23A-093 (21) BP-2022-0176
17 FAIRFIELD AVE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
23A-093-001 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-2022-0176 PERMISSIONIS HEREBY GRANTED TO:
Project# bath reno Contractor: License:
Est. Cost: 34000 KIM RESCIA 022464
Const.Class: Exp. Date:01/02/2024
Use Group: Owner: GOTTLIEB SETH G &JENNIFER N
Lot Size (sq.ft.)
Zoning: URB Applicant: N GOTTLIEB SETH G&JENNIFERKIM RESCIA
Applicant Address Phone: Insurance:
17 FAIRFIELD AVE
FLORENCE, MA 01062
311 Locust St (413)320.1831
FLORENCE, MA 01062
ISSUED ON:02/23/2022
TO PERFORM THE FOLLOWING WORK:
BATH RENO
POST THIS CARD SO 1T IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter: Footings:
Rough: Rough: House# Foundation:
Gas: Final: Final: Rough Frame:
Rough: Fire Department Driveway Final: Fireplace/Chimney:
Final: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: �
g ! , 1
i . , '1 •
Fees Paid: $221.00
•
41 587-1
212 Main Street, Phone(4I3)587-1240,Fax.( 3) 1272
Office of the Building Commissioner
II i 1�----
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$, The Commonwealth of Massachusetts/ 2 3 20 7
;d Board.of Building Regulations and_Sian ds 22 OR
.il'ALiT`i
��i, j + Massachusetts State Building Code,,780 (:`it r rt1 1
TFige n�N In1 AE,
IBuilding Permit Application To Construct,Repair,RenovateOr hi .lis ;�T°Nevis1USE
d Mar 2011
One-or Two-Family Dwelling _I
�j This Section For Official Use Only
Building Permit Number?" *0°1?" /76. Date Applied:
iV : 1 , a a as
Building Official(Print Name) Signature I -- e
SECTION 1: SITE INFORMATION
1.1 Proper Add 1.2 Assessors Map&Parcel Numbers
1 ? Foul (OW 1'1 L. 23A -09$
1.1a Is this an ac ed street?yes no Map Number Parcel Number
1.3 Zoning Information: `, A 1.4 Property Dimensions: ,
Li k i v P ' 13 5-0 132- , S
Zoning District Proposed Use Lot Area(sq ft) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard i
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Swage Disposal System:
Zone: Outsi Zone?
Pub Private CICheck.if.ye Mumcip On site disposal system 0
SECTION 2: PROPERTY OWNERSHIP'
2.1 O er'of Record: .�
11f < Cr, 4 t t�4 i'lo feµ _e_. l V4 4 0(06
Name(Print) City,State,ZIP
SidAtitet...grat,..... .c14e,e4
No.and Street Telephone mail Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) ❑ Alteration(r s) Addition ❑
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Propo ed Wo Z•
k)[4,t IU 2 '11 rtsair 14a rocs
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1, Building ; s I, Building Permit Fee: $ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ 30« i 00 0 Total Project Cost' (Item 6)x multiplier x
3.Plumbing $ S j) , 60 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
ion) Total- All Fee;
Check No. 4 51 0 Check Amount: a'!t/ Cash Amount:
6. Total Project Cost: $`"2
la),DO 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
i u,iiif[i i dMa kuri e(CCLFcyz j [/ / la
1.
J W gxse__/4l License Number E piration Date
Name of CSL Holder
31 List CSL Type(see below) Le
No.and Street Type Description
�G��� I V �� ' I Unrestricted(Buildings up to 35,000 cu.ft.)
l ( ib R Restricted)&2 Family Dwelling
City/Town,State.ZIP hl masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
3 ZO--/(3/ I Insulation
Telephone Email address D Demolition
5.2 Registered Home Im provement Contractor(MC) '4-)y a (J ZL
r` t S G 14 HIC Registration Number on Date
HIC C y an e or HIC Registrant Name r
) CAA F
No.an treet Email address
ore v -Q �1 O 2- 3 Zd/�S3/
City own,State,ZIP Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
YV Vij\Gib uij{A;affidavit jjjiwi ciii'tl Jiii{jjjjtiGii with iijiil Ya}j�%jji.YiiV1j. risjjW G lti}3j 131jJ�r
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes 'AEI 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 14 ) Zvi e SGI
to act on my behalf,in all matters relative to work authorized by this building permit application.
SPA C-caalt e6 /aa/ZZ(Electronic Print Owner's Name Si e
gnature) D at
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.
Z 7�Yn re Sci�.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. 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"
City of Northampton
'g ,r. 1 DEPARTMENT OF BUILDING INSPECTIONS
r ° 212 Main Street • Municipal Building
„ .."4 Northampton, MA 01060 fseh . %��
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 I V,c: ��e< < _
v \ 1
The debris will be transported by:
Name of Hauler: K! PS�1
Signature of Applicant: l`" Date: ZL Iz-e—
The Commonwealth of Massachusetts
Deportment of Industrial Accidents
1 Congress Street.Suite 100
Boston. .!!.-10211 4-2017
n'tvn:ntass.got/dia
tSs` 11orkers' Compensation insurance Affidasit: Builders('ontr*ctors/Ekc1rieians/Plumbers.
set pt. I.tl_L t)«l R st s tut_ vs sastt t-s sus t; t tr•t•ttrttar-tlf Applicant Information Please Print Legihts
Nance(Business Organti_tuon lndis Moab: 1 1M
Address: ' I (
City''State'Zip: rc • (/i t o 1 v6 Phoney : 3 ZO--/6-3 /
Are yw as napalms'?Cbre the appropriate Mot: r
Type of project(required):
Ica l am a employer with ernplosees'lull aniFor pat-batch.' 7. 0 New construction
I am a sole proptn'nor or partnership and bass-nu employees.working for one in Remodeling
workers'capacity.(No workat comp.imunsX.ra mimed-) LJ
9. ❑Demolition
3.11 1 am a lx+nrs_rtwnet doing all wink nnsclt.tNo workers'cants!.noontime mooned!r ! _
4.01 an a honwoo net and will be hiring contractors to conduct all week on my property_ t will 10 Building addition
ensure that ail contractors either have cookers'compensation insurance or are sole 11.0 Electrical repairs or additions
prayrtict.rs is ith no employees.
12.0 Plumbing repairs or additions
5C3 I am a ga teral contractor and l lave hired the sub-etnetracum lucent on tit:4114CliCkl sheet_ 13.0 Roof repairs
These sub-contractors lave employers and lass:workers'comp.insurance.;
6.1-1 we ate corporation cmration and its officer:have outlived their rivht of usemMxet net!AtGI_c.
14.0 Other
I152.§hilt-and.se has.tie.employees.[Nis workers`comp.insurance required.)
*Any applicant that checks hot 41 must also fill out the eetion below showing then norkets'compensation policy.information.
!Immo%acts.s lira subttnt tlus atttJas it indicating they ate Joule all work and then hue outside contractors meet submit a new atrrda%it indicating such
-('unuaek.r,that check this hoe.must attached an additional sheet shooing the name of the sstb-comtracto sand state whether or not those entities hase
empI ee+ It the soh-eotdraetors lust corpkyon..tlicy oust pn.sidc their workers'armp-policy ntnnb►Y-
1 um an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
informmation.
insurance Company Name: -----------.______
Policy#or Self ins.Lic.#: Expiration Date:
Job Site Addre : City/State&Zip:__
Atta('h a copy of the gsggrkerr'cttmpe!trttion 1 celery tl tinratioon pitge(shnwing the policy mtnllber acid expiration date).
Failure to secure coverage as required under MCI c. 152.*25A is a criminal violation punishable by a fine up to$1,5(10.00
and or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to$250.00 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 and f ins a allies of perjut y'that the information provided above i.►trite and correct.
Signature:, /,< Date- z z C
Plane#:
Official use only: not write in this area.to be completed by city or torn official
r T "'ertnlZ."I_icen±oe
Issuing Authorit, (circle one):
I. Board of Health 2. Building Department 3.('ity::'town(leek 4. Electrical Inspector S. Plumbing inspector
6.Other
('ontact Person: Phone#:
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