32A-248 (9) 43 FAIR ST BP-2021-1529
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A-248 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2021-1529
Project# JS-2021-002543
Est.Cost: $12850.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: FAMILY TREE AND HOME - JILLIAN SOUTHWICK - HALL
112720
Lot Size(sq.ft.): 21605.76 Owner: JASINSKI JOSEPH W&MARY A
Zoning: SC(100)/ Applicant: FAMILY TREE AND HOME - JILLIAN SOUTHWICK - HALL
AT: 43 FAIR ST
Applicant Address: Phone: Insurance:
PO BOX 3699 (413) 478-8159 WC
AMHER5TMA01004 ISSUED ON:6/24/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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.
•' r � ''1 •
Certificate of Occupancy si�gnatu. : i
FeeType: Date Paid: Amount:
Building 6/24/2021 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
The Commonwealth of Massachusetts /�'
�`
0) Board of Building Regulations and Standards ��-� F R
' IPALITY
Massachusetts State Building Code, 780 CMII✓1� 3 1•'`2 SE
Building Permit Application To Construct,Repair,RCM r Demolis�2 evil d Mar 2011
One-or Two-Family Dwelling _�f, h�1 p,
This Section For Official Use Only �4tr I(IN tiQpEcrro�
� lS
Buildin Permit Number: �'off/" /ca ' Date Applied:
c0„-) ' Kos 1 j/ 1,-2 -2oZj
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: c � 1.2 Assessors &Parcel Numbers 4 Q
1.1 a 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 0 Private 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record,
a t ,..) 03 k S (�.i do rl-itc"p-l'0>n M(k)
Name(Print) City,State,ZIP
Li 3 Q%tr SAIr4-11
No.and Street 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 Work': RA-vu.v� e.,).i.S'- J rOO�' A) A re i y -e.� c 1,e
�✓" sr•. EA,1',4.._ 5.ef k,� lKS ,t �„ rel,1 ltu.A .( rt)0ct A.5
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ t y S(,o6 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 $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fee
Check No. Check Amount: "/ if Cash Amount:
6.Total Project Cost: $ ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS II 21 20 tP 21 f22
(Iiha� )t1Ylivicic- (I License Number Expirht ion'Date
Name of CSL Holder
List CSL Type(see below) (J
3-I tif1e. sa':
No.and Street Type Description
�� ()I O V 1 U Unrestricted(Buildings up to 35,000 Cu.ft.)
City/Town,State,ZIP R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
2 H-'`% I Insulation
el one Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /?88 q 5 f 21�22
F �► ( d. J rfU>'1tnn HIC Registration Number Expiration Date
HIC Company N or HIC Registrant Name
some
an Street
' '' (5� 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 Iss a 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 /�► 0 � �'"��t `
f •
/ to act on my behalf,in all matters relative to work authorized by this building permit application. q ,n
s.
/ \ 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 i n '- ,. I plication is true .. , a .i, ate to the best of my knowledge and understanding.
p1/ /� /22l2f
Print Own: Authorized Agent's Name(Electronic Signature) l Plate
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(I IIC)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
YM�M��
a° 'Oav Sys.... sic
Massachusetts LL/ a� !c•
gtJi
k ` x'• 9 DEPAR22 ENT OF BUILDING INSPECTIONS 74
.-* ,414 w =, 212 Main Street • Municipal Building ZJ` .:b
. i., Northampton, MA 01060 rsy .• `moo i
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: A & C % 0 Vi°(,,r(- /Y 1A
The debris will be transported by:
AO
Name of Hauler: � T — �C:1t' ' Y - 4344A-C---
Signature of Applicant: Date: `���-02)1 °1a 94
The Commonwealth of Massachusetts
,t el. Department of Industrial Accidents
=tip._E
__,:>♦11 ; 1 Congress Street,Suite 100
Boston, MA 02114-2017
wwx.mass.gov/dia
11 urkers' Compensation Insurance Affidavit:Builders"(iintractors/EkctrklanstPlumhers.
1'O RE FILED WITH'I iiE PERMl'Err(;AUTHORITY.
Applicant Information Please Print Leeibly
Name 1.8ustr►es5-Organ►zauoa lndiv!dual
•
►:
Address: S.-7 T'I in e S+t'e4--
C:ity/StatefZip:134,lCke -4,1 /'1 A OIOC)Phone #: /j3"`1 in-a(SQ
Are you an employer?Chuck the appreprlaic box:
Type of project(required):
1.21i an a employer with ! employees!Cull and or part-ureic I• 7. 0 'ew construction
lam a sole prupnetur or partnership and have no enmluvees working for me in K. Remodeling
any capacity.[No workers'comp.utauranu require(.]
9. ❑ Demolition
t.01 am a homeowner doing all work myself.[Ado workers'comp.rn.untnte n-gurnd j'
I0 o Building addition
40 1 am a homeowner and will be hiring rxmuacturs to conduct all a ,rk on my property. I will
ensure cure that all contractors either have workers'compensation entrants or are sole I I.❑ Electrical repairs or additions
proprietors w ith no employees. I I❑Plumbing repairs or additions
v{:1 I am a general contractor and I have hired the sub-eontraetun listed on the attached sheet.
These sub-contractors have employees and have workers'comp.rresurtnce. 13❑RuUftepatr5
6.0 Vie are a corporation and its officers have exenised then nght of exemption per MCiL c.
14.❑Othet
132..§l(4),and we have no employees.[No workers'comp.insurance requm:d.j
":any applicant that checks box Ri must also till out the section below showing their workers'compensation policy infox:natiuti.
r Homeowners who submit this atl'idav it indicating they are doing all work and then hue outside contras:toes mint subnut a new atfulavit indicating such.
:Contractors that check this box must atta:li d an additional sheet showing the name of the sub-contractors and state whether ev not those entities have
employees. If the suhrcuntract+.vs have employees.they must provide their curlers'comp.policy nurnb:r
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
Information.
Insurance Company Name: Am
t�lu1U11J�
Policy#or Self-ins.Lic.#: \NL' (00— ft 2I Ll— Expiration Date: -?/22/21
Job Site Address: 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 S1,500.0X)
andlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA fur insurance
coverage verification.
I do hereby certify er the pain and penalties of perjury,that the information provided above is true and correct.
Signature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town officiaL
('its or Town: Permit/License#
issuing Authority (circle one):
I. Board of Health 2. Building Department 3.Cityrlown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#: