOLLOWING WORK.-GARAGE RENO TO LIVING SPACE 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 SilInature: FeeType: Date Paid: Amount: Building 7/23/2020 0:00:00 $98.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner The Commonwealth of Massachusetts VAIN 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 T 's Section For Official Use Only Building Permit Number: Date Applied: Tj�U_X Building Official(Print Name) Signature4 Da SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assess rs Map&Parcel.Numbers lX l.l a Is this an accepted street?yes t/ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(d) 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❑ Private❑ . Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSWPI / 2.1 Owner'of Record: Name(Print) 00il City,State,ZIP X13- 0��3 60 d slrli-�1�, No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction-0 Existing Building❑ Owner-Occupied ❑ 'Repairs(s) ❑ Alteration(s) 13 Addition ❑ Demolition ❑ Accessory Bldg.❑ \lumber of Units Other ❑ Specify: Brief Description of Proposed Work2: D 7,v,,1(1 s Q )vl SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials) 1.Building $ L bo© 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ -2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ 6.Total Project Cost: $ Check No. Check Amount:_C_- Cash Amount: ❑Paid in Full ❑Outstanding Balance Due: �u o q17 ��9 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 1 X64 t 3 C o 2@ License Number Expiration Date Name SL Holder '1 � VJk — �\--rJJ�� List CSL Type(see below) No.and Street \ ype Description Unrestricted(Buildings up to 35.000 cu.ft.) Restricted 18:2 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 5.1 Registered Aome Improvement.0 ntractor(HIC) oql 2-t 1•11C Registrati 41he Axpirutioftate MC Company Name or HIC Registrant Name t� No.and Street `� �C 7 Email address ca 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.......... 13 . No........... ❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR A—PPLIIES FOBUILDING PERMIT I,as Owner of the subject property,hereby authorize v�1!�_ C /l to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Dat 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. Print Owner's N Authorized Agent's Name(Electronic Signature) Date NOTES: . 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 tvww.mass�ov/oca/oca Information on the Construction Supervisor License can be found at«ww.mass. ov/dpss 2. When substantial work is planned,provide the information below: Total floor area(sq.fr.) (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"maybe substituted for"Total Project Cost" i The City of Northampton Building Department 212 Main Street Northampton, Massachusetts 01060 Phone(413) 529-1402 Fax (413) 529-1433 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance with the.provisions of MGL c40, 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___?=o= �� b _ CV "` �.QU oc3 The debris will be transported by: Name of Hauler— 1^-_U\I.-c _ ' — — — — — — — — — — — Signature.of Applicant :—_ ___- _1, — ——— Date:_ l l I The Conttnonwealtlz of Massachusetts Department oflndustrialAccidents 1 Conb ess Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia NVorkers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organizadon/individual); Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.2 am a employer with —' employees(fill)and/or part-time).* 7. E]New construction 2.[71 am a sole proprietor or partnership and have no employees working for me in S. E]Remodeling any capacity.[No workers'comp.insurance required.) 3.F71 am a homeowner doing all work myself.[No worker9. ❑Demolition'comp,insurance required.]r 4,7 I am a homeowner and will be hiring contractors to conduct aII work on my property. I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 1 LQ Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑l am a general contractor and 1 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. 1,4.❑Other 152, 1(4),and we have no em to ees t § p y [No workers'comp.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compeusadon policy information. t Homeowners wbo 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site arfornratiOn. ` Insurance Company Name: t Ld l L4 L Policy#or Self-ins.Lic.M_Uur - Expiration Date: Job Site Address: � ��V City/State/Zip: 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 certify under the pains and enaldes of perjury that the information provided above is true and correct Si--nature: Date: ? C Phone 4: Z 2 Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitfLicense# 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 4: 15x \-;� W/rA o 1 J w I _ 6 -v4A