22D-083 (4) 35 BLISS ST BP-2021-0955
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 22D-083 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ADDITION BUILDING PERMIT
Permit# BP-2021-0955
Project# JS-2021-001633
Est. Cost: $149500.00
Fee: $971.75 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: SACKREY CONSTRUCTION 079384
Lot Size(sq.ft.): 16030.08 Owner: SARAH M RIGNEY
Zoning: URA(100)/WSP(100)/ Applicant: SACKREY CONSTRUCTION
AT: 35 BLISS ST
Applicant Address: Phone: Insurance:
83 SOUTH MAIN ST (413) 665-9995 () Workers
Compensation
SU N DERLAN DMA01375 ISSUED ON:3/5/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:FAMILY/MUDROOM ADDITION,WINDOW
REPLACEMENT
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.
.; • is, .5.2 • +.• •
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 3/5/2021 0:00:00 $971.75
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
2 -OK'
File#BP-2021-0955
APPLICANT/CONTACT PERSON SACKREY CONSTRUCTION
ADDRESS/PHONE 83 SOUTH MAIN ST SUNDERLAND (413)665-9995 Q
PROPERTY LOCATION 35 BLISS ST
MAP 22D PARCEL 083 001 ZONE URA(100)/WSP(100)/
THIS SECTION FOR 0 SE ONLY:
PERMIT APPLI�a: •► a. 'W4 .
ENCLOSED ' .QUIRED DATE
ZONING FORM FILLED OUT
Fee Paid ILLVISI �M 'ILCIMI
--
Buildinl Permit Filled out
Fee Paid
Typeof Construction: FAMILY/MUDROOM ADDITION,WINDOW REPLACEMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 079384
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
X Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: . Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
iVat
TTTTTT
Si! ature of Building Offici• Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
ram _ '(�
h01-iL,c P I-AuS
1V
1 /
g, The Commonwealth of Massachu etts 4/,4 -
110t Board of Building Regulations and S nda ds R 1 FOR
Massachusetts State Building Code, 80 ��21 MfJNIGiPALITY
r�_. USE
Building Permit Application To Construct,Repair,Renovate Or a._ 4?evised Mar 2011
One-or Two-Family Dwellings /
��` This Section For Official Use Only
Building Permit Number: b�')/'q4-5 Date Applied:
1 li
` , 1 ► 2, �ii _ 3 L5 oZl
Building Official(Print Name) Signature i' Date
I
SECTION 1:SITE INFORMATION
1.1_3 open Address 3�i -r�Rn 1.2 A;easy Map&Parcel Numb
1.1a Is this an accepted street?yes no Map Number 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 Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
NP\ i - 52'- G'' 30 (01- gyz4
1.6 Waatte/r�Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0�" Private❑ Zone: _ Outside Flood Zone? Municipal LY/On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Jcs. h \ (2 ( w--,- . 1 c-i.kiv-,c c . , o A t� () i C G.Z
Name(Print City, State,ZIP ,
`7
� ` �s S S� `-I/3•`,�E��G5,5 r1.� �vt� e�•1 tticc:,, 1.C�
No.and Street Telephone Email Address'
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 11 Owner-Occupied ll Repairs(s) 0 Alteration(s) Ill Addition Ell/
Demolition 0 Accessory Bldg. ❑ Number of Units Other 0 Specify:
Brief Descrip of Proposed Work':
t_, lnn 1 IZA)vv1 /1NtVQa11w1 A-D 0 LT!D 0
Wi►.1,DrJ IcUsi cer,frvirvvor
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ r 3 S, on 1. Building Permit Fee: $ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ q 50 O . 0 Total Project Costa(Item 6)x multiplier x
3.Plumbing $ i SO d 2. Other Fees: $
4.Mechanical (HVAC) $ 3 5,6 d List:
5.Mechanical (Fire $
Suppression) Total All Fees:
t Cost: t Check No.ItAlb Check Amount:4fl1i sh Amount:
6.Total Project $ I I,.5 0 b 0 Paid in Full 0 Outstanding Balance Due:
X (p 'so
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) C S.O—P 9 3i ( O�l
Jo it 14- License Number Expi thou ate
Name of CSL Holder
S • ,v At/ ) List CSL Type(see below)
No.and Street Type Description
6 n nri t(4 ^ 7/ ^^ 1s, i 2 ) Unrestricted 2 Family up elto 35,000 Cu.ft.)
