24D-155 - ERROR ON 1ST PAGE 19 CARPENTER AVE BP-2021-0059
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24D- 152 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit# BP-2021-0059
Project# JS-2021-000087
Est.Cost: $2000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO.-
Const.
O:Const.Class: Contractor: License:
Use Group: PHILIP SHUMWAY INC 105743
Lot Size(sg.ft.): 14418.36 Owner: SHUMWAY PROPERTIES
Zoning: URC(100)/ Applicant: PHILIP S H U MWAY I N C
AT. 19 CARPENTER AVE
Applicant Address: Phone: Insurance:
P O BOX 522 (413) 687-9400
HADLEYMA01035 ISSUED ON.712012020 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT 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 7/20/2020 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
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111
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C31r o The Commonwealth of Massachusetts
FOR
>N °A,,, Board of Building Regulations and Standards
n ;I Massachusetts State Building Code,780 CMR MUNICIPALITY
USE
G� Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Alar 2011
NOne-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: 'dj Date Applied:
Building Official(Print Name) Signature UUD e
SECTION 1:SITE INFORMATION
1.1 Property Address V 1.2 Assessor Map&Parcel N'umber�s C�
1
1. Is this an accepted street?yes no Map Number !•G 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 Yazd 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❑ Private❑ Zone. Outside Flood Zone? Municipal❑ On site disposal system ❑
Check ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 .Qwnerl of Rec d:
S Ith � I—(_a�t c , ► n 1 a S
Name(Print) ity,state,AP
RA V f x, (A �na
o. o�eet Te ephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'-(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) CI Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Specify:
Brief Description of Proposed Work': W 1kv
SECTION 4:ESTL lATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building S 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $
❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: S
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ -
Suppression) 'Total All Fees:$ ya.
^ C eck No.0 &Check Amount: Cash Amount:
6.Total Project Cost: t�, Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) -7c]
License Number ExpYation Date
Name of CSL l4oldef , I
n _ s, ��� List CSL Type(see below) L/
No.and Street Type Description
1—1
�� I U Unrestricted(Buildings u to 35,000 cu.fl.)
T�� Irt�ZIP `Q R Restricted 1&2 Family Dwelling
CiAylTown,Statl(, M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
L� I Insulation
Tele ho Email address D Demolition
5.2 RegisteredYI me Improvement Contractor(AIC) ni� � '�
{— ________— HIC RKgistiatibn Number Expiration Date
RIC Company Name or HTC Registrant Name
No.and Street Email address
Cit /Town,State,ZIP Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be c9mpleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the lssuan of the building permit.
Signed Affidavit Attached? Yes.......... No..... . D
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED 1�'AEN
OWN'ER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize �VIU�wu5 S e-rv1(c 5
to act on my behalf,in all matters relative to work authorized by this buil ing permit application.
I,—)t� i ca�(-—�r ef (ki, AA 2
Print Owner's Name( lectronic Signature) it I I I ll to
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of petjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
A-t k.a
Prik Owner's or Authorized gent's Name(Electronic Signature) ate
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
wvvw.mass.,nov/oca Information on the Construction Supervisor License can be found at www.mass.pov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq.fr.) (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 hearing system Number of decks/porches
Type of cooling system Enclosed Open
3. 'Total Project Square Footage"maybe substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
a 1 Congress Street,Suite 100
s
z Boston,MA 02114-2017
www tnass.gov/dig
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
A212licant Information Please Print Legibly
Name(Business/Organization/Individual)n V^--S, l
Address:
City/State/Zip: 2z4A Phone#: (/
Are you an employer?Check the appropri a box:
Type of project(required):
1.Vla
loyer with employees(full andlor part-time)_* 7. ❑New construction
2. ole proprietor or partnership and have no employees working for me in g, ❑Remodelingacity.[No workers'comp.insurance required.l9. ❑Demolition3. omeowner doing all work myself.[No workers'comp.insurance required.]f
10❑Building addition
4.❑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.❑Electrical repairs or additions
proprietors with no employees.
12.���jPlumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. I16f repairs
These sub-contractors have employees and have worke 'comp_insurance.t
6.F_1 We are a corporation and its officers have exercised their right of exemption per MnGI.c. 14.e
152,§1(4),and we have no employees.(No workers'comp.insurance required.)
Any applicant that checks box#1 must also 511 out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hue outside contractors must submit a new affidavit indicating such.
'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state wbether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
fain an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
iunfornration.
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 MGT.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 S'T'OP 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 0 cc of Investigations of the DIA for insurance
coverage verification.
I do hereby certify un er to ins and peof perjury that the information provided ab ov true and correct
SigLiattire: Date:
Phone#:
Oficial 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#:
The City of Notthampton
Building Department
,y+ 212 Main Street
�Asreosu0, Northampton, Massachusetts 01060
Phone (413) 587-1240
Fax (413) 587-1272
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVAT ION PROJECTS)
In accordance with the provisions of MGL c40, 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, sl50A-
Thedebris will be disposed of in: i !y J�,- 4I(\L,-c[<
Location of Facility 1rG1 (It-� Ce-1- I
The debris will be transported by:
Name of Hauler �lyn`^�a t����'¢L � 4/1-C-
-71 ql
Signature of Applicant: Date: ,A