37-132 BP-2022-0461
526FLORENCE RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
37-132-001 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-2022-0461 PERMISSION IS HEREBY GRANTED TO:
Project# BATH RENO Contractor: License:
VALLEY HOME IMPROVEMENT
Est. Cost: 74000 INC 077279
Const.Class: Exp.Date:06/21/2022
Use Group: Owner: B.H, ROTH-KATZ, SUR1
Lot Size (sq.ft.)
Zoning: SR Applicant: VALLEY HOME IMPROVEMENT INC
Applicant Address Phone: Insurance:
P O BOX 60627 (413)584-7522 0055030215
FLORENCE, MA 01062
ISSUED ON:04/29/2022
TO PERFORM THE FOLLOWING WORK:
RENO 2 BATHS
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Fi na I:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: •
it U
1' 0 r
Fees Paid: $481.00
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212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
. .::;;',,,, . .
s. The Commonwealth of Massachusetts - J
IA Board of BuildingRegulationsand an B 'OR /
5f dal c o� (9Q MCIICIPA .ITY
r Massachusetts State Building Code, 780'CM ,?:4>,,,..- US
Building Permit Application To Construct, Repair, �'Renovate Or �i-ubi�t' � R vised ar?/�11
One-or Two-Family Dwelling :��sp a„ `
This Section For Official Use Only ,'
Building Permit Number: r;'ia ' Date Applied: J
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4-vii...) ars 5 1Z/_ i't Zq-ZZ7.
Building Official(PiintName) Signature Date
SF.CTTON 1:SITE INFORMATION
1 1 Property erty Address: 1.2 Assessors Map&Parcel Numbers
52(0 c'torente. �.' ---.) t.3 Z
1.1 a Is this an accepted sheet?yes -no M.ap Vursaber Parcel Number
'1.3 Zoning Information: 1.4 Property Dimensions:
Res -, a >i Qe CC s - -
Zoning District Propos d Use LetArea(so ft) Frontage(ft)
1.5 Building Setbacks(ft)
F nt 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 Own 'of Record:
;Tenn' kair e-.. r< «-in• KCkk- ... tr,•yerzC.L r1'\o- to b(02_
• Name Wit) City, State,ZIP
52ii, V Vc),--eri.�e ( c3t-tS S . 532-ILIA,
No. and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s).❑ Alteration(s) le-Addition 0
Demolition ❑ Accessory Bldg.II : Number of Units Other O Specify:
. Brief Description of Proposed Wgrk2: ' e. -; d 4 he /I kQiI& j 1/4Lr
a A. 0�l • , l� ate' ♦ �. .[. i l' •.)w
�Limn
�� rei �Il I IN -e 'Li... I NV . . . VI " g
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: ! Official Use Only 1
(Labor and Materials)
I.Building $ �j,1-367) 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $
L O 13 Standard City/Town Application Fee
0 Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ i( (fb 2. Other Fees: $
1
4. Mechanical (RVAC) $ -- List: • -
5.Mechanical (Fire •
Suppression) $ - Total All Fees: $ ' l�j r
Check No. 1 a1'k eck Amount: "I"Cash Amount:
6.Total Project Cost: . $ 714,U(JL!a 1 1J Paid in Full Cl Outstanding Balance Due:
SECTION 5: CONS.E'RUCTION SERVICES
5.1. Construction Supervisor License(CSL) . 011 ,2,�1.7 tD17 I. (40Z2
-C-V 0 C-3.0\leg("1-1 1 License Number Expiration Date
Name of CSL Holder
` 7fl List CSL Typo(see below)
P C) ?G1� c (o No.and Street Type 1 Description
a`� U Unrestrictedcu.ft.)
` \Oc ) j R Restricted I&2 Family Dwelling
City/Town,Sta , hti _lulasoia•J
/ RC, Rgoling.Cuvttng.n
/ WS Window and Siding
• SF - Solid Fuel Burning Appliances
1A6-,UL.t`1522— i Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(I-TIC).\10 a���2 O+zo���
�\\e (r}ti`i°!(Y�YI,�" HIC Registration Number Expiration Date
FTC Compa 'Name or H1C Registr nt Name
Y.c,..(2), c;ic .c,o4,0•7...7) f-tv-e.rlc-e,(Y b ku
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 ...
