32A-047 (4) BP-2024-0945
69 MARKET ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
32A-047-001 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-2024-0945 PERMISSION IS HEREBY GRANTED TO:
Project# 2024 MINI SPLIT Contractor: License:
Est. Cost: 25000 WILSON SERVICES, INC
Const.Class: Exp.Date:
Use Group: Owner: BRIAN KANE,
Lot Size(sq.ft.)
Zoning: URC Applicant: WILSON SERVICES, INC
Applicant Address Phone: Insurance:
P O BOX 1570 (413)584-3317 08WECAZI ZJ3
NORTHAMPTON, MA 01061-1570
ISSUED ON: 07/30/2024
TO PERFORM THE FOLLOWING WORK:
INSTALL MINISPLIT UNIT
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: 772.
Fees Paid: $187.50
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
7 , 1 /S"&-,
The Commonwealth of Massachuse s joz
' VI Board of Building Regulations and St. dare FOR
Massachusetts State Building Code, 7:0 k �'r / US ITY
ro Op
Building Permit Application To Construct,Repair,Renov. -'a ised ar 2011
One-or Two-Family Dwelling ti'"To,�'Nsp
This Se ion For Official Use Only "im o'O''t'S
Building Permit Number:',N4/1 Date Applied:
4.,....4z, ./00 7-Nzo2y
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Proper?Addr_ e: 131._ 1.2 Assessors Map&Parcel Numbers
111 Ma(
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 0 Private 0 Zone: Outside Flood Zone?
— Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Recbd t q ��f`- 11e- 1O( c r r M o/Q ‘O
Name(Print)(("" City,State,ZIP ��1
CC 1\& k-e{— S)— 5c1-3d5-R72 brnz75 (6'
No.and Street Telephone Email Address G_ t 1 , co,wx
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units_ Other 0 Specify:
Brief Description of Proposed Work2: 1 n S < 5- Zo M`n t 5p I i 3. H P
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ 2,S aoU List:
5.Mechanical (Fire $ d
Suppression) Total All Fee 4i► 7 6°
Check No.3� U check Amount: 1�j '
6.Total Project Cost: $ 'a„C5 OO( CIPaid in Full 0 Outstanding Balance Due:
Cityof Northampton IP< J "
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?-.'a Massachusetts �4/ _ -`c'(t
f„rrul c
;� DEPARTMENT OF BUILDING INSPECTIONS D4 !t
M1 o 212 Main Street • Municipal Building yOb iQ
t; + Northampton, MA 01060 'r�. ;0P
Wi
•
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS,ROOFS,RENOVATIONS, ROOF MOUNTED SOLAR, ETC.
1. 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. Construction Debris Affidavit filled out and signed by applicant.
4. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance.
6. Energy Conservation Compliance Certificate (new/replacement windows).
7. Home owner's License Exemption Form (if applicable).
8. Note any Special Permit requirements(if applicable).
9. Energy Code —all new construction (Gut/Rehab) requires a HERS Rater Affidavit
10. 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)
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 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 �' or p Co►N�
3a1 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:OWNER1 OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penaltieref perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
GrA)S1SQJ 7 - 2 `I— aY
Print Owner's at 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"
""� The Commonwealth of Massachusetts
., ►' Department of Intlrrstrial Accidents
I Congress Street,Suite 100
_-t(ttre .
Boston,MA 02114-2017w nt ww . ass.gov/dia
Walken13t- 'Compensation Insurance Affidas it: Builder+.`ContractorslElectriciansiPlunbers.
I BE FILED N fill Till-. I't:it'll I I l\c..st I HOR1I'Y.
Applicant Information a Plere Print Leluibls
ss-`Name(Businc (h nt,ition`lttdi idual1: l LsOvJ Se( f.e( VC .r/(..,
Address: (A _4-b et wl e PA
City/State/Zip:N d i \Nct tp+t1&1 (IA a LOCO Phone#: (3- 5S`'(3 3(?
____
Are you as rmtpinycr:'1 heck the appropriate boy:
1')pe of project(required):
1..r 1 am a employee with tO_....seller,:;c,i full area b/part-ii ,e i,• 7. []New construction
201 am a wee proprietor or partnership and Ilse e no C'nipluvira working for mile in g, 1a Remodeling
any capacity.[No workers'comp.insurance require(.] 11.•��
9_ ❑ Demolition
ID I am a homeowner doing all work myself.[No workas'camp.insurance monad.]'
.1.0 I am a homeowner and will be hiring cwauraclurs to L-xtduct all week on my property_ I will
10 O Building addition
ensure that all coaizractors either have"conkers'cornpe-nmatrun insurance or an:sole 11.3 Electrical repairs or additions
proprietors with no employees_ 12.p Plumbing repairs or additions
50 I am a(general contractor and I have turd the sob-contractors listed on the attached sheet. 13.0 Roof repairs
These sub-contractor lsase employees and have workers'comp_insurance.•
6.0 We are a corporation and its officers have exercised thou nght of cmraptiun per MIA 1 . Other
152,§114I.and we has.:no employees.[Nn workers'comp.insurance required.]
`Any applicant that cht'cks box u I must also till out the section helow show tag then workers'compensation policy mifunnauen.
t homeowners who submit this affidavit indicating they are doing all work and Eisen hire outside contractors must submit a new affid:ac it indicating such.
:Contractors that cheek this box must attxbcd an additional sheet showing the name of the,sib-emote ctoc and state whether or nut thus minks have
employs:es. If the sub-contractors base employees.thew must pros ide their worker cosine policy number.
I um art employer that is providing worliers'compensation insurance for nay employees. Below Is the policy and job site
ire J.rrntaliun.
Insurance Company Name: Wt\- Lg T tJSk.IrG1.f1 Ge. —
Policy#or Self-ins.Lic.#: U V J E Q. Pr-i t Pv 3-3 Expiration Date: )S—I._.a5
lob Site Address: CC‘ Ll J City/State/Zip: N o r TV\Cu_ f`t1 6
Attach a copy of the workers'compensation policy declaration page(showing the policy number acid ex�iiration date).
Failure to secure coverage as required under IvIGL c. 151§25A is a criminal violation punishable by a fine up to S1,500.00
andror one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.011 a
day against the violator_A copy of this statement may be forwarded to the Office of Ins cstmations of the DIA for insurance
coverage verification.
I do hereby certify untie se s ad (ties of perjury that the information provided above is[true and correct
Signature: aBale -a4- 2(4
Phone#: 11( 3 "5 8 l- 33 ) 7
Official use only. Do not write in this area,to he 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#:
City of Northampton
Massachusetts A?
�yyG s 1
h, cif' DEPARTMENT OF BUILDING INSPECTIONS
RS; ;" 212 Main Street • Municipal Building Q�-• P
• 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: S\\ \\\
Location of Facility:
The debris will be transported by:
Name of Hauler:
Signature of Applicant: Date:
City of Northampton
Massachusetts '�/ 5 - tee `tGf wi 1DEPARTMENT OF BUILDING INSPECTIONS SI
212 Main Street • Municipal Building y%), CDi
ji;) Northampton, MA 01060 �s►% ;••1r:):'
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 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 invplve 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. 1 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 day of , 20 .
(Signature)