42-142 (7) BP-2022-1258
1075 WESTHAMPTON COMMONWEALTH OF MASSACHUSETTS
RD
Map:Block:Lot: CITY OF NORTHAMPTON
42-142-001
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2022-1258 PERMISSION IS HEREBY GRANTED TO:
Project# ADD BATHROOM Contractor: License:
Est. Cost: 6000
Const.Class: Exp.Date:
Use Group: Owner: LYNN SIMMONS BLAKE E &
Lot Size (sq.ft.)
Zoning: WSP Applicant: LYNN SIMMONS BLAKE E&
Applicant Address Phone: Insurance:
1075 WESTHAMPTON RD
FLORENCE, MA 01062
ISSUED ON:10/03/2022
TO PERFORM THE FOLLOWING WORK:
CONVERT BEDROOM TO BATHROOM
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:
of 6 ).2 . (P1 •
Fees Paid: `h65.0(1
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
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1, The Commonwealth of Massac sett `Sep ,`,i F R
Board of Building Regulations an Staa rds 9
� / Massachusetts State Building Co , 8 o 2Q�? I SE LITY
qr vi
Building Permit Application To Construct,Repair,Reno q .sh a Revi ed Mar 2011
One-or Two-Family Dwelling n4,�Aq"�c_
n,o'oovs
This Section For Official Use Only
Building Permit Number: A " 3,2.—/L fa Date Applied:
5� 7'
ElitiJ(�►�o //4 q.5a ZOZZ
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
• IVO n. 1.2 Asses4 Map&Parcel Numbers
.30
1.la Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 4 ng 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 li Private 0 Zone: _ Outside Flood Zgne? Municipal 0 On site disposal system Er
Check if ye
SECTION 2: PROPERTY OWNERSHIP'
2 Owner'of Record:.gIjL + Lyn Record:„
u�S rIo(entet 'j114 b / c ,
Name(Print) City,State,ZIP
?5 10 We S'ha Kip/vet Raw? (H13)53- •.a15 0 glaca'i'nimons VYtSh-cam
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) MI Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
iiiiiPscription of Proposed Work2: C 0(NW-rS I d in d P lotd ro a AA. ri b
a_ bailnv()uvvt I vocl e roa✓�. • hill 'oil e/-&Kc!
. li(fwe V �C-Ua//• ,'
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 0Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No.411 Check Amount. 6 Cash Amount:
6. oral Project Cosi* $ loi t(D•00 0 Paid in Full 0 Outstanding Balance Due:
Massachusetts 4,`" _ 'q'�,;.
*
t DEPARTMENT OF BUILDING INSPECTIONS I
212 Main Street • Municipal Building
Northampton, MA 01060IV pry 0� ��,
t,krine OW ri-e r_
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR NEW
1 & 2 FAMILY DWELLING, ADDITIONS, POOLS, DECKS, ACCESSORY STRUCTURES,
FENCES, GROUND MOUNTED SOLAR, ETC.
I. Building Permit Application signed by legal owner and filled out by owner or authorized agent.
2. One set of plans and specifications of proposed work. (Digital and hard copy)
3. Site plan with location of proposed structure(s) and set backs.
4. Construction Debris Affidavit filled out and signed by applicant.
5. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
6. Contractors must supply a copy of CS License, HIC Registration and proof of Liability Insurance.
7. Energy Conservation Compliance Certificate (new/ replacement windows).
8. Home Owner's License Exemption Form filled out and signed by Homeowner (if applicable).
9. Note any Conservation and/or special permit requirements (if applicable). 10.
Driveway Permit (if applicable).
11. Proof of Water and Sewer entry fees paid (if applicable).
12. Trench Permit - public land by DPW / private land by Building Dept.
13. Stretch Energy Code - all new construction will require a HERS Rater Affidavit to be submitted with permit
application before issuance of permit.
14. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton.
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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 0 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
fTION 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.
/Uc7iina4s _
Pr utOwner'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
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
_ ,__,
City of Northampton
'' Massachusetts t%
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� � :� DEPARTMENT OF BUILDING INSPECTIONS y
212 Main Street • Municipal Building -%F `4
\ Northampton, MA 01060 sp ys,10>v
CO$STRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
er-,(
Location of Facility: Va // J ► ( c(
secl
11167t-ha 1 1 4/0/7/4- mg-
The debris will be transported by:
Name of Hauler:
Signature of Applicant: Date: q I oZ
The Commonwealth of.tfassachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gouldia
'Workers ('ompensation Insurance AMILIVit: Builde.rsiConiractorsiLlectricians/Plumbers.
It) 13i. I I LED WITH I lIE PERMITTING AUTHORITY.
Anolicaiii Information Please Print 1.effitilv
Name 4liusines-cOrganuation In,:; :,:u.:. IS ta_it e_ c) (n,vvuo y'l$ .. ..
Address: )03S W/5 jlqa mpie_44 iziad .
City/StateiZip:_nrence/ mg am4foi- Phone 4: 1/13.) " 3 7- &I °
Art Veil Vali enspinyer?Cheek the apptepria le rarat:
' Type of project i required):
I.01 am a employer with employees :.111 innVor part-tune I..* 7. 0 New construction
2..:Thin a suic propnetor or portnership and have no employees working for nse in R. 0 Remodeling
-apaeity [Nu waiters'cutup.insurance required]
l ACTI' honseowlla doing all work myself[No*bairn'comp insurance required]*
Ilay.i.
9. Eii Dernolition
it am a hunteetwaer and will be hiring ooratractors to conduct all work an my propinty_ I will
av
1 0 0 Builifmg addition
ensure that all contractors either lui,e worten.'converts:stun insurance iN are sole 1 I ID Electrical repairs or additions
prtvietors with nu employees.
12.0 Plumbing repairs or additions
s{:limli a!fractal coati:clot and I have hared the nitt-f-ontracuirs listed on the;steadied sheet
These sub-contractors Itave emp es loye and have workers'cousin.insuranc (30 Roof repairse.;
14.001iter
60 Vie are a cfmxiestion and its aliens have exercised their right of exemption per MGI...c.
1:52.§1(4).and'A e have no employees.[NO warteni*eurrap.insurance required.]
-.km applicant that clefts bcf 4) trat4.than tin OW the aicusyn tvli.rw,show mg then*unis,:...an:ripens:mon policy information.
'I is;rnevwriers who submit this affi1aN3t tridiewase they are..leing all wink and then hire outside cnaniaacor*MUM subriut a new affsdaii it indifating suels.
Coraracturs that check this box must attached an'id-Ulan:11 sheet showien the mune of the ssib-eontraetors and state whi_t...icr or nut those entities he
cinpluyi..es. If the sub-coistractors Fsafe ensplo%eeN,thcy Mtiki pm...ide their workers'emnp pols,:y number
lam an employer that is providing workers'compensation insurance for my enrployees. Below ir the policy and job site
information.
Insurance Company Name:
Policy 4 or Self-ins.Lic.#: Expiration Date:
Job Site Address: CityrState.,Zip:
Attach a copy of the workers'compensation policy declaration page Ishowing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to S1,500.00
aridior one-year imprisonment,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 Office art Ina esugations of the DIA for insurance
cr:rticatiori.
I ch.,hereby certi ''unit-1-the pains and penalties of perjury that the inlininatian provided abort'i.% true and correct
, . -D-
.
Phone : /119,) 5 3 -7 - ...1 6 D
Official U.Ne()oil-. Do not write in this area,to he completed by city or wrt n official
City or Town: PermitiLicense#
Issuing Authority (circle one):
I. Board or Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone*:
City of Northampton
°? 1 Massachusetts
4,1
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 skg sr,
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HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAW,
I, Blame S)1 mc1,f (insert full legal name), born (insert month,
day, year),hereby depose and state the following: iG itC A y j'9 7
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 ) day of. ?fiem,er, 2C )-
(Signature)
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