23A-044 (5) BP-2023-1606
19 WEST CENTER ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
23A-044-001 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-2023-1606 PERMISSION IS HEREBY GRANTED TO:
Project# BATH RENO 2023 Contractor: License:
Est. Cost: 18000 CHRISTOPHER SOUTRA 112569
Const.Class: Exp.Date: 09/08/2024
Use Group: Owner: CARLSON BIRD MARK J& SUSAN M
Lot Size (sq.ft.)
Zoning: URB Applicant: CHRISTOPHER SOUTRA
Applicant Address Phone: Insurance:
117 PLEASANT ST (413)575-6367
SOUTHAMPTON, MA 01073
ISSUED ON: 11/15/2023
TO PERFORM THE FOLLOWING WORK:
2ND FLOOR BATH RENO
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:
A J,. .
Fees Paid: S117.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
friar I RECEIVED
Main kited
The Commonwealth of Massac N 0 V 1 5 2023 OR
itBoard of Building Regulations and tan' ds
Massachusetts State Building Code, 80 t 0 ' UNI IPALITY
a SE
Building Permit Application To Construct,Repair,IRenoFPT.vdte OF RD w"V�� cr wise Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: 81D'-".3 - /0 60 Date Applied:
II
f.
6. : r/ , • ► ;; _105 e3
Building Official(Print Name) Signature I D
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
I' -' S+ C'P YIi-e/ S+-
1.1a 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 CI Private El Municipal Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑ _
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of-Rcord
�r s31 id �re/C e MA Of
� ;,L
ame(Print) City,State,ZIP
iR LdeS 4- cen4 d S-I - 413 -SksrllA M i1'at I ;.0&3 &cdrn<c:51, /1r1—
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building y Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work': ''1't x 4.4ri i,JGto 13C¢i/{ Se.GOnal 7C/ >/
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ '. .0 0 6 1. Building Permit Fee: $ Indicate how fee is determined:
��� 0 Standard City/Town Application Fee
2.Electrical $ 0 Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 3 3 a ° 2. Other Fees: $
4.Mechanical (HVAC) $ O List:
5.Mechanical (Fire $
Suppression) Total All Fees: Si
Check No. i.41 Check Amount: ill Cash Amount:
6.Total Project Cost: $ ( U 000 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS
� �+
C n(i S i(7 .�10`rl o rq Le s e Number�� ExpirationD o4/0 ��?I,z�
Name of CSL Holder
1 pot
ersc List CSL Type(see below) (J
No.and Street [ Type Description
S2tfs _'11,N wrimi eus7 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
575 3 7 le C% h5' es,c A� Insulation
Telephone Emaidrs D Demolition
5.2 Registered Home Improvement Contractor(HIC)
H r;She l r( Sc�1-r 6 6 rg' i p/�15
HIC Registration Number Expiration Date
HIC Compaqy Name or HIC Re strant Name
117 e frotic.� c +- ( s p r it �,,al•coal
o d feet Email al I, s
ti'W" ' )14 al 073 tt13.57s 60.?
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 1,1 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 G),f
to act on my behalf,in all matters relative to work authorized by this building permit application.
Marl( Biv(X (Aoki Evvri(- t 1 -0)-zwL3
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 a e to to the best of my knowledge and understanding.
ar/°s S1r4 t1/l ') 13
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
V•�"� � Massachusetts
( t . DEPARTMENT OF BUILDING INSPECTIONS
P'.w•'x , '' 212 Main Street • 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 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: Vz:j
C
Location of Facility: 3 £1 g'GS)tiuisle ke) IVOri'44w►p4dr) 1- vldGG
The debris will be transported by:
Name of Hauler: C Jir', 4 Soy, r�
Signature of Applicant: • Date: i'i/L3 / ,J
The Commonwealth of Massachusetts
1W. _ 1. Department of Industrial Accidents
_us= 1 Congress Street,Suite 100
W� Boston,MA 02114-2017
` � www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): eli r c SOL,4m
Address: l i 7 p f�Pa44hr:1 g,.)-`
City/State/Zip: 51, } t I yiZ) Phone#: L,I 57 c-r‘f 3 4 7
Are you an employer?Check the appropriate box: Type of project(required):
I.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction
?.VI I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.] 9. Demolition
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required]t
10 Q Building addition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.n Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
t,.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/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 MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine 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 the pains and penalties of perjury that the information provided above is true and correct.
Si ture: __ . Date: I//j3 ,L/
Phone#: it)'z -L 7S —43 tL7
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
Policy Number: MPT8376Q
MAIN
STREET BUSINESSOWNERS COMMON DECLARATIONS
AMERICA MAIN STREET AMERICA ASSURANCE COMPANY
4601 TOUCHTON ROAD EAST,SUITE 3400,JACKSONVILLE,FL 32245-6000
Item 1. Named Insured and Mailing Address Agent Name and Address
CHRISTOPHER SOUTRA AQUADRO &ASSOCS INS AGCY INC
117 PLEASANT ST
SOUTHAMPTON, MA 01073-9440 PO BOX 357
NORTHAMPTON, MA 01061
Agent Phone No. (413)-586-7373
Agent No. 201107
Item 2. Policy Period From: 01-06-2023 To: 01-06-2024
at 12:01 A.M., Standard Time at your mailing address shown above.
Item 3. Form of Business: INDIVIDUAL
Item 4. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to
provide the insurance as stated in this policy.
This policy consists of the following coverage parts for which a premium is indicated. Where no premium is shown,
there is no coverage. This premium may be subject to adjustment.
COVERAGE PREMIUM
Section I—Property NOT APPLICABLE
Section II —Liability $1,951.00
Inland Marine $200.00
CYBER $43.00
Total Policy Premium: $2,194.00
For Coverages subject to premium audit: Annual Audit Applies
Item 5. Form(s)and Endorsement(s) made a part of this policy at time of issue:
See Schedule of Forms and Endorsements
Countersigned:
Date: By:
Authorized Representative
THIS BUSINESSOWNERS COMMON DECLARATIONS AND SUPPLEMENTAL DECLARATION(S), TOGETHER
WITH SECTION III —COMMON POLICY CONDITIONS, COVERAGE PARTS, COVERAGE FORMS AND
ENDORSEMENTS, IF ANY, COMPLETE THE ABOVE NUMBERED POLICY.
BPM D 1 1207
INSURED COPY