13-021 (3) BP-2024-1491
480 NORTH KING ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
13-021-001 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-2024-1491 PERMISSION IS HEREBY GRANTED TO:
Project# REBIULD CHIMNEY 2024 Contractor: License:
Est. Cost: 16750 DAVID OSIECKI CSL089376
Const.Class: Exp.Date: 01/05/2025
Use Group: Owner: L COURAGE, KENNETH F&DEBRA
Lot Size(sq.ft.)
Zoning: RI/SR Applicant: WESTERN MASS MASONS LLC
Applicant Address Phone: Insurance:
383 COLLEGE HIGHWAY 4l -527-1800 4283978
SOUTHAMPTON, MA 01073
ISSUED ON: 11/06/2024
TO PERFORM THE FOLLOWING WORK:
REBUILD CHIMNEY
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:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.Signature: 172.
Fees Paid: $125.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
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The Commonwealth of Massacpusett Nov
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Board of Building Regulations and`Standards — 6 20�4 IPALITY
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Massachusetts State Building Co ,7 R SE
Building Permit Application To Construct,Repair, 'Vak'�9Y ' h a Revi d Mar 2011
One-or Two-Family Dwelling 'J'kxv.pir, e7.7oNs
is Section For Official Use Only �'O
Building Permit Number: -d•54'17gj Date Applied:
hwra /Koss 1I-G ZOZ'i
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION ,
1.1 Property dress: Si- 1.2 Assessors Map& Parcel Numbers
1.l a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use I 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 yes0
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner' f ecord•
Name(Print) City,State,
4c ' ,ram(, / (v ,a�--)yis-
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 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 Work2:
11, --a-a,.-4---7
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:
❑Standard City/Town Application Fee
2.Electrical $ 0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All F‘i.$1.
1 /
I Check No.1N2Check Amount:
6.Total Project Cost: $ /G.7Ji-Go 0 Paid in Full 13 Outstanding Balance Due:
City of Northampton
�� j Massachusetts (-'' ._1 '1"- -_,_
DEPARTMENT OF BUILDING INSPECTIONSI�i�y2. 212 Main Street • Municipal Building ;�IP
.
\' Northampton, MA 01060 •'- %
•
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) etk q'3 6 7qc -ats
041,0 Os er,-14, License Number Expiration Date
Name of CSL Holder
Sidi Gw¢i J t List CSL Type(see below)
No.and Street ( Type Description
C C� a^ A4. a,/02 U Unrestricted(Buildings up to 35,000 Cu.ft.)City/ToWhi,Stat f ip,vCam!' / R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
t I , ,y- T SF Solid Fuel Burning Appliances -
��J�/Y l'K �`,1 /4J/�^" 1j�7�1�FG� I Insulation
Telephone L Email address D Demolition
5.2p Registeredg Home Im�prroove`ment Contractor(HIC) ,2/ 2_/2 '
L )tj/ (/ Ar4z j "-' HIC Registration Number Expiration 6Date
HIC om ny Name orIC Registr Name -%
5 �a`1 I4-i a..,0, et.owern_Assf).44famf. c../fri
No. d S et /L ,v 4. Ola)1 ) Email3 address
< -1�(�
City/Town�tate,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 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
conta•• 4 . is ap icatio ' true and accurate to the best of my knowledge and understanding.
r
Print tq' s or uthorized 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
►* r�i Department of Industrial Accidents
-�• 1 Congress Street,Suite 100
"•= _74 = Boston, MA 02114-2017
? , www mass.got/dia
11I),kers' Compensation Insurance Affidavit:Builders'Contractors1ElectriciansiPlumbers.
10 BE FILED WITH THE:PERMITfi\t::AtrI'HORI'1'1'.
ilttt{.cool litfuru tatiurt "f4�j Please Print l.eeiltls
1/
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Name fliusittcss-Urttanewtiun.ltulividtwlt: �_..l�WC t'r y ��,f j yA
Address: 301)3 (c `( `A7
CityiState/Zip: ( l #1 A . 1I'Phone#: ,St)
----------
.sre you am employer?c'hcek the appropriate bolo. Type of project(required):
i. lama employer with ' employees(full andbr part-Brost.• 7. CI New construction
20 lam a sole proprietor or pdnnershmp and have no entpkoyerx working forme in K. Q Remodeling
any capacity.(No worker,'comp.utsuranee required]
9. 0 Demolition
;.�lam a homeowner doing all work inwaett.]No wotkcxi comp.insurance required.]'
4.0 I am a hu owner unit be hums euatarrctnrs to conduct ill work on my property. 1 w ill l0 O Building addition
rt
assure that all cuntracturs either Irate workers'comp.-mat:on insurance or an sole 11 CI Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
lam a several contractor and I hate hired the mb-contractors listed on the aaacticd sheet
•ihese sub-cuntras hate employees. worker and lute s'comp.insurance. 13 a Roof repairs
ctur
6.0 We are a corporation and its officers have exercised their ngla of exemption per k4C;L c.
14_ er
152.)l(4l.mind w e hate tat?employees_[No workers"'comp.Insurance required.]
`Any applicant that checks box PI mua also till out the ocettort below show ins their wind:**"compensation policy information.
Homeowners who submit this atThlavit iniheatins they arc doing all work and then hire outside etmtractoes must submit a new affrdat it i ilk:dmy such.
:Contractors that cheek this box must attached an additional sheet showing the name of the Sub-etnttrseturs and state whether ix not those entities]rate
cmuplote'i,. lithe)ub-cunt:actor,l:.ise drip] ees.Il. nlu-.t rn'.id.their workers'scamp.potist number.
I am an employer that is providing workers'compensation insurance for m} employees. Below is the policy and job site
information. _
Insurance Company Name: /21C ,i 't'
—ANf _
Policy#or Self ins.Lic.#: J7,1"YK 9 Expiration Date: q�i
II//
lob Site Address: ,�rg lilt (5 City/State/Zip: 4 - Q 6c
Attach a copy of the workers'compensation ptl cy declaration page(showing the policy number nd expiration date).
Failure to secure coverage as required under MGL c. 152.025A 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 font,ofa STOP WORK ORDER and a fine of up to S250.00 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 certif er the pal s and penalties of perjury that the information provided above is true and correct.
Si mature: f)atc. /4 r- 92
Phone TM:
Official use only. Drr rent 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.E:lectrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
P<'
%',.�'' Massachusetts ��
i1 i DEPARTMENT OF BUILDING INSPECTIONS ,
'•►, , r' 41' 212 Main Street • Municipal Building -� 'r
!�0-,' ate' Northampton, MA 01060 rs1- I���
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: (Ji4'`l7 / c-cyc tf..5o
The debris will be transported by:
Name of Hauler: ,SC //
Signature of Applicant: Date: //���y
City of Northampton
t_,ti,.,,,irk. NS .SI
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`' �.-' Massachusetts ��?S'�� = '''<<�
wf :S
f;i ' DEPARTMENT OF BUILDING INSPECTIONS �:
l y y 212 Main Street • Municipal Building yJb,
— q�f^ Northampton, MA 010609 sj`'��C
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 1 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-ok 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 day of ,20 .
(Signature)