31A-090 (6) BP-2022-0526
27 VERNON ST COMMONWEALTH OF MASS CHUSETTS
Map:Block:Lot:
31 A-090-001 CITY OF NORTHAMP ON
Permit: Alts Renovations
Repair
•
PERSONS CONTRACTING WITH UNREGISTER CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY F ND (MGL c.142A)
BUILDING PE MIT
Permit # BP-2022-0526 PERMISSIONIS EREBYGRANTED TO:
Project# bath reno Contractor: License:
Est. Cost: 18000 JOHN LEBHAR 075531
Const.Class: Exp. Date:07/10/2023
Use Group: Owner: WESTON H RMINE LEVEY
Lot Size (sq.ft.)
Zoning: URB/WP Applicant: JOHN LEBH R BUILDING & RENOVATION
Applicant Address Phone: Insurance:
68 SCHOOL ST
HATFIELD, MA 01038
ISSUED ON:05/16/2022
TO PERFORM THE FOLLO WING WORK:
RENO BATH
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 NORTHA PTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: f '
Fees Paid: $117.00
212 Main Street, Phone(413)587-1240,Fax:(413).87-1272
Office of the Building Commissioner
: 74--------
The Commonwealth of Massachusetts e ` ''
Board of Building Regulations and Standards M y F R
//WMassachusetts State Building Code, 780 CMR/ 3 "�l CAL
�` riry
SE
,,,.,.
Building Permit Application To Construct,Repair,Rer:fovatp(:),;ropes ,a,_ Revise1Mar 2011
One-or Two-Family Dwelling -- rf14,,�r IN^;IN;u ; ,
This Section For Official Use Only 1A`�
Building Permit Number: 4p )�-- 6.-.4./ Date Applied:
4/6tl1rU &ms / 5- Ic-2022
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
2 01-.N o t--) 3T— .'51 A- rt'W
1.1 a Is this an accepted street?yes X no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
N A- A)k
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft) N 4
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 lif.. Private❑ Zone: _ Outside Flood Zone? Municipal�On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
tgaM 10/- Lf V i( W i.}76lrJ Na Pi ti AMV?i) k D( a6 a
Name(Print) City,State,ZIP 1
7-4- VjjZ ON $1 ryl3_ Zoq- 537-g kieVeytaiMaAstzwn.
No.and Street Telephone ' Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
i
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Aklteration(s) it Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Spe4ify:
Brief Description of Proposed Work2: CO 0 I 'E L- Li A 12- ,13/ 't q-ao 0 ►". f o
,fit- C0I-fl611 tTe0r'J , 71'/1-1r, u.4%io/ 7 A 37"A4B "
.S 7f 0 L Z re-
e
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ /S., 3 (Tog 6.4 1. Building Permit Fee: $ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ /13-(We 6r9 0 Total Project Costa(Item 6)x multiplier x
3.Plumbing $ / 2 ( i ,0r1 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:
�� Check No() Check Amount: 1 t 7 Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 0 outstanding Balance Due:
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
CS- 67-5 5-3 7/1b ZoZ3
*01) 44;1(4 Z— License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) 11
6 $ sC orb
Sr No.and Street Type Description
i er t 14, MA Ol 6 3 U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted'.&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
I SF Solid Fuel turning Appliances
h13—ZZ 1' ( I� 3 J 4I b e)l\ 016FriadiCDV1 Insulation
Telephone Email a@dress D Demolition
5.2 Registered Home Improvement Contractor(HIC)
�o��' ��� 1�/��-- 176 o8/ 74to zo23 HIC Registration Number Expiration Date
6 Company Name orb Registrant Name ` A
'— JGboi 4 9w^all1 (. ws.
No.and S et Enlail address
fl�T tc-l0 hole} DIU3i `//3 -22/—(i/3
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 COMPLETID WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize Tp N1`1' F}
to act on my behalf,in all matters relative to work authorized by this building permit application.
141-e`r4 N 4 t IV ir w z.Sfv r`) , —//3 /2 o 2—
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.
