38D-009 (9) B 2022-1294
17 REED ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
38D-009-001 CITY OF NORTHAMPTON
Permit: Acc Structure
PERSONS CONTRACTING WITH UNREGIS11-,RED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2022-1.294 PERMISSION'S HEREBY GRANT:+D TO:
Project# 2022 SHED Contractor: License:
Est. Cost: 100000 JESSE MONTGOMERY CSL07741 0
Const.Class: Exp.Date: 12/01/2023
Use Group: Owner: A DUNPHY JOHN A&DEBRA
Lot Size (sq.ft.)
Zoning: URB Applicant: JCM HOME IMPROVEMENT
Applicant Address Phone: Insurance:
PO BOX 329 (413)374-2787
LEEDS, MA 01053
ISSUED ON:10/11/2022
TO PERFORM THE FOLLO WING WORK:
BUILD 30 FT X 15 FT DETACHED STRUCTURE FOR HOBBYIST& STORAGE
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 VIO ATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: I
2
It
Fees Paid: $35.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
IV
The Commonwealth of Massachus 1ts E"
Board of Building Regulations and St ndar i OCT IC
r.* J 2022 LITY
Massachusetts State Building Code, 7 0 C R
Building Permit Application To Construct,Repair, en 05 :- dish a isr 2011
One-or Two-Family Dwelling NORTHaai°�N(3 INsFF
This Section For Official Use Only n4 ti--A�°6p Ns
Building Permit Number: aa, . (,,.,g y Date A plied:
11,,:
Building Official(Print Name) Signature 1 . D to
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
0 C�.e ed SA-. 3 8
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1
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 0 Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 tianerl of Record:, NOr MA O 1060
b h�. tc�n?III
Name(Print) City,State,ZIP
11 R etc( (. 33 ' —9757 SA.4(lihy&gor:te rs;i-i •Coy'
No.and Street Telephone Linail4Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. Number of Units Other ❑ Specify: �1
Brief Description of Proposed Work': aVi i d, a.. -1D • Je /S i De+etcheat
,f' c. ry a 4itse is habbf�s't-1 s•- f�fe,e '0 pLJw+bt%�►
/ec- 'lt host 4- /
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ qQ/ c7(ap 1. Building Permit Fee: $ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ s0r� 0 Total Project Cost3(Item 6)x multiplier x
3. Plumbing $ -._--'' 2. Other Fees: $
4.Mechanical (HVAC) $ ..��✓v%_—
List:
5.Mechanical (Fire
Suppression) $ Total All Fees: $ ,
Check No56)( Check Amount: Cash Amount:
6. Total Project Cost: $ Paid in Full 0 Outstanding Balance Due:
City of Northampton
G�rr�r. i
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
5
\.„ 212 Main Street • Municipal Building Northampton, MA 01060 rp� _ Dt,,,
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.
•
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) `
/y� fn74110 / 3
3i sst � - I� ey License Number Expi atio Date
Name of CSL Holder
+ *.SiList CSL Type(see below)14 S�t
No.and Street Type Description
} U Unrestricted(Buildings up to 35,000 cti.ft.)
` � i �� .fir
�3 (� 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) �,�,t' �S ; 9 r 2
Zes ` �` HI Registration Number Ex I ation late
HIC Company Name or HIC Re strant Name
144 SS. h* + �'c.•o tit•`t n c • V e
r.
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 ('S$e iv i e*'b4 )✓✓✓Orr1 ose y
to act on my behalf,in all matters relative to work authorized by this building permit application.
ZS e 'au eh /0/`' / o+i�,
Print Owner's Name(Electronic igna e) 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.
ZSee►se. h ertteeimel / / k >� a
Print Owner's or Authorized Agent's e(Electronic Signature) ate
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.) lab (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) 0 Habitable room count 0
Number of fireplaces 0 Number of bedrooms * 0
Number of bathrooms 0 Number of half'baths 0 _
Type of heating system ix 1 ' L E s c t"•' C Number of decks/porches
Type of cooling system , , .� L^i<<4rric Enclosed ve... Open_ _
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
•
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
�..._ City of Northampton
Massachusetts 4, tf.
DEPARTMENT OF BUILDING INSPECTIONS j "
212 Main Street • Municipal Building of
Northampton, MA 01060 j5I Di
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: VGt`\tty ( C.. 1.1 .i0"*.relpi
The debris will be transported by:
Name of Hauler: All -ualL • t
Signature of Applicant: Date: /CJ' w .2.
ca;41:4N.
The Commonwealth of Massachusetts
1,0 ci4 Department of Industrial Accidents
31 j 1 Congress Street,Smite 100
Boston, Al4 02114-2017','....
www.mas,s.govidia
— Workers'Compensation Insurance Affidavit: Buikiers/ContractorsiEktiricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name tBusinessiOrganizittion.indieidual.1.
- ' es,se M dr\A' ornelV._._
Address: 1 1-1
City/State/Zip: j•-:el-nr. 1 .,4 . tA _7)10:7p Phone#: LI I 2 IN' 0.7 107
Are yeti an employer?Cheek the appropriate trot:
I Type or project(required):
1.0 1 ant a employer with, _,empiuyees i full ad *part-time 1,4 7 RI New construction
25iri lin a sole proprietor or partnership and base no.)employees Working for inc in 13. 0 Remodeling
any capacity_[No workers'eitrop.uulitarliX revolted.)
.
30 lam a horneowner doing all work myself.rs.workersi'comp.insurance reiturnal]' 9 El Demolition
IC 0 Building addition
4.0 I am a hornoownin and will he luring isnitracuars to ixasiluet all work on ray provenly. 1 will
ensure that all Contra...Una either have workers`immpensation insurance LH are SO I e 11.0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
50 lam a iicass.d contractor and I halve hired the ntractors listed on the nached sheet.
34::These sub-contractors have employees and have workers'comp.insurance.: I Roof repairs
Other't
6.1g w r are a collimation and iis.aliens hare exercised their right 0E-exemption per 1s4CiL c. i 41.
152.11141.and we have no employees.[No workers'corrip.in .mix reqUered I
'Any applicant that cheeks but g I must Ilan till out the section below show=their wuriass'eompernation polvilf minimal' wet_
'I Lomenwners who submit dies affiehisit isidicatim they are doing all work and then hue cc bide contractors min/infanut a new affidavit axhi.ating Nuolt.
:Contraelom dug cheek this Dux must attached an additional sheet Epeo,...,ins the name of die%ab-etintractor.and state whetter or not thoie enithcs ha',r
empluyta.-3, If the 4,Lib-eOntrictoPi.lia...e.employees.they nowt pm,ide then workers'swop pa hey eaciolvr _ . ..
- -
I am an employer that is providing workers'compensation insurance for my employees. Below i., the polity and job.%ite
information.
Insurance Company Name: ____
Policy#or Self-ins.Lk,#: Expiration Ihte:
Job Site Address: City/State,Zip:
Attach a copy of the workers"compensation polky declaration page(showing the pokey number and expiration date).
Failure to secure coverage as required under MOE c. 152.*25A is a criminal violation punishable by a fine up to SI.500.00
an&or 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 of Investigations of the DIA for insurance
coverx2.:-,c r rICZIOrl.
1 do herebi t.ertity limier the pain% and penalties of perjury that the information provided above is true and correct.
DaiL 10/81 P?
Phone :
-'— 1-ri - 3'161 • •Iwie 7
I, Official use only. Do not write in this area,to be completed by city or town olliiiii I
', City or Town: Permit/License P
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing, Inspector
6.Other
(Ontact Person: Phone 4:
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