18C-165 49 WARBURTON WAY BP-2021-1183
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C- 165 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BASEMENT RENOVATION BUILDING PERMIT
Permit# BP-2021-1183
Project# JS-2021-001978
Est.Cost: $15000.00
Fee:$97.50 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 0.00 Owner: ROKOWSKI JOSEPH
Zoning: URB(100)/ Applicant: ROKOWSKI JOSEPH
AT: 49 WARBURTON WAY
Applicant Address: Phone: Insurance:
49 WARBURTON WAY (401) 309-2685 ()
NORTHAMPTONMA01060 ISSUED ON:4/14/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:BASEMENT RENO
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.
� 1 5• .1-1
•
Certificate of Occupancy Signature: • r ' 1
FeeTvpe: Date Paid: Amount:
Building 4/14/2021 0:00:00 $97.50
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
I11=UCIVIL`.
APR 1 4 2021
i
14 The Commonwealth of Maslsga ft$,ILOING INSPECTIONS Board of Building Regulations T" N. ON•MA 01060 FOR
MU
��' Massachusetts State Building Code, 780 CMRNIUSE LITY
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building P rmit Number: $ p—a,(./( $3 Date Applied: 'Y��3/o7/
0,0 �i�,5 1 -2y-Iy-Zvzi
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1.4 PropertyZddiess:L 1.2 AssessItap&Parcel Numbers 6,
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❑ Private El Municipal— Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow r'of Record: G` L ��
Jose $�cur+0+c �Mtv5r—r A(a— 'la 2,4,-. /1 i 9 2/a
Name(Print) ) / / City,State,ZIP
At, (1c4 4.4• +•, 424.7 `%3 75--7vf/7 T-G/`,vc.Jsie J 6'C'c�,, llgo.,G
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building..- Owner-Occupied lr Repairs(s)ee Alteration(s)Kr Addition 0
Demolition ,2 Accessory Bldg. 0 Number of Units I Other 0 Specify: ..,s"�f /1k J-S
Brief Descc ption of Proposed Work2: hie et.,_, - o� ' • ,sh /s .3" ce
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $
36vO 0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ Goav 2. Other Fees: $ 9 7-54-
4.Mechanical (HVAC) $ sap) List: C-j ,1/4- /,5" _ 97-SO
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check Noll/..1 Check Amountl �_ Cash Amount:
6.Total Project Cost: $ / a� aid in Full 0 Outstanding Balance Due:
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 Name 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 .❑
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' application is true d accurate to the bes of my knowledge and understanding.
Pri er's or Authorized Agent's Name(Electronic Signature) Date
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"
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
• / e'4
AO. / Co'
? �. 1
v ,tm � L
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton
o =" s - s
w Massachusetts mow `` . `'ec
W x
g, 1 , z� . DEPARTMENT OF BUILDING INSPECTIONS % it
W fi 212 Main Street • Municipal Building v�. ..t,
$ Northampton, MA 01060
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.
/1 /e(/
-74o 4 CtLLc c G %lc� <77;,,
. , ,-/s'7 / C'=S Gf/=5- - --s, "1-19 �// /d/
/ V
The debris will be disposed of in:
Location of Facility:
The debris will be transported by:
Name of Hauler: T3I
Signature of Applicant: �� ��/v/ " Date: //.3Z7/
The Connnoitlyealth of Massachusetts
Department of Industrial.4ccidents
, 1 Congress Sweet,Suite 100
Boston,M.4 02114-201
'•.0
tr-trw. ss.gar/dia
wkirkers*Compensation Insurance Affidavit:Buikiers'ContractorsElectricians-Plumbe r
TO BE FILED NAITH 1 Ht.PIEMIITTING AUTHORITY_
..3rpplicant Information Please Print Legibly
Nanie 03ininess.Orpramtioni...
Address: /-/,
City/State:Zip: V‘‘--// ..,-,i,"(•••-t Phone 4: A7/ 3 - - 7c,r-7
_—
Are you am employee!Check du appropriate box: Type of project(required):
Is= ruspl..7,..si srt . employaos iron ander part-tirce).• 7 Ej".`:ew et:mut:ruction
ElI orn a sole propnetc:c:parceership and'nava no otopkiyees wciaina fax me on S RP_MOrieling
my capacity.[No secrhan'comp.=1331=4 reczimi)
9 Demohtion
1(13.1 tun a homeowner dome aL wart nr..aelf.(No workers'comp atm.-once
10 13 Britt/ire addition
4.0 I am homeowner and will be hiring contrarian to zooduct aro on my property I will
efaura that 1141 cantractors orthar have workers'romponacion il31=1.1:3 CC aZa o! E 11.0 Electrical repair:ot additions
proprietcc;with no employms
12.0 Pharabing repair:or addition:1
a amoral caotrairar and:have imad the sot-c CUZICE011 hstod c 3i1+3 attached shear
.[DRoof repar-,
These sub-contrwtors have scap havor ioyaes and e workers.'comp.1.73;3313C34; 1
14.Ej Other
0 We are a corporaton mei officers:11113 exercised thair narc of arempoco par IVGL c
152,11(4),and wo have ao omploysaa.[No workers comp :manioc*reconed.).
— - .
'Any applicant that chocks box al must also ell out tha lemon Wow tho-3:12hair c c.c..7.33.1313312 policy information
licsarnowisars who submit that 215dasit talicammy they am doing all wort 3341:34.11 hass snide cot actors mint vskinz a dew afficlarcr:iredicanns such
:Contractors dam chay.-1.Otis box mast=loned an additional dame showing iba came of the sob-contruttat and state whathar cc aol those armies have
amplorial If:ha-.=i:s-iontracrars have ortmlo7mos,crag mast peok-rda Moir warier-1'comp pelicy=rubor
Jam an employe-7-that is providing workers.'compensation insurance for tny employees. Bela.4 is the policy and job site
information.
hnuarxe Ccampauy Name:
Policy*or Lic. Expiratton Date:
Job Site Ikddress: CityStatelip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure co required under MGL c. 152.§25A is a cnminal vioLaton punishable by a fine up TO$1,5C0 00
andior one-year implasor-nrent a:well as civil penaltiesin the form of a STOP WORK ORDER and a fina of up to S250,00 a
day apirv-,t the violator.A copy of dau statement maY be forwarded to the Office of Inv -tigaticm-of the DLL,for nrurance
coverage verification
I do hereby certify u he ant I pt af perjury that the information provided above is true and correct
Si mature: e Dates '47, 7/27
Phone= /7/3
Official use only. Do not*site in this area,to be completed by city or town official
City or Town: Permit License u
L'.:11111g Authority(circle one):
1 Board of Health 2.Budding,Department 3.CityTown Clerk 4.Electrical Inspector 5,Plumbing In:pector
6 Other
onzact Per:ou Phone
S 4
City of Northampton
Massachusetts t.. 'f•!{c
e.
N DEPARTMENT OF BUILDING INSPECTIONS S
212 Main Street • Municipal Building he it
�',',',,� 4�
Northampton, MA 01060 —0f
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
r
I, NIG'S Pr/ 74 4,4 ' (insert full legal name), born c7h G5 (insert
month, day, r), 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.
r
Signed under the pains and penalties of perjury on this /g day of 4.--.7 ,207(
( ' ature)
7.'"•'`f4-41Pci o?,,4-2,C, ),/:* '04?-1.,...,!/ P )d'ov u ,:?,•7 -
jr,I,E1 7 --....,0
r...1 •
...„:„,,-,a/ ,,Avi 2-27-47 c/ .7.,.514-0,-).,7 .
'--- ,,..„0/ x„
ey-- "6"47y0 ...,',CA>4. 1''
.74_41P1/4,10,2 .1) 1 Ol- j/ /.(1 • i :714-*
S/fV/ I 'C'../714,Z17__C e7 •
...„-orzo/17 .i> .. e •
t - Jo/
---
_.. , .
•
. - --- 7esk
______
..1)
...\------ ,$
---A -t
-----`r
— --1 .......-.-.
•"‹.; , I-. ' ...^---'-'
(
c.)\\
4.N't
I ' ''• i
---.I
iegd"
ric/,
1 !
f 47,1.1.` . •
I i ce%
,o/
..___
,--)
aco,y..../..1-2.71
I
‘i01(4. 6-',If.e:1)fg41 '4:rrVZ-
lyi I
I .4)or7 ),
--._
Cs., SPA'
)I
iW; 7
_--------- ---
i i
..,--------
--- / /I
. ,.,....-.
———.—--•--—-—---"
).0/C// /