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 +��.� Xl t rrrAC1 r�
.to act on my behalf,in all matters relative to work a o ' by this buil • 't application.
- Yv S/L V /vrl, L 0/75 c;7 ,p.
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.
(� �-- Ss u wt to'T H-fL.A•T-e Vie q /�z
`+ 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
v,-ww.mass.aov/oca Information on the Construction Supervisor License.can be found at www,mass.Qov/dus
2. When substantial work is planned,provide the information below:
7 ,1� finished t,..._ � decks �
, Total floor area(sq.f.) (including garage,. basement/attres,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of hall baths —
Type of beating 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 Northampto �:
r }� Massachusetts ...:s .., ..2,.
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t '• aF t ° '` DEPP12Tt�r NT Vila:Fs
BUILDING £NSPECT?02JS 7` g i
212 Main Street a Municipal Building v�.
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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 MEL c 111, S 150A. .
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The debris will be disposed of in:
Location of Facility: `Va U1l i o ci, , '--Y \C ,
The debris will be transported by:
Name of Hauler: _ `itk e j(y\Q Tttilityyt 4e r j -- -
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Signature of Applicant: l 09 I. r`/' Date: 5"— lld
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The Coinrnorr.wealth of!fassctcliusei"ts
`)-�=— Department of Industrial Accidents
1-.1 , ._ }} I Congress Street, Suite 100
F If'' Boston, ]TfA 02114-2017
•`� � www.mass.gov/dia
Warkers' Courp.cosa_tio-te Insurance Affidavit:.Bunters/Conn-actors/Electricians/Plumbevs.
Ti)BF,Cii'FY)Willi Ti-IF,Plal!VII T T ING AliTHOrR(Tir'.
Applicant Information Please Print Legibly
Name(Riivintu /Car Hniixi.innf ndivichrxi): \I a_.G k-eji pcmg r rep,..pr3 Jf IrrIe .J- 'ailc
Address: -1(.`") \.sf saa,C...,- r i v-��P- r-. co 0(e a
City/State/Zip\.U.rey2(P .V-1,0-01_j( 2a. Phone#: 1-4, 2-)- S`1-1 S 2 2-
Are you an employer?Check the appropriate box:
1 Type of project(required):(1.®I am a employer with lg employees(full and/or part-tune.).` 7. 0 New construction
2.0 I am a sole proprietor of partnership and have no employees working for me in 8. ®Remodeling
any capacity.[No workers'comp.insurance required.]
3.0I1 am a homeowner doing all work myself rNo workers'comp.insurance required.]
9. ❑Demolition
i u El Building addition
4.0 l am a homeowner and will be hiring contractors to conduct all work on my property. I will
• ensure that all Gonuacoore either have workers'compensation insurance or are sole • 11.0 Electrical repairs or additions .
prop,ieto s with no employees. 12.p Plumbing repairs or additions
❑I am a general contractor and.'have hired the sub-contractors listed on the auached sheet. 13.❑Roof repairs
These sub-contractors have employees and have worker;'comp.insurance?
6.0 We::re a corporation and its officers have exercised their right of exemption per MGL c. 14. Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
"Ar y applicant that checks box#1.must also fill out rho section bciuw.showi_g 4h:u- cilte s'compensation policy,afU rmatie
..
t Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such.
-tOorat antors that ebetit this dux must attac'hed-an-additional sheet showing-the name of the Snb tuntcal;tor5'and state-whether or'nut these entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: H-+(hPAlcA., 71-X1<:ThUit9 Y1i c_ (1{-�c.:) —
Policy#or Self-ins.L,ic. #: OC)5 5•,C' o21 ---, Expiration Date: C ) I 1 caoAJ
Job Site Address: --(e ciU/-enc•tj `-- • City/State/Zip: ets,4- ( .(1k-ilO d el. 41-o1 oa
Attach a copy of the workers'compensation policy declaration page (showing the policy number and expirktion date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine 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 certzf r under - ,,ins and penalti of per-' e irzforniation provided above is true and correct •
Signature: � q, Date: Lt1k31z2--
Phone#: 'A k 0`l- ¶22-
Official use only. Do not write in this area, to be completed by city or town official
,
City Qr Town: Permit/License# ii
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
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Contact Person: • Phone#:
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