17C-059 (2) 191 CHESTNUT ST BP-2021-0005
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-059 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-2021-0005
Proiect# JS-2021-000009
Est.Cost:$6500.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 23783.76 Owner: KROLL JENSEN P
Zoning: URA(100)/ Applicant: KROLL JENSEN P
AT: 191 CHESTNUT ST
Applicant Address: Phone: Insurance:
191 CHESTNUT ST
FLORENCEMA01062 ISSUED ON.71112020 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. Buiklim„ 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 Shmature:
FeeType: Date Paid: Amount:
Building 7/1/2020 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)'587-1272
Louis Hasbrouck—Building Commissioner
F-00
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 7
1.1 Property Address:
This section to be completed by office
Mapes Lot_ `� Unit
e
191 Chestnut Street - Florence,MA Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Jensen P Kroll 191 Chestnut Street Florence, MA 01062
Name(Print) Current Mailing Address:
413-320-8088
Telephone
Si Lure
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by permit applicant
1. Building 6,500 (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) 6,500 1 Check Number
This Section For Official Use Only
Building Permit Number: SJ Date
Issued:
Signature:
Building Commissioner/Ins for of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
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Ot,vliSy.,,;rll,ft.l;olI a'1'' :.brdi.r'',
City of Northampton
Massachusetts
c
DEPARTMENT OF BUILDING INSPECTIONS S:
212 Main Street •Municipal Building
Northampton, MA 01060 rfNh N')\
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:
N ( ChCaid(Y S
(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:
(Company N e and Address)
gnature 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.
M
A
oP FIRu
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
D Boston,MA 02114-2017
www mass.gov/dia
4 kers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
��information Please Print Legibly
Name (Business/Organization/Individual)-J1�5%,�► h:LQ/-
Address: 11 i _) c fn� . 71
City/State/Zip: Phone#: :ap
Are you an employer?Check the appropriate box. Type of project(required):
1.[]I am a employer with employees(full and/or par(-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. ✓)I am a homeowner doing all work myself.[No workers'comp.insurance required.]f
10❑Building addition
4.❑f 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.®Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
G.❑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#I 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 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 certify under the pains andpenalties o�per* ry that the information provided above is true and correct
Si attue: - - i Date:
(�
Phone#: z//Z - HCl
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#:
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