29-478 (5) 591 BURTS PIT RD BP-2020-0551
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map-Block:29-478 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT WINDOWS/DOORS BUILDING PERMIT
Permit# BP-2020-0551
Project# JS-2020-000951
Est.Cost: $2500.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot SizOsq.ft.): 79714.80 Owner. BRIN JOSEPH V JR&JENNIFER L
Zoning. Applicant: BRIN JOSEPH V JR & JENNIFER L
AT. 591 BURTS PIT RD
Applicant Address: Phone: Insurance:
591 BURTS PIT RD
FLORENCEMA01062 ISSUED ON.1013112019 0:00.00
TO PERFORM THE FOLLOWING WORK.-REPLACEMENT DOORS AND WINDOWS
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:
FeeType: Date Paid: Amount:
Building 10/31/2019 0:00:00 $40.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
W/A,/0 acyl L /J 0VX--"
Department use only
rye City of Northampt /� Status of Permit:
Building Depart nt �� Curb Cut/Driveway Permit
212 Main St et wer/Septic Availability
Room 100 0 ell Availability
Northampton,'MA4 r 0 s Structural Plans
.�. phone 413-587-1240 Fa -127 ��� Plot/ to PI s
`9 O er Sp ify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, R ✓ R EMO SH A ONE OR TWO FAMILY DWELLING
eo 'yS
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
5- Rdr S Map Lot Unit
//,, f r1 Zone Overlay District
V 1 � n ` v 2, Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
NamePri t) Current Mailing Address: a)
� 2 /�(f
Telephone �j /5— 5J 1 V 1�� �n
Si a re `� /
2.2 uthorize A ent: -5 — L'SS
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building �UV (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Feer 'l(�
4. Mechanical(HVAC) "1 D. Do
5. Fire Protection
6. Total = 0 +2 +3 +4 +5) Check Number C�i59
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: )0 S09
Building Commissioner/Inspector of Buildings Date
N 61+0 f► K1� @ olo m (�t Sf 4 ei
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement VAndows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [q Siding [O] Other[O]
Brief Description of Proposecj
Work: �p Ole ���� , ( if ` f
rr Jdoors �- (�In (/l ()wS !o
Alteration of existing bedroom Yes No Adding new bedroom Yes No
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
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.
Signature of Owner Date
-To s h r)Irl as Owner/Authorized
Agent hereby declare that the statements and information 6fi the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury. /
J G -Sri-vi
Print ame 3o W
Signat Owner/Age Date
City of Northampton
Massachusetts
, c DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building 4
Northampton, MA 01060 Vis,
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:
S�l D f P, 90 Flo revy�'t'�-'
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
hI'(-,dci'�
(Company Name and Address)
"d"
Ig—
Sign atu of Perm pplicant 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
0 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.
Avylicant Information Please Print Le ibl
Name(Business/Organizatio dividual): / I� '� lel^
Address: J4�wrj�
City/State/Zip: e 0106�- Phone#: 7 13 6-3 J b V S
Are you an employer?Check the appropriate boa:
Type of project(required):
1.Q I am a employer with employees(full and/or part-time).' 7. ❑New construction
2.❑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'W I am a homeowner doing all work myself[No workers'comp.insurance required.]t
10E] Building addition
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.E:]Electrical repairs or additions
proprietors with no employees.
12.E]Plumbing repairs or additions
5.a I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.� p
ROOf 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.
tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the subcontractors 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 thepolicy 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 verifica'
I do hereby c yy un kr the pains and penalties pe u that ihe information provided above is true and correct.
Si afore: Date: , 0/
Phone#: / 3
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#: