11A-004 (8) BP-2022-0494
17 EVERGREEN RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
1 1A-004-001 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-2022-0494 PERMISSION IS HEREBY GRANTED TO:
Project# 2022 GARAGE Contractor: License:
Est. Cost: 4600
Const.Class: Exp. Date:
Use Group: Owner: SCHUMANN HOBBS DAVID B& LYNN
Lot Size (sq.ft.)
Zoning: URA Applicant:
Applicant Address Phone: Insurance:
ISSUED ON:05/05/2022
TO PERFORM THE FOLLOWING WORK•
DRYWALL GARAGE
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: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: I
• ' 51-1.
Fees Paid: $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
'
The Commonwealth of Massachusetts'' ;
Board of Building Regulations and Sta lards *��'�.l FOR
Massachusetts State Building Code, 7 0 C 4' q'1r '_l7s ALITY
Building Permit Application To Construct,Repair,Renbva4 0 I emolis' t Revis d Mar,2011
One-or Two-Family Dwelling 91y,4/,)iE> /
This Section For Official Use Only \\1NSiOR\ �`
Building Permit Number: I I �`' y q `f Date Applied: 7,7°7o rlo`„;'
� ti
EU)1.3 Zs / 5-5-ZOzZ
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
I.! Property Address: / 1.2 Assessors Map&Parcel Num�eaq
11 6Ytrc reeA tce1 I LeecLS ;IA ((JJ
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private CI Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SIIIIMIIMIIBIIIIIIIIINIIIIIIIIIIIIIID
2.1 Owner'of Record:
c),•t,;d 14dA,k>1 4' L)44 S-Ltt.Mart✓t Leeds P1 A 01063
Name(Print) City,State,ZIP
l'1 Ir.' v-r-,r t-Ce vt Q ) qi 5-5 12- o Of. d-1' e\I$ agc cf 1Gt .el et"
No.and Street S Telephone Email Address
DESCRIPTI011ial.111111NW WORK2esprau t apply)
New Construction 0 Existing Building® I Owner-Occupied 0 I Repairs(s) 0 I Alteration(s) 0 I Addition ❑
Demolition ❑ Accessory Bldg. ❑ I Number of Units Other ❑ Specify:
Brief Description of Proposed Work': d r v t.j a1( n, cr a 1-a e,
alliallINIMEMISED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ Y (, O O 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All F- rI
�(� 0(5 Check 1\ p�y}_Check Amount: l,�(i
6.Total Project Cost: $ 0 Paid in rull 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 ❑ 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
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.
•a1/ tA 1-1 0\.A.s S15f 2027--
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"
i
City of Northampton
(r-t
Massachusetts
` DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building vti •
Northampton, MA 01060 x'isk4
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
z\i°�65
% A k s (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 Stµ day of M0.Y , 20Z—?
(Signature)
The Commonwealth of Massachusetts
► " T t Department of Industrial Accidentsr' I Congress Street,Suite 100
_• Boston, MA 02114-2017
rfr!vn:nalfss_gtvidiva
ot kers'( Ilnitlensatinn Insurance_%I1idas it:Builelersi( ontractorst''F kctriciansi1'lumherc.
TO BE FILED WITH f ilk: .t1"fll(oRI'I'l_
.koolicaut]nforulation 1 I Please Print Legihll,
Nam: q l3thtat -..[h_:,n'il,.uienl ludo.KIRA r
Address:_ I vs r�T ��✓I C`el
City/State/Zip: (, e e el> M A U I O 5 3 Phone ##: `I L 3 - 2 q a - I S 7 '
Art yes-emeloyer~4.beck 1111r apprnpruic but
T�pr of project(required):
I.71 I am acnripllr r W ih employees ttidI aaId oM ratE-ltrrr I.' 7. J Ne%% cun4tructKin
'.�I Will a,uk taupricwr or Ifiunm.rnlur and have w eny?b',0.7.avtnrkulF for ni m S. 0 Remodeling
am,.afucit .[No uarIcrs.crane.uuuranee ectruar.tl.I
9. ❑ Demolition
4101.0 a flume owme3 doing all work an}s.li.INo vvrtet.erx"eunaFn. air C1r Ntee retl.uiral.l
10 0 Building addition
a Iurmreunvnru.a and nadl ie ituuly 00.11.1ta+.9ars,W t:vretduct all nMtak on nt}raopcity. I
.at,ure that all conic:aturs cation II:na.%qui ers-eratrinem,:tlotrt wtsutaneti yx use MAC I I.. Electrical repairs or additions
rIa,1•Itet1M,1nlib mo eInrluVL•e1..
12.0 Plumbing repairs or additions
I alrt a ceatCial c,ral:li do!aaul I lane lhned the wl.-eunu:utt.rs lutert uro doe attacihed,lee1_
l lrc.e iau aru 13.�Roof repairs
,ul•-ea.ultardtn,Icrr u:wurlu%ceu and Irani:+vtxkwr� et�n}*. m:.
14.®Othei d r Y w wit
14.0 We are a eimp audio n and ILs otim'rs hat elriu right of etenrateat pet !LK i. J
IS2.§If4i.and N.e Slane txn erq*lurcca.l to uluters"etanp.m+ucnice required.!
*Am appbemu dun.lu a ks box..I mass alstn till nut du:secniaat below.show DIM miler!u urkers•coutpenNation wino:utlrarnalular.
Itnm.aj,ya net, atl ti l4 et utuhealant'[Ito,are dome all~Murk and iln:Il hue MASI&eoltirav;taa.7 rnu,n untunal a u.a atlidann rtalil".►nrmu••sock_
{.umlraenols that.ehea1 11,t,la..mull an da..11 act adulal.a,nal sheet.Itt.w ini ilk maane uni du:41.1.-eMIILla+elonr.and.,iiare 4111c81ten el not dims,:....Maio,.lune
cnmrlute.s. It Ilse soh-eninraer.v,Ic+oe orgnlu}.c,.rhea mina prunulcall.lr rxaxkers'crane.puke.number_
I am an entpint•ci that is providing n'arLer.►'compensation insurance for my employees. Below is Her/k lic;l'and job site
in Jifrniation.
Insurance Company blame:_ _
Policy#or Self-ins.Lie.#:_ _ Expiration Date:
Job Site Address: City'Stale'Zip:
Attoclh a copy of the workers'compensation policy d.erl.ariitiun page(show nig the istlicy number and expiration date).
Failure to secure cos rage as required under MGL e. 152. *25A is a criminal %iulation punishable. by a fine up to SI.500.0I
tnr.l or one-year imprisonment.as%%ell as en it penalties in the Conn of a STOP WORK ORDER and a fine of up to S250.(M0 a
dak against the %lcalatur.A copy of this statement Tn1aV be forwarded to the Oti1ce of Ins estluatiuns of the DIA for insurance
cot crage%♦'ril leation.
I du hereby certify under the pains and penalties ofperjnrp that the infnrmafiin provided above i.s true and correct.
5 I S -2.t-
Pin Inc l 3 _ Z 1 0 - d
(l ricrl use only. Do not write in this area.to be completed hl•city or town official.
('its or Town: I'crnlitl.icense 4I
Issuing_%uthorit% Icirrle one):
I. Board of Health 2. Building Department 3.Cityllussn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone it:
City of Northampton
.- ,M Tom,. `5 S,
a?-✓I �` Massachusetts ?�' • �-
lt`
d a E K�a. 4 ii DEPARTMENT OF BUILDING INSPECTIONS
\ '�. r iQ 212 Main Street • Municipal Building ys) DO-
\N" '''" Northampton, MA 01060 �sN,, 3d'
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: \iaH k' cy�l i -`) I C os S4-�`,✓`11•1-et` RA
The debris will be transported by:
Name of Hauler: L + iZ e ck.. 1• -1 + ,c--y at I
Signature of Applicant: `k --i\ v" Date: 515/ zz