City/Town,State,ZIP �'�Pi1/ V v�,1'S 0 7 R Restricted I&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
�," / f^ - pp�� � SF Solid Fuel Burning Appliances
�[l3-5'44"tP (°31 sac ski ( C Cce474_ I Insulation
Telephone Email address •<ANA D Demolition
5.2 Re stered Home Improvement� Contractor(HIC) f L(e e I '�11Z"L
i �' ' L-K-et HIC Registration Number Exp do Date
HIC Company Name or HIC Registrant Nanie
S 3 S. %NA_Aa r l , 5 Ad01-61 CGC—d C.,U-rve_. , C ALA
No.and Street Email address
50 q p► c _pc 1419 rApc of 37{ (I/3.4.3 -b 031
City/Town, State,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 0 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 .A c k vz. C(iv1/4/
to act •, my behalf,in all .ers relative to work authorized by this building pehnit application.
Print Own: 's ame(Electron.. :I/ a ; •) ate
SECT ON 7 1: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
contained in this applic • n is true and accurat to the best of my knowledge and understanding.
3s0 / 3/ / )
Print Owner's or Authorized Agent's Name lectr •c 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"
City of Northampton
• p, p 5 S
(r Massachusetts �� .- <<,
� DEPARTMENT OF BUILDING INSPECTIONS ;. n .4
yv D.
+
212 Main Street • Municipal Building
, . + '' Northampton, MA 01060 �sbjli ir5 o
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: V,A-1 .- - ' 114c LtAig-
The debris will be transported by:
Name of Hauler: ,S A-{i (10,6C/VWC:ri,014
Signature of Applicant: \ Date: _3 Ji Z I
_.__---- The Commonwealth of Massachusetts
lt= =; Department of Industrial Accidents
t •
• ` ' I Congress Street,Suite 100
• =,'� = ' Boston, ,iIA021142017
=.. , H'lvw mass.gov/dia
r
11'urkers'Compensation Insurance Affidavit:Builders!Contractors/l:kctricians/Plumbers.
'TO BE FILET)".S WI'1'l1E PERWIl rTINC AUTHORITY.
Annlicant Information Please Print l.egibls
Name(Business Organ►zation•individual): 5 Qr- 6 v1 C C , -,
1
Address: S 3 S- U.it 4A,fi
City/State/Zip: SulaSieptz.Gp.t4 c I - Phone#: 9 13 - 5'1, -4,, (0 3 1
.ire you as employer!Cheek the appropriate hot:
Tope of project(required):
I. am a empIo cr with _ .employees(full want part-time 1 Er7. ale—modeling
New construction
U, I am a sole proprietor or purmership and have nu ernpluyet's workung for me in K. alemodeling
any capacrts.(NU IA Wiser,'comp.insurance noquar�d.) t�
9. ❑Demolition
30 I am a homeowner doing all Murk myself.(No s otters'comp..rnsuramx recounal.)'
10 0 Building addition
40 1 am a come owner and v.ill be huing contracture to conduct all w uric on my property. I will n
ensure that all contractors either}laic%mien'cornp►naatnan insurance ur are sole I I L Electrical repairs or additions
proprietors w ich no employe".
12.0 Plumbing repairs or additions
5CJI 1 am a general cuntractur and I base hired the sub-euntracturs hated on the attached sheet. 13 1:1Roof repairs
These sob-euntnctun have employers and Inure workers'comp.insurance.:
6.0 We arc a corporation and its ufficcrs have cxc eised their right of exemption per Wit.c. I4.0Other
152,:li4i.and we base no employees.[Nu worker'comp.insuranec required.l
'Any applicant that cheeks but al must also till out the section below show ing their workers'compensation pulley information_
lions owusers ssho submit this attodasit indicating they are doing all stork and then hire outside contractors must subrrut a new atfodat it inclining such
:l untracturs that check this box must attached an additional sheet show ing the name of the sub-eura-actors and state whether or not those entities hate
eniplu\ces. If ttse sub-contractors late ertgeluyees.they must pros ide their workers'comp.pe,Lcti number
!am an employer that is providing workers'compensation Insurance for my employees. Below is the policy and job site
information. �1
Insurance Company Name: ( A • L. e 1 ' 1 . _
Policy#or Self-ins.Lic.#: 1,0F6.6(71/2. Ai-VD C121 4 hit l- Expiration Date: 2- 2- ! 2-1--
Job Site Address: 3-5- V U✓> ST, City/State/Zip: -F Lo IZJz4C.ft t A L' —
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 SI,500.00
andior one-year imprisonment.as well as civil penalties in the form of a 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 c rta under pains and >r allies of perjury that the Information provided above is true and correct.
Sitmature: Date: 3 /[ / Z-J
Phone#: t /3- S(v c ✓✓ ./1
Official use only. Do not write in t/tit area,to he completed by city or town official
( its or Iossn: Permit/License#
Issuing.%uthorit} (circle one):
I. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
('ontact Person: Phone#: