46-050 (7) B 1-2022-1376
99ISLAND RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
46-050-001 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-2022-1376 PERMISSION IS HEREBY GRAN D TO:
Project# SHED Contractor: License:
Est. Cost: 5450
Const.Class: Exp.Date:
Use Group: Owner: ADAM BASS, KATHRYN &
Lot Size (sq.ft.)
Zoning: SC Applicant:
Applicant Address Phone: Insurance:
ISSUED ON: 10/25/2022
TO PERFORM THE FOLLOWING WORK:
FINISH INTERIOR OF SHED
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:
4 PI •
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
\4
14 The Commonwealth of Massa use ACT
Board of Building Regulations and St rds 2
9nS �0 R
Massachusetts State Building Co e,,7g0E r �� USEALITY
Building Permit Application To Construct,Repair,Renova , ' a Rev' ed Mar 2011
One-or Two-Family Dwelling N"4q of�rioys
0
This Section For Official Use Only
Building Permit Number: 6 P A 1• Date Applied:
j•., I�l fp
7
Building Official(Print Name) Signature
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
99 /si. 10
1.1 a Is this an accepted street?yes V no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
l s>y4')/o
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:
Zone: _ Outside Flood Zone?
Public Er.- Private❑ Municipal 17On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP' 1
2.1 Owner'of Record;
M 777 may,✓ ,; 400.4A_ c&4 S Nar,Yn 'mxJ, Ac./if o/o too
Name(Print) City,State,ZIP'`
99 fs4. J (�t'IG 4'/9- 7"ff6ce al/22/l/l& g,mi tee d-C—
No.and Street Telephone Email Addr ss
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building❑/ Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. !El Number of Units Other CI Specify:
4 Brief Description of Proposed Work2:5 7/ __/ c fj,,
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 2-6b :'` 1. Building Permit Fee: $ Indicate how fee is dettrm
sined:
2.Electrical $ g,,^ 0 Standard City/Town Application Fee
0 Total Project Cost'(Item 6)x multiplier x_ _
3.Plumbing $2—� 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fee ;$ /�h
�— Check No. /` Check Amount' ((J-�
6.Total Project Cost: $ h) L{�jt 0 Paid in Full 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.)
City/Town,State,ZIP R Restricted 1&2 Family Dwelling
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
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 ofrny knowledge and understanding.
4-6(._ S /0.sue Z�
rint Owner's or uthorized Agent` me( ectro ' ignatur 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/dOs
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 The Commonwealth of Massachusetts
1 _, - '/ Department of Industrial Accidents
i ..,.
=�l_ r, I Congress Street,Suite 100
.r =ii: ' Boston, MA 02114-2017
www.mass.gor/dia
11 otters'Compensation Insurance:111idanit:Buildersi('ontractorsiEkctricisnst'Plumhers.
TO BE FILED N OM"111E PERMUTING A1-1.11okl l%.
Applicant Information Please Print Letibh
Name(nosiness/Organization Individual): _
Address: ! t'jsS-9 i-i/) "7—i) M5 -71/A)-t-1P; r W/�
City/State/Zip:. _ Phone#:
Art an to mink orl l beck tie appropriate boa:
Type of project(required):
10 I am a employ et with employees thin and ur part-time►.' 7. Ej New construction
20 I:on a sole prupreeter or putncn ip and hate no employers Meriting for me m 8. 0 Remodeling
an►
9. El Demolition
apacit► [\U.trkcn comp.insuranix required.)
�3/ am a htmneuwner Jurng all r►urk rrtyselt.[Nit workers`comp.insurance n'gwred.l'
10 Q Building additias
QI am a homeowner and all be bump amirxwrs to conduct all wort on my property. I w ill
eosin that all cunnraators either lute winter.`cumpeitsateun mamma!ur are sok I I a Electrical repairs or additions
proprietors with nu employees,
12.0 Plumbing repairs er additions
30 I am a general contractor and I hate hued the sub-etaOr On listed on the attached died. 1343 Roof repairs
Thaw soft—contractors bare employees and late at taken'eurnp.enstrtanae.;
6.0 we are a eptration and its Writers hate e�dertased their tight ul a sengttrtrt pea Wit.
14.in Otter
tn
•
152..;li ii.and we hate no ernpk+yeryes.[No workers'cony_Insuranac requircd.l
"An!,apphaant that chocks bu%,a I mist also fill out the settaun bald.shin me their wtrters conspensatron popes tnlartnataun.
'Ihernevwncrs who submit this attidas it indicating they are doing all work and then hire outside cuetraattrs mint submit a new attain ut iaditaliltg such.
't untraetors that check this bus must attached an additional sheet shins mg the name ut the sub-ceNractcrs and state w hethet or not those easigias base
atuplutccs. It the sub-ctnuratttrs Fate et plows..then must pros Kit:their workers'sr Nip,policy number,
.. .,. . . __. w .. . . . . . . . — — rr. r.
r r r -air_
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy antti.!►al&
information.
insurance Company Name: j
Policy#or Self-ins.Lie. #: Expiration Date:
Job Site Address: Cits'State'Zip:___-
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGI c. 152.125A is a criminal violation punishable by a tine up to$1,500.00
an 'or one-year imprisdntment,as well as civil penalties in the form of a STOP WORK ORDER and a tine 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 certify under th tie• nd penalties of perjury that the information provided above is true and correct.
111111111/ il---1 ----
Phone r.
Official use only. Do not write in this area,to be completed by city or town official
(1t♦ or'FONn: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building fepartnient 3.('its"Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
(i.Other
( ontact Person: Phone#:
City of Northampton
4?"--"
_ S‘5 . SAC'
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS a ra'
212 Main Street • Municipal Building yv` D`
�+'~ Northampton, MA 01060
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT ���%Q6`
//(1��/1// S� (insert full legal name), born_ (insert
month, day, year), herebydepose and state thefollowing:
y
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. 1 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 2Sday of , 20 Z'�
(Signs
City of Northampton
Massachusetts `
*
DEPARTMENT OF BUILDING INSPECTIONS a
212 Main Street • Municipal Building ivy C1�
Northampton, MA 01060
(FOR ALL DEMOLITION 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:
The debris will be transported by:
Name of Hauler:
Signature of Applican Date: d t i 2Z-