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23A-178 (6)
24 PINE ST BP-2021-1253 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23A- 178 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: REPAIR BUILDING PERMIT Permit# BP-2021-1253 Project# JS-2021-002079 Est.Cost: $5000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq.ft.): 6185.52 Owner: GARDNER ROBERT R&MARY F ALBE Zoning: URB(100)/ Applicant: GARDNER ROBERT R & MARY F ALBE AT: 24 PINE ST Applicant Address: Phone: Insurance: 24 PINE ST (413) 586-0772 () FLORENCEMA01062 ISSUED ON:4/28/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:REPAIRS TO FRONT PORCH 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. A Ar Certificate of Occupancy Signatu . . FeeType: Date Paid: Amount: Building 4/28/2021 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner , R .----O------- The Commonwealth of Massachuse s ��0Board of Building Regulations and Stalard�P� 2 8 202/ ICI>'ALITY Wt Massachusetts State Building Code, 78 R USE Building Permit Application To Construct,Repair, Ren'R*Rta li R ised Jl1ar 2011 One-or Two-Family Dwelling rTiv.mA o cri°Ns This Section For Official Use Only �` ----- _ Building Permit Number: 64',41'.1153 Date Applied: .Aw,n) Koss lei.Z3-zdal Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Nufit7 -.4w P 1 rt B SFcLWi a-3 A 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.V gjng Information: 1.4 Pronely Dimensions: 5S Zoning Districti Proposed Use- Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flooddone? Public Private❑ Check if yes Municipal f2rOn site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'tL of Record:l (77 AM t ri T f-1'O V t) rtA 0 k Otoc)- Name(Print) City,State,ZIP d'-1 41►JE S 1 r 41S•S 79.5 ff8 rIR TS)-jf moo. e11 No. and Street Telephone Email ress SECTION 3: DESCRIPTION OF PROPOSED WORK2 check all that apply) New Construction 0 Existing Building 0 Owner-Occupied Er—Repairs(s) B-I"Alteration(s) 0 Addition 0 Demolition e Accessory Bldg. 0 Number of Units I Other 0 Specify: Brief Description of Proposed Work2:_r o s� tpt•Aisi 41 j'tt p e 0 kkeee.4 • (,cpLLcz_ kkooe i�n t o0 rhdllas A• lr.Sl�$ Ca;1: sin ctv- S. �-5SCOS e *' •re•L `� 6 c waft e 4 TR 1 � S �1JGA ss� (Y1).4J' oS' [K��i�[ tts n�ttss r'�• SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ S 000 1. Building Permit Fee: $ Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ 0 Total Project Costa(Item 6)x multiplier x 3. Plumbing $ 2( 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire Suppression) $ Total All Fees: 0 lit Check No. ill Check Amount: kr) 6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due: City of Northampton of " as Massachusetts '?er DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building + aft* Verr 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 specification 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. Homeowner's License Exemption Form(if applicable). 8. Mote any Special Permit requirements (if applicable). 9. Energy Code-all new construction(Gut/Rehab) requires an HERS Rater Affidavit. 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.) City/Town,State,ZIP R Restricted l&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone - Email address D Demolition gistered Home Im rovement Contractor(HIC) t al to 40(0.7 f '44 F HIC Registration Number G. piration Date Company Name or HIC egistrant Name $Cl D PO Veit - 0109%cVairkrli n.I.clDel No.and Street address 1ej $)1A ©t0%.0 `lt'j•`'{' ' tIa- 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 . ❑ 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. 4 1( R - 1012.1 Print Own is or Authorized Agent's Name ectronic 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 Superyisor 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,fmished 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" The Commonwealth of Massachusetts 01 Department of Industrial Accidents -...01111,,lar k . _-. 1 Congress Street, Suite 100 Boston, MA 02114-2017 wwwmassgovidia ;•,„ Workers'Cocnperisation insurance Affidavit: BuildertiContractorsiElectritiansiPlumbers. To RE FILED WITH THE PERMITTING AUTHORITY. Applicant Informatioia Please Print 1.teibls Name(BustriessiOrganizationlindividual y : atI_ __ISAI__ Address -4 V,Itr\a-SA". f Vcicen‘Ce,,I ti A City/State/Zip: Ticcerg"s1 A 0 to L, -. _ Phone #: 9 1 •51)4 • 3 4 _ AS;yea tW eamplayerl Cheek the appropriate boa: Type of project(required):. Lot ant a employer with ,employee%troll dant'or rtune I,* 7. 0 New construction 2C3 I am a sok proprietor or pannership and have no employees working for me in $. ErG-modebrig any capacity,fNo workers'enmp.insurance rOgiii11311 9. Demolition 0 -- =- • a homeowner doing all work trwielf,[No workers'comp.innarance required]' •,,, 10 El Building addition 4 M a homeowner and will he hiring contracturs to conduct all work on my property, I will mane that all contrackitA either have workers'compensation uniunance UK art sole 1113 Eloettical repairs or additions propneton with no employeni, 12.0 Plumbing repairs or additions k 0 I inn a general contractor and 1 have hired the substontracton listed cent the attached sheet 13.0 Roof repairs More subsamtractors have employee%anti hive workers'comp.innigninCt.' , 14.10 60 We are a COrptlfainin and its officers have exercised their nate of exenwtion per AttiL e. other I , It 4 t.and we have no employees.[No workers'comp.insurance re-qui:evil 'Any Appiscant that clio.,k A IV k 1'1 moat atao fill mit die section below showing their winters'compensation pulley information, t lionavvw tiers who submit due affidavit indicating they art doing all work and then hoc outtinkt contractors must submit a new affidavit nidicming such. :Contractor%that chock Met box must attached an additions/sheet%towing the name of the sabwaintritetoes and state whether or not those entities have empluyeea.. If the au .seat havoc ouployees.they mutt provide their workers'coin ,whey number lam an employer that Is providing workers"compensation insurance for my employees. Below Is the policy and job site information. Insurance Company Name: — — Policy#or Self ins Lie.#: Expiration Date; Job Site Address: City/State,'Zip: Attack a copy of the workers'compensation policy declaration page(showing the policy number sad expiration date). Failure to secure coverage as required under'VIOL c. 152,%25A is a criminal violation punishable by a fine up to$1,500.00 anttor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 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 paint and penal ' 0 ' ury that the information provided abase is true and correct. - ; •1', ,,,, i ,,,.:,11AltAA1—)/(1,14'3-4"11.—.____ Date: ili7i..2 I --'---,'W;, Phone#: tif 5 - -574-3110r Official use only. Da not write in this Aired,to be completed by city or town official City or'Town: Permit/License# ,, Issuing Authority(circle one): I. Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5. Plumbing Inspector 6.Other f'ontact Person: Phone 4:-- - -- j City of Northampton -04 )001 Massachusetts �?* f , DEPARTMENT OF BUILDING INSPECTIONS .? 212 Main Street • Municipal Building c3a,, fi* tea, Northampton, MA 01060 ^"t 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: \)GAe V,ec,J.�41 ^- The debris will be transported by: Name of Hauler: e).owQ.c.1- Signature of Applicant: 1____4�/1�-w1 Date: i{/27/2I_ 1J I City of Northampton ./ pry Massachusetts ,' . ,„'pr tit DEPARTMENT OF BUILDING INSPECTIONS r'' 212 Main Street • Municipal Building ��\ fib $Northampton, MA 01060 HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT �,�I 415)Sz I, ?vz C1 (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 O ' r aii of 2 7 , 20 Z/. • (Signature) cit ,, 1/ 11 Y 1.443vo 4 7 4y �?� c. 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