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"
City of Northampton /�
T f
C Massachusetts
-- 1(:,,IP ) -
��
DEPARTMENT OF BUILDING INSPECTIONS I-
}, 212 Main Street
mp • Municipal Building \.,‘, ...„)
Northampton, MA 01060
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of wilding 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: V At L / C Y6*/,- L--) '`/.4
The debris will be transported by:
Name of Hauler: .-- --6 CttiL' Lcz C-A--(1-
4110
`—
5/Signature �3 1
�of Applicant: � `� �'—
NN I� gate:
i
The Commonwealth of Massachusetts
n - fir, Department of Industrial Accidents
s::ID ti. / Congress Street,Suite 100
iii`1 Boston, MA 02114-2017
*'T..04' www.mass.gov/dia
%%inkers' ( unrpensation Insurance Afmldasit:Builders/C ntract° ns(Phansbeht'n.
It)HE: t!LED ss fl"11 THE PERMITTING A[tTNO Tli.
Applicant Infurrmatuitt _ L � C ✓,� fit Print l.etlbh�
Name 4iiusine-u r aer nati n Indta'dual I: ��� i� I l� 4- '
Address: ,4 8 S G Cr 4---- r
O103Q 99
City/State/Zip: t ?'T— I ff L t2. ("1! ._ Phone#:_ t i j .- 2.-c_-L L l_.
Are)own emp rr?l Inv k the appropriate boa:
Type of project(required):
1.0 I am a employer atth cnsplo+ec+I lull and Of part-tine I• 7. 0 New construction
l ant a suk prupnctce ut purtnc-nhtp and ha%c nu cnipkrycI a urkm5 for nu:In 8. Remodeling
and capacd} [Nu Honkers'comp.insurance roywtsd j
9. Demolition
tEj 1 ant a Ixmxva nor doing all stork myself.[too Markers comp insurance reguired.j'
10 CD Building addition
4 Q I am a hwmc.aa net and%III he hiring avnuaetors to conduct ail is on tin pnrpert} I is ill
ensure that all cunu:ktun either lease workers'caxnpcnsahom insurance ur are soh: I 1 Llectrical repairs or additions
prupnctom arch no emplo}m
12.0 Plumbing repairs or additions
S.C3 I am a general contractor and I base hired the soh-cuntracton listed on the attached sheet. i 3t""�Rtkyt'rt'pIItra
These sub-t cnruac:tun base employees and base acnkcrs'comp Innuran.c- LJ
14.❑Otiret
h.Q We a .a corporation and its officers hate-exercised than right of exemption per NA(it c.
151 ycIi4I.anti a hasc no c-rrtphus.es.[yiu stutters'coop In,usaree required.)
•Airs applicant that cheeks hot ti must also till out the section talus%husking their syurktis'compensation patio."information
'tiotreoaisen ate submit this afltakastt indaealrtrg the}are doing all aotk and than hue outside contractors Must submit a nee atlidas it indicating such
:(unuatun that check this h+os must atucbcd an addruonal sheet sloe ins the name of the silt►:onrtr-r.ctor,and state a lather ow not lbws:Cootie',ha .
crnplovccs It the suh•contractors base cinplo yes.then must pro+Ida then aorkcis'.x,mp-poles ntiinhen
I am an employer that is pro►iding warders'compensation insurance Or my employees. Below is the policy and job-site•
information.
lnaaance Company Nance.
Policy#or Self-ins.Lie.#: _ Exptratpon Date:___
Job Site Address: CitytSt4e'Zip: __ _
Attach a copy of the%corkers'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 unishable by a tine up to S1,500.00
and'ur one-year imprisonment.as well as civil penalties in the form of a STOP WORK )RDE R and a line 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 senticat .
4
I do hereby';rt., tit ti and penalties of perjury that the information provided abor•istr a and correct.
Sibnatuic. !hate 5�� �O -.2 `�
Phonc,. i'M l - z--0 t t q )5
Official use only. Do not write in this area.to be completed b)•city or town official
( its or I trss n: Permit."ieense u
Issuing.Authority (circle one):
I. Board of Health 2.Building Department 3.( ity, I-own("lark 4. Electrical Inspector 5. Plumbing Inspector
b.Other
("ontact Person: Phone#: