24C-096 (5) 73 MASSASOIT ST COMMONWEALTH OF MASSACHUSETTS BP-2021-1803
Map:Block:Lot:24C-096-
001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2021-1803 PERMISSION IS HEREBY GRANTED TO:
Project# Contractor: License:
Est.Cost: 7470
Const.Class: Exp.Date:
Use Group: Owner: MELLEN KATHLEEN A TRUSTEE
Lot Size(sq.ft.)
Zoning: URB Applicant: TRUSTEE MELLEN KATHLEEN A
Applicant Address Phone: Insurance:
73 MASSASOIT ST
NORTHAMPTON, MA 01060
ISSUED ON:08/30f2021
TO PERFORM THE FOLLOWING WORK:
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.
Signature: I• , . 511i
Fees Paid: $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
R`CEI RECEIVE
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AUG 2 7 2021
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ulCD1n",,to on ealth of Mass NORTHAMPTON MA 01060
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'otigudin Regulations and Standards OR
Massachus e Building Code, 780 CMR MUNICIPALITY
USE
Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
s Section For Official Use Only
Build' g Permit Number: ' "f W 3 Date Applied:
Ki:v Uu 100,5 / /G- 8 Z-7-zozi
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
- o,i5-1-.
1.2 Assessors Map& Parcel Numbers
1.1a Is this an accepted street?yes r no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O er1 of Record:
�.#0e11 f e//eh /f ar r x, in/1.- 4/06 0
Name(Print) City,State,ZIP
I& .M-et ssa'E 51. Vi3--6.9_c b D,qZ km-e_ilet»/,r Crr7Q 1/(ova..
No.and Street Telephone Email Ad res
V1ON 3:DESCRIPTION OF PROPOSED WORK'(check aft that apply:)
New Construction 0 Existing Building$, Owner-Occupied ($ Repairs(s) 0 Alteration(s) K1 Addition 0
Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2:X'pfy\UUl, Ctthihds'Sir-eh/ill,wOas(fritteli • 4,p14. -e
SECTION 4:ESTIMATED CONSTRUCTION COM
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ if tJ-70. 1. Building Permit Fee:$ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ �eV. 0 Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $►
Check No.0 a '7 Check Amount:
6.Total Project Cost: $ 1 V 70,07) 0 Paid 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 71g.OWNED'OR A[.ITBORIZED AGorr 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.
{4a-14k44er M. 'limo ./(v, zez I
Print Owner'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"
The Commonwealth of Massachusetts
==-71. Department of Industrial Accidents
+may 1 Congress Street,Suite 100
} t1 Boston,MA 02114-2017
,�� KWw.mass.govidia
in kers' ( unspensatiou Insurance Affidavit:Builder i('ontractors}Elrctriciansi lumbers.
10 BE FILED W7T11•1111{PERMIT-11M;:11 111t)1t111.
Applicant Informal- Please Print Let,ibls
Name t HusinessKhpanmatton lndit aJual l:
Address:
C'it} State Zip: Phone :
Sri you an cmptyrr:'(btc►the appropriate Iwo: Type of project(required):
1 I am a employer nail employee.Ifu11 and are part-time I..* 7. PIeW construction
3 I am a sole proprietor or partnership and bale art employer-,Nohow tor me in B. o Remodeling
capa ity.[No*utters'comp.insurance nquirt:J.I
9. El Demolition
r a fih.11900441113 doing all+wail tmxlt..this Mortar+.-tong* an ura n e required
10 Q Building addition
a lr/nwvwir-a and n ell he tumor ctwMraniors to conduct all%oak on my property. I w ell
Wm:that all contractors either laic workers`comperi.altrat insurance as ae ode I I a Electrical repairs or additions
proprietors with no eanployec%
12.0 Plumbing repairs or addition.
1 ant a general contractor and i hate hired the,uh-cclniraeicrrs listed on the anacticd lit i_
130 Roof repairs
The.c soh-contractors lute eanpluyees and have*writer,'comp.tnwuranui.
6.0 N'c are a earpoaation and its officers hat a exercised then nght tit exemption pa t►t(il.
14.0 Other
I52-yI141-and we hate no unplotec,.(No*orL-m'comp.mwranee required.'
"Ant applicant that checks box=I rn net alvl t/lit out the section heloK shooing their worker,:e'onipcn.au .nun policy urmah un..
t ItaMil1.13Mk s rt*hit submit this atltifat it intieatintr thief arc doing all nosh annilinia hire outslwk ennarachies mist submit a now atfda%it notitatirr.,ta,.h.
:(ontracton that check this box must attached an additional sheet shtrw.ngthe Rame of the.ub e, fi:tctut%and'late wfidhcr or not those entitle,here c
ernplo}ees. It the sub-contractor.have 1.1110 lr..k ens,they nuts pn+idc dote winker.•comp.potict number
1 am 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.Lic. =. Expiration Date:
Job Site Address: City'State?Lip: _
Attach a cops of the workers'compensation polka declaration page(showing the policy number and expiration date).
Failure to secure cuserage as required under Mi(L c- 152.§25A is a criminal violation punishable by a line up to S1.5(KI.(KI
and or one-year imprisonment,as well as cis ti penalties in the form of a STOP WORK ORDER and a tine of up to S2501.10 a
day against the stolator.A copy of this statement may be forwarded to the Office of Investigatloms of the DIA tiff insurance
coserage s'enticatiun.
I do hereby c rllfi•under the pains and allies ofpe •that the information provider!above is true and correct.
Phonex: l� ��9.� �2
Official use only. Do not write in this area.to be completed b) city or town official
City or Town: Permitilicense
Issuing.Authority (circle one):
I.Board of Health 2. Building Department 3.City Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
('outset Person: Phone It:
City of Northampton
op?M_-^-MPro 1 5 S
Massachusetts e ,•`
*
( " * ¶ DEPART ENT OF BUILDING INSPECTIONS x
0, a 4. 212 Main Street • Municipal Building
• ''.yrrru..' Northampton, MA 01060
tilOMEOVIWERSI EXEMP7TEN EUGIBUITY AFFIDAVIT
(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 /61 day of ,20g.
(Signature)
City of Northampton
"� Massachusetts ��� '<<
A' '
AL
LL
L DEPARTMENT OF BUILDING INSPECTIONS
t,y� 212 Main Street • Municipal Building Jti �D
r � Northampton, MA 01060 srt-j�. -4•1\'‘-
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: Va gey le,
V.r.Lc�,, 2 3 41 fac Girt 7&A_ .) /l/Ir)1 fla�7 9--
(l {/
The debris will be transported by:
Name of Hauler: il /)G(/1GL?S , /SZ)bi-1 /S/ V- PA-€11t4.4._
Signature of Applican Date: t,L(,C140', 24Z/
Building permit application
August 16, 2021
Enclosed, please find a building permit application for my home at 73 Massasoit St.,
Northampton.
Tlir you.
at I I
homeowner
413-695-6082
kmellen18@gmail.com