32A-221 (9) BP-2024-0103
83 POMEROY TERR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
32A-221-001 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-2024-0103 PERMISSION IS HEREBY GRANTED TO:
Project# WTR REPARS 2024 Contractor: License:
Est. Cost: 8000
Const.Class: Exp.Date:
Use Group: Owner: M WAKSMAN, STEVEN
Lot Size (sq.ft.)
Zoning: URC Applicant: M WAKSMAN, STEVEN
Applicant Address Phone: Insurance:
83 POMEROY TERR
NORTHAMPTON, MA 01060
ISSUED ON: 02/02/2024
TO PERFORM THE FOLLOWING WORK:
WATER DAMAGE REPAIRS
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: Ili 46 6
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
j
i I
� Z I
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR MUNICIPALITY
` ,. USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Buirding Permit Number:Z•5
6442C�_/b3 Date Applied:
all N < ///IZ Z-2 ZO zi-f
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Propet0 Address: 1.2 Assessors Map&Parcel Numbers
83 r'o vile To/ Te✓race-
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.C.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: _ Outside Flood Zone?
Check if yes❑ Municipal 0 On site disposal system 0
SECTION 2: PROPERTY OWNERSHIP'
2.1 O er'of Recoqrrd:
ve Wa.kswia h /V c .i.ina M R- 0 i oC o
Name(Print) City,State,ZIP
T3 Powiecc,! Terr4CC 11?-2to-24F sw�ksi►-,4h&sn+,�, .ec�k c—et�ctef
No.and Street Telephone Email Address rt-ni f
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work': Repa ro e4 dar kka ye 41, p n ye .t• !•/ ,l ri 3 r� f I or-
u u d a�'l 0;-1. ker4J- wevier du.�R7e �o ce,`1,:, I i:,1E/,u,
Aw-
n-yowl wu f of 31d Aw-
0 .
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 0O 0 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All F , , et
Check No. " heck Amount: S�Cash Amount:
6.Total Project Cost: $ 9000 ❑Paid in • 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.)
R Restricted I&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
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 applicatio is and accurate to the best of my knowledge and understanding.
i-21 - a /
Pri er's or Autho ized ent'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
oaH�M
'' � Massachusetts 44+ s "er,
j •
6 K„l DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building yJ a
Northampton, MA 01060 ssI,h 4,30'
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: EuS.fl a p P ecyc11�q Cevkc
The debris will be transported by:
Name of Hauler: � t��Ao de f ccL. Z(AC
Signature of Applicant: Date: ! -3 i Zy
The Commontc'eulth of Massachusetts
) Department of Industrial.-1 ccidents
=�a RI 1 Congress Street, Suite 100
." $ '4. Boston, .t1.1 02114-2017
sty- t$tt'tc.mass. roi'frlia
11enleers' ('onrpensation Insurance Altidasit: fluildcrs ( untractors`Elcctricians,)'luothers.
It) BE I-ILE!)WIftl I III-.I't toil I I I\(, Ut THORI fl.
%Indicant Iufurntatiurt Pleas. Print I.t'ihls
Name i13usincss Or am:anun;lndisiduat): . -)GVC Wct ics0,1
Address:_ 3 Porte-col�ro7 7 e rrgct _ ____
City/State/Zip: Aioytith olpJ.sy.(/ }- 0 10_.&Q Phone : Li 3 -210—268'''
Are yam en entptay rr'Cheek the appropriate hoar:
'type of project(required):
t.Q I.a n a employ cc with emplusccs(full and'ur part-time)-* 7. c New construction
21 I ant a sole prupnetw or partnenhtp and base nu employee.working for me in 8. CI Remodeling
capacity.any .cacity.[No workers'comp.insurance required.; CI
30 I am a horn xtwner doing all work my elf.[No workers'comp insurance required.]•
9. El Demolition
I U 0 Building addition
4.0 ant a Ium eo no and will be hiring contractors to conduct all work on my property 1 will
ensure that all corm-Alum either have workers'conicena:ttruut Insurance or are wee l 1.Q Electrical repairs or additions
ptuprictan with nu ermployees.
12.0 Plumbing repairs or additions
51:3 I am a general contractor and I hate hired the sub-contractors listed on the attached abed
These sub.cetntracturs bask etitiployees and have workers'comp.in,survnce.; 13 Roof repairs
6.E]We are a corporation and its officers have exercised their right of exemption per NMI c. 14.12(0� Gnu kept/! W
152,il(4),and we havenoemployees.[No workers'comp.insurance required.] marl tr -GV
*Amy applicant that chocks box=I must abu till out the accusal below below showing the worker p'cam ekisat ion policy ud'ecmation.
+Homeowners who submit this aPfrdavit indicating they are doing all work and then hire outside eonira.tors must submit a new affidavit indicating such
k'untractun that check this box must attached an additional sheet showing the name of the stir-ccattraetcw,anti state wtether or not those entities lt.ati,.
en irk cc„ If the sub-contractors lase rnnplu!ecs.they oust prosidc their wurken'Oentp.policy r.LII I'.r
1 inn on 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.Lie.4: __.._. Expiration Date:
Job Site Address: —__City State Zip:___-_____
Attach a copy of the workers'compensation polio) declaration paste(shot%lug the Indic, number and expiration date).
Failure to secure coverage as required under MGL c. 152,{25A is a criminal violation punishable by a tine 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 fine of up to S250.00 a
dos.against the violator.A copy of this statement may be forts at to the Office of investigations of the DIA for insurance
coscrage verification.
I do hereby err(' nder the tilns,r rf L Wallies of perjure'flail r the information provided above is true and correct.
Signature: (/' ,1'..: Dale: 1-3! 'at(
Phone#: Ll13 -210 -2 r
Official use only. Do not'trite in this area.to be completer)by city or town official
City or Town: Permitll.icense:r
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.( iI :Town Clerk -I. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
��t H A M,:To,
..._1;� 0`.
- -sir.
Massachusetts t°"'' �, {� (� DEPARTMENF BUILDING INSPECTTONS
k�y,_> .�,,r. 212Main Seet • MunicipalBuildingYs;,.:%....- Norampton, MA01060
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
12 —8'-67
i, 5-le-ye yi M,clnn4r/ ,,„a,Svnav, (insert full legal name), born (insert month,
day,year),hereby depose and state the following: 4
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 31 day of Ja h 44r7 ,20 2.4.
( ture)