25C-175 (9) 81 PARSONS ST BP-2019-0728
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C- 175 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2019-0728
Proiect# JS-2019-001196
Est.Cost: $10200.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: TIMOTHY LUCE 100515
Lot Size(sg.ft.): 5227.20 Owner: MITKOWSKY RONALD
Zoning:URC 1( 00)/ Applicant. TIMOTHY LUCE
AT. 81 PARSONS ST
Applicant Address: Phone: Insurance:
PO BOX14 (413) 387-9800
LEEDSMA01053 ISSUED ON:12/20/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE ROOF
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:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department 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.
Certificate of Occupancy Signature:
FeeTyne: Date Paid: Amount:
Building 12/20/2018 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Northampton Status of Permit;
-� Building Department Curb Cut/Dnveway Permit
212 Main Street Sewer/Septic Availability,
.rt
Room 100 Water/Well Availability
\'f Northampton, MA 01060 Two Sets of Structural Plans
- phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
APPLICATION TO CONSTRUCT,ALTER,REPAIR,R NOV OR IWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION Q 9 O B SSC " 75
1.1 Property Address: This section to be ompleted by office
Ir�sPFCTIp8P Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Ron Mitkowski 531 41st Street, D7, Brooklyn, NY 11232
Name(Print) Current Mailing Address:
< 347-256-8921
Telephone
Signature
2.2 Authorized Agent:
Qct /6S 3
Name(Print) Current Mailing Address_ /
Sign re Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted b-,-ermit applicant
1. Building U -26e--)
(a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4 Mechanical(HVAC)
��
5. Fire Protection
6. Total=(1 +2+3+4+5) U VJ Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
I Signature:
ol
—}1uil ngC mi io,n�er nspector of Build'49s Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Site
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement WindowsAlterations) Roofing
Or Doors O
Accessory Bldg. ET", Demolition ❑ New Signs [a] Decks Siding [CI] Other[a]
Brief D cription of Proposed
Work: K�yU-
Alteration of existing bedroom Yes No Adding new bedroom Yes No �,j Al
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing complete the following
a. Use of building -.One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Ron Mitkowski as Owner of the subject
property
hereby authorize ^^
to act on my behalf,i all matters re ive to work authorized by this building permit application.
�[��� 12/17/18
Signature of Owner Date
as Owner/Authorized
Agent hereby are that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pans and penalties of penury.
Print Name.
s OwneirAgent Date -
I
I
i
i
•
r
I
k
I
SECTION 8-CONSTRUCTION SERVICES 7
8.1 Licensed Construction Supervisor: �j� Not Applicable ❑
Name of License Holder: Ynuy u
4 L* nse Number
/J`
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
.% Expiration 9
Address � ate
Telephone
SECTION 10-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...... ❑
i
�.
r�
City of Northampton
ss sic
Massachusetts ��? '<<
A
DEPARTMEffT OF BUILDING INSPECTIONS y e`
212 Main Street •Municipal Building .
Northampton, MA 01060 rfN�
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
t 2-W56,1%
(Please print house number and street name)
Is to be disposed of at:
�e,l�M ��ee-, VoIlIv—p�A1 1144
(Plea a print nam and Io ation of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
ture of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
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 Le ibl
Name (Business/Organizatio v'dual ' I
G 6 y✓l D LQ—-
Address: POS l
City/State/Zip: U/0 Phone#: �d 7
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am�emf withemployees(full and/or part-time).• 7. ❑New Construction
2. amprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.[31 am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10E] Building addition
4.❑1 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.❑Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. oof repairs
These sub-contractors have employees and have workers'comp.insurance.'
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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.
iContractors 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 cern Fy under the pains and penalties of perjury that the information provided above is true and correct
Signator . Date:
/Z/7-//�
Phone#: 3 717
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#: