29-281 (4) BP-2021-2240
367 BROOKSIDE CIR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
29-281-001 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-2021-2240 PERMISSION IS HEREBY GRANTED TO:
Project# BASEMENT RENO Contractor: License:
Est. Cost: 20000
Const.Class: Exp.Date:
Use Group: Owner: ZADWORNY ALLEN M&ANNA MARIE
Lot Size (sq.ft.)
Zoning: WSP Applicant: MARIE ZADWORNY ALLEN M&ANNA
Applicant .Address Phone: Insurance:
367 BROOKSIDE CIR
FLORENCE, MA 01062
ISSUED ON:12/03/2021
TO PERFORM THE FOLLOWING WORK:
BASEMENT RENO -ADDING 2 BEDROOMS AND 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.
Signature:
I I )2 3-11 •
Fees Paid: $130.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
The Commonwealth of Massachusetts NQU
YT-s -\ \
202-1
W Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR�..__ __ 7 , 'CIPALITY
n, G''1i �'' '.. USE
Building Permit Application To Construct, Repair, Renovate Or Deiuolish a Revised Mar 2011
One- or Two-Family Dwelling
This Section For Official Use Only
Buildin Permit Number: I S • ate-440 Date Applied:
cv,Nl/ �5 7 921 /2 3-204
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numliers
367 BROOKSIDE CIRCLE 267 �% /
1.1 a Is this an accepted street?yes V 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 la On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
ALLEN&ANNA ZADWORNY FLORENCE,MASS.01062
Name(Print) City, State,ZIP
367 BROOKSIDE CIRCLE 413-548-6719 zad777@comcast.net
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 El Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work':
FINISH OFF BASEMENT BY ADDING 2 BEDROOMS,BATHROOM AND LIVING SPACE
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $15000 1. Building Permit Fee: $ Indicate how fee is determined:
�. El Standard City/Town Application Fee
2.Electrical $ `a C 0 Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2 6 CL.' 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
giSuppression) Total All Fees: $
+ Check No. ou Check Amount: Val/
6.Total Project Cost: $ �,. C.,C< <
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.)
City/Town,State,ZIP R Restricted 1&2 Family Dwelling
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 ❑ 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
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.
_' • Lk. 1
NOTES: �A!
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
Department of Industrial Accidents
, 1 Congress Street,Suite 100
1 • Boston, MA 02114-2017
� A
www.mass.gor/dia
%1mkers' Compensation Insurance Alliidalit:Builthers+Co.itractnrs(ElectricianstPlumiters.
TO BE FILED WITH TIIL P RMITIING AUTHORITI.
Applicant Information Please Print Letiltlw
Name
Address:
City/State/Zip: Phone#:
Are ytiu ao cmlalarrem'Cheek the appt ui rlrrte bac Type of project(required):
1.D I am a employer with crnplay^ees(full aeuVor part-time).' 7. 0 New construction
201 am a sole proprietor or partnership and have no employees working for me In 8. Remodeling
y orpm'ny.['Nu workers'comp.inauranue required.]
112 am a l ainieoverter doing all work myself.[No*nails'comp_insurance required.]"
9. ID Demolition
I 0 0 Building addition
ri I am a homeowner and will be hiring einaracturs to eonduct all work on my property. I will
ensure that all crtntraeturs either have workers'uortypensatiun insurance or are sole I I.a Electrical repairs or additions
proprietors with no employees_
12.❑Plumbing repairs or additions
SO I am a general contractor and I have hired the sub-eonrraetora listed on the attached sheet 131:1 Rc1of re sirs
Thesesub-contractors have employees and have workers'comp.insurance.;
ei.0%\'c are a corporation un and its officers have exercised their ri bt of exemption 14.0 Oehler
� g rnptiwt per MGL t
151,§1(4).and we have no employees.[No workers'comp.nun:micerequiaed.]
*Any applicant that checks boa n1 must also fill out the s.eetiun below showing their workers'compensation policy information_
t Homeowners who submit this affidavit utdicatims they are doing all work and then hire outside contractors trust submit a new affidavit hall:sting such.
:Contractors that check MO box must attached an additional sheet show w ing the name of the:sub-contraetura and itate whether or nut those entities have
employees_. If the sub-contractors have employees.they oust provide their workers`caanp.policy number.
s----
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
&formation.
Insurance Company Name:
Policy#or Self-ins.Lk#: Expiration Date:
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 S I,500.00
attdlar 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 for insurance
coverage verification.
I do hereby certify undelrri1te pains seal pens iec ofperjnry that the Information provided abet is tr a and correct.
Si gm 74/Cil 11111111. 2q
ihfrt•irr!u c only. Do not write iii this orcu, to be completed by city or town Vidal
('11s or Town: Permit/License#
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#:
City of Northampton
(\„l,e-/ -......r-.r.-,e-r:.si.',f l,
Massachusetts �� /F,
DEPARTMENT OF BUILDING INSPECTIONS 7? '
' q¢ vg 212 Main Street • Municipal Building $v' }t
1 *� Northampton, MA 01060 '14i -- 1gC
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:
it Il
Location of Facility: , 1 >u `QC��.J c i i v
The debris will be transported by:
Name of Hauler: ? life', Z. ae(tUer✓l
,f1d1) /
Signatureof Applicant: `- - l Date: -` 4l 2
:I!
City of Northampton
�,? ': ,,?`4,,\ gas •Si
" • Massachusetts Rti,?r' ... ` -/e
i� y1�^ wf * e;
\il�,. �� ( '°�4 DEPARTMENT OF BUILDING INSPECTIONS i i
� `w 212 Main Street • Municipal Building 5J`., a,
� = Northampton, MA 01060 is' •• i".
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
12/17/1969
I Allen Zadworny (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 ains and penalties of perjury on this day of ' Z 3 20 LI.
se
/76
(Signature)
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SHR 150 Fresh Air Appliance {7.: fantech®
Item#:463864 a systemair company
Variant:120V 1- 60Hz
Description
•Airflow up to 159 cfm @ 0.4"PS serves 2 to 5 bedroom homes
•Side port connections
ti` to •Compatible with Fantech's low-voltage controls
Application
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Technical parameters Performances
Product H N Cons
e Suppl et ume Sensible Apparent Latent
a y air sensible recovery/midi
ti temps n d ecovery elfectivenes store
Voltage(nominal) 120 V n rotors o posse
efficiency
a transfer
9
Frequency 60 Hz ci
°F m w %
s)
Phase(s) 1-
85
....... ...... 32(0) 1, 70 61 76 -0.02
Input power 156 W 0
to
Input current 1.4 A 32(0) 34)
95 63 71 -0.02
Air flow 159 cfm 15
32(0) (, 140 60 68 -0.01
Static pressure 0.4 in.wg 5)
Certificate CSA,HVI 25) b4 71 58 75 -0.01
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Exchanger type Heat recovery(aluminium)
Dimensions and weights II
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Used for Y
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A a C D 11
23 3/4(604) 2 1/8(55) 17 1/4(438) 16 1/4(414)
Dimensional information is in inches(min)
Item name:SHR 150 Fresh Air Appliance I Product link:https://shop.fantech.neVen-US/productPermalink?p=512708 I Item#:463864 I Variant:120V 1-60Hz
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