16A-020-065 B1-2022-1394
501 FAIRWAY VILLAGE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
16A-020-065 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-2022-1394 PERMISSION IS HEREBY GRANTED TO:
Project# BATH RENOS Contractor: License:
Est. Cost: 27000 LOUIS MONTGOMERY 013471
Const.Class: Exp.Date: 11/19/2023
Use Group: Owner: HARRINGTON NANCY B
Lot Size (sq.ft.)
Zoning: URA Applicant: LOUTS MONTGOMERY
Applicant Address Phone: Insurance:
PO BOX 951 413-268-2028
WILLIAMSBURG, MA 01096
ISSUED ON:10/28/2022
TO PERFORM THE FOLLOWING WORK:
REMODEL 2 BATHS
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:
• j i
1 .
i I
Fees Paid: S176.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
[- RECEIVED
The Commonwealth of Massachu tts
Board of Building Regulations and St ndar OCT ? 5 2�22 IF PA1fITY
Massachusetts State Building Code, 70 C R SE
Building Permit Application To Construct,Repair,Deno R ise Mar 2011
One-or Two-FamilyDwellin -.-_-_,.,.. u.pTc, iMA O1O toNs
NC1i1TF1A"✓IPTON.MA O70 0
This Section For Official Use Only
Buildingng Permit Number: g0 3.1-IVY Date Applied:
Ui....) <5•5 i( /O.213-Iza-z
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
SO/ ',..vi tw.41/ l/, /7't7/
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 6g Private El _ Outside Flood Zone? Municipal gf On site disposal system ❑
Check if yesD
SECTION 2: PROPERTY OWNERSHIP'
2.1 O 'ofRecor 4/ f / 0/as2
Name(Print) ' City,State,ZIP
6-2)/ P4i/Cagy 1//14 PJ "13 ,rp
No.and Street / Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2 (check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) IS Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: ',Li-pie/ c/ / , o// 64./!/e /2*r-rdv2 l'rsdsZ`..� eS/eTZ 4
//'.'sT.nil cr/-0/tC I,Z.S` o'64,/rit-7 /Z.2rte./.,/ , d,i_TG/ /s r#/&e,z,,/v. i
$/4.1.Tl+ac t /1.✓4%' Ti /-'z milk A"...........,4. r t .0/d.+frt.A,- '''c•?`rim..1 4L rs11 E'RT.61,96Vir s
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ /Z./oil. dv 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee
Zi Pov• ao _ 0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ /31 00,• 0 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) Total All Fees: $
Check No. VP7 Check Amount: (, ash Amount:
6. Total Project Cost: S 2 7, e c d 0 Paid in Full 0 Outstanding Balance Due:
City of Northampton
Massachusetts } 1,
DEPARTMENT OF BUILDING INSPECTIONS a
��• 212 Main Street •• Municipal Building �0,, rb
ii
Northampton, MA 01060 'rsy` -'��-
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.
VConstruction Supervisor License(CSL)SECTION 5: CONSTRUCTION SERVICES
Of3ct7 / ////1/3
Leta s f rgei 47-6,1 ev),-K License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) (/
Sf Adrica4t 1I/// /?a
No.and Street Type Description
// ���� �I U Unrestricted(Buildings up to 35,000 cu ft.)
W i L/ t I�(S I(4 0/Q `/ 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)
Lowc r ,41Ti. I'` IC 3$/ti S/i 7, 3
L
�4, a HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant'Name
31 !ozi in co i.r pit// Pq'
No.and Street Email address
tt-I'Kt•1-+44'/3cu4.1 ,i41 ,e,g4 ww 24 20 Z r
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 fi'1/Z TGa Div/# p� LGvls'f 1a�ra
i( to act on my behalf,llff,-/,4
in all matters relative to work authorized by this building permit ap ication.
�,►.c./ TOE /c „,), _
Print Own s Name(Electrc 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.
Lavi S /11d0-c7 Co0Nt,',y ta1/4 4122—
Print Owner's or Authorized Agents Name( ec is 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 H
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
t*- '- , y
C-- .
y* DEPARTMENT OF BUILDING INSPECTIONS
'., •, , 2212 Main Street • Municipal Building (1.:1
Northampton, MA 01060 r.
