23A-123 (11) BP-2021-2276
20 MIDDLE S1 COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
23A-123-001 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-2021-2276 PERMISSION IS HEREBY GRANTED TO:
Project# ENCLOSE PORCH Contractor: License:
Est. Cost: 24439 RHI CONSTRUCTION INC 055236
Const.Class: Exp.Date:01/18/2022
Use Group: Owner: WYMAN JOSEPH D&GINA B
Lot Size (sq.ft.)
Zoning: URB Applicant: RHI CONSTRUCTION INC
Applicant Address Phone: Insurance:
128 RYAN RD (413)885-9038 7PJUB 1 K060384
FLORENCE, MA01062
ISSUED ON:12/14/2021
TO PERFORM THE FOLLOWING WORK:
ENCLOSE PORCH TO MAKE MUDROOM
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:
• * • >2 -
Fees Paid: S24, _ .00
4
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212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
�i I
The Commonwealth of Massachusetts
FOR/
wt Board of Building Regulations and Standards DEC ' 8 2021M ICIP�ALITY
Massachusetts State Building Code, 780 CMR USIr
Building Permit Application To Construct,Repair,Renovate, ?fr;r'D$rw Rev sed Mar 2011
One-or Two-Family Dwelling c'A =TJON�
[15n
This Section For Official Use Only ---....
Building Permit Number: 761n' c' .)c' .)a.J7 l o( Date Allied:
,1
, . ►a�y i
Building Official(Print Name) Signature p
SECTION 1:SITE INFORMATION
1.1 Property Address: i 1.2 Assessors Map& Parcel Numbers
1.la 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) i
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided c
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private 0 Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
E3:NA 4, :Yt1( LA),9-. c-AvrUwt-- (A [1l( v
Name(Print) City, State,ZIP
(\ 1,N (7\c-ba A‘3-Z31_-)Iyc1 i'i \.. '4r @,y aw;.k.Guy
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': C Yr . - .' 4. Zt, e abk --fit) neat-C.
4\, cA vv.)Zruxv\
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 77,4 .6--1 1. Building Permit Fee: $ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ k000.60 ❑Total Project Cost3(Item 6)x multiplier x
3. Plumbing $ i V O) o, 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) ti Total All Fees: $
"`
Check No. g Check Amount: - Cash Amount:
6.Total Project Cost: $ t 3C1 0 ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
CS-65SL3(7 \"" -ZL
\ License Number Expiration Date
Name of CSL Holder
CA List CSL Type(see below)
Nond Street" jJ T e Description
���� ,�,�n ,. . Z Ji Unrestricted(Buildings up to 35,000 Cu.ft.)
{1 '1 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
t\\3--IW C )' Ajtr,Pic_c qn'G Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) ,�..,�
sq
3' L'�U` w HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
c 14. (LZ tom 0- n1r\c .AC
As
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 'c.S "��� �a . y\ \
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's NamejElectronic 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.
—11•0(Y � (��.�v� \Z 1— 26 z 1
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.) (o 5 (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"
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City of Northampton
oaT�NA—M• 0 - 5 -:.�'r
4, Massachusetts �1.?S� *x_
DEPARTMENT OF BUILDING INSPECTIONS ?' c
'v s1 212 Main Street • Municipal Building
v+ -".i'1 Northampton, MA 01060 ssljY 3,3N'y1
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: Le - c . ,ry
The debris will be transported by:
Name of Hauler: K, N vw\4..s
Signature of Applicant: Date: -1-A
-- The Commonwealth of Massachusetts
_ ..( � Department of Industrial Accidents
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� 1 Congress Street,Suite 100
Boston,MA 02114-2017
www:nrass.gov/din
VI utters'Compensation Insurance Affidavit:BulldersfContractordElectriciansfriumbrrs.
TO BE FILED Whit THE PERMHTING AlITHOIRITY.
Applicant Information Please Print Lerlbly
Name(Busi ess,Organi ationt'tiidiv ideal):
Address:
City/State/Zip: Phone#: —
Are y.0 as employ rr'('heck the appropriate It..:
Type of Protect(required):
LC]lam a employer with employees(full mode pant-hire)_+ 7. ew construction
i am a sole proprietor ins partnershipand have no employees wading for me in S. Remodeling
any capacity.[No wwicrs.comp.msurane requital UUU
3� ne I am a ho iwricr doing all wort myself.I *others'u*others'comp.irnunr ra required'* 9. Demolition
10 Q Budding addition
a.[D I am a haneownr and will be hiring uunrradors to conduct all work on my property. I will
ensure that all coat actors either have workers'caunpensat.ut msuranr or arc sale 11 a Electrical repairs or additions
prieturs with no employ�ees-
12.❑Plumbing repairs or additions
5 1 ain a general coats etur and I have hied the s.b-caniractus listed un the attached sheet_ 130 Roof repairs
These sub-eotaractors have employees and have workers'corgi.iruurance.a
6.El We are a cutpuratiun and its affirms'have exercised their sigh of exemption per AKit-c. 14. Other
152.$1(4),and we have nu employees.[Nu wailers'camp insurance requirevt l
'Any applicant that checks buoy e i mini abo fill nut the iaccliun below showing their workers"tumpinentioit policy infunnatiu..
t Homeuwners who submit this affidavit indicating they are doing all work Nadine hire remark ru tracuus rmbl submit a iii.-iv affidavit indicating such
IC"outrackxs that cheek this box must attached an additional shed sbow ins the manse of the imbeinurartors and stalk whether or nut those entities base
employees. If the sub-luraractth base employees,ties writ provide their workers"comp policy number_
I am an employer that is providing workers'compensation Insurance for any employees. Below is the policy and job site
information.
Insurance Company Nai el-Trevt l/ ' l(AS C --vt'v� ` (tJ.�Nens4.
Policy#or Self:ins.Lin..#: -1 \pp S�/`) 1 t 0 b 03 T( Expiration Date: 11—36 Z.Z.
Job Site Address: Z.0 Ci\" - . Ae- S{l Y.4- City StateTip: ckgeoL{Y - (AU Z
Attach a copy of the workers'compensation policy deelaradsu page(showing the policy number sad expiration date).
Failure to secure coverage as required under MGL c. 152.§25A is a criminal violation punishable by a tine up to S1.500.00
and/or one-year iniprisomnent,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a
day against the violator.A copy of this statement may be forwarded to the Oftice of investigations of th DIA for insurance
coverage verification.
i do hereby certl fy under the pains and penalties of perjury that the information provided above is true and correct.
Signature: D)ate:: 'Z�"
Plane i#: \i,"- 15--- U
IOJjcial use only. Do not write in this area.to be completed by city or town officiat
( it, or Trns u: Permit/License#
issuing Authorit► (circle one):
I.Board of Ilealth 2.Building Department 3.Citslroan Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
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