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: S 4 4 "L17 4i'4-1/ ) T-.+-'-'
Location of Facility: S'/vTlf S1 /Y/ /,s' t/46/&7 /e?cyc /b.-1 j
The debris will be transported by:
Name of Hauler: 4/ �Mr�rµ�'u2� TPr
/ Lv< <� j'��e �o�
Signature of Applicant: Date: /0G/Z�-
1
...16.....'11N, 1 The Commonwealth of Massachusetts
.....-,.
.,,, ..-.....1.1.j.
.-r...- .1.!-..*
Department of Industrial„..ircidents
.: 1
1 Congress Street,Suite 100
Boston, MA 02114-2017
WWII/.inass.govidia
Wurkers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED VI ITH't HE PERMITTING At IllORITE.
Applicant Information Please Print t.e2ibh
Name iBusinessiOrganization/Individual):
Address:
City/State/Zip: Phone#:
—
.i,re ou an inaptirrelri( hsv L.Ilse 11 pcircoirriarc trot:
Ty-pe of project(required):
1.D 1.„„a employer*cal _eraptuyeeh(lull araVor parminat, 7. 0 New construction
2.D i AITI a wee penpnek)e or partners/13p and have no ettyloPyers. working for me in • 8. 23 Remodeling
..,I: capacity.[No workers'comp.ensiorania required1
9_ El Demolition
lain a homeowner doing all work myself.[No workers'comp imunrace required]'
10 0 Building addition
4.0 1 ion a homeowner and will be bmng emoracturs to ceadnet all'A tark um my property. 1 will
aware that all,..-oanicturs either have W4irkers'conaperbalton insurance or are NOle : II.0 Electrical repairs or additions
pt-oprietors with no employees.
I 2.0 Plumbing repairs or additions
.5CI I km a general contractor and I have hired the ratb-contraciors fisted on the anadiestl sheet
1
AM I 3.EI Roof repairs
These sub-contrackns have employees have Wurien.''comp.111.SLIMICC;
I 4.0 Other
6.r i,ii are a corporation and its officers have eharised dam right of exemption per MGL e.
15.2,11(4).and.we ha,c no enwloyees.[No workers'comp.insurance rendered.]
'Any applicant that checks boa al must aka till out the oectson below showing their*others'eompernation policy inforroatioeL
Homeowners who miasma du s atildarit inthcatinir they Marking all work and then tare outside contractors mite subnut a new atfidav it indicating,,och.
:Contractors that check this box must attached an additional brit ihowung the name of the hub-ctaarsetor.and state 44 hether or not thaw..iti ate,ha,c
emplo.) , tithe sob-eontractor%bate cterlo.,ec%,they most pro..idc their workers'comp.policy number
/ion an employer that is providing workers'compensation insurance for my employees. Below is the policy and job sire
information.
Insurance Company Name: _
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: CityState2ip:___
Attach a copy of the workers"compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MILL c. 152,§25A is a criminal violation punishable by a fine up to S1,500,00
and'or one-year imprisonment_as well as civil penalties in the form of a STOP WORK ORDER and a time of up to S250.00 a
day against the violator.A copy of this statement nay be forwarded to the Otlice of Investigations of the DIA for insurance
coverage verification.
1 do hereby certify artier the pains and penal:in of perjury that the information provided above is true and correct
Signature: -- 7‘S------------- Date: (4"/.) 0/Z 1---
Phone#:
Official use only. Do not write in this area,to be completed by city or lawn official
City or Town: Permit/License#
Issuing Authority ieirele one :
I.Board of Health 2. Budding Department 3.Ckyaown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
,
' Contact Person: Phone#:
City of Northampton
,-J -,ir
,i, Massachusetts ��+,5 '_.
Itcl
DEPARTMENT OF BUILDING INSPECTIONS
y
212 Main Street • Municipal Building am`'
Northampton, MA 01060 ,r. �,�4'
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, (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 requ rements 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 home. ers'exemption,
does not involve the field erection of manufactured buildings constructed in accordance with 780 'MR 110.R3.
3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110. .1.2:
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on w ich there is, or
is intended to be, a one-or two-family dwelling, attached or detached structures accesso to such use
and/or farm structures. A person who constructs more than one home in a two-year peri 1 d shall not be
considered a home owner.
4. I do not hold a valid Massachusetts construction supervision license and, except to the extent t 't 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 ork involving
construction, reconstruction, alteration, repair, removal or demolition involving any activity r:; lated 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 , 20T
(Signature)