36-144 (6) 316 BROOKSIDE CIR BP-2021-1029
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:36- 144 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BASEMENT RENOVATION BUILDING PERMIT
Permit# BP-2021-1029
Project# JS-2021-001756
Est.Cost: $3500.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 17162.64 Owner: JANICE FRANCIS
Zoning: Applicant: BARNES JANICE AKA JANICE FRANCIS
AT: 316 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
316 BROOKSIDE CIR
FLORENCEMA01062 ISSUED ON:3/23/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:FRAME BATHROOM IN BASEMENT
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. Q
I •
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 3/23/20210:00:00. $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
RECEIVED
MAR 1 9 20Z1
The Commonwea h of assachusetts °
FOR
Board of Building R lat.., and Standards MUNICIPALITY
Massachusetts State uildfri 'Cod �; �'f•..ecnoNs USE
NORTHAMP7gN p
Building Permit Application To Construct,Repa oli_s a Revised Mar 2011
One-or Two-Family Dwelling
Thiskction For Official Use Only
Building Prmit Numbert P /• l0Z7 Date Applied:
Et.M3< Foss 3 23-2e21
Building Official(Print Name) ignature Date
SECTION 1:SITE INFORMATION
1.1 Pro a Address: 1.2�` '0 a�i 1.2 Assieo rs Map&Parcel Numbers
1.1 a 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 It) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard 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 0 Private CI Zone: _ Outside Flood Zone• Municipal 0 On site disposal system 0
Check if yes❑
2.1 Owner'of Record:
Ta ell ae. Frntrsci S Flor2ii c,P, M.A., 010 6 2
Name(Print) City,State,ZIP
31b f3e'ookstck Cyr- ice -1i3- V14.23c'c) kBCtr.+c ti 03 u;I•cori
No.and Street Telephone Email Address
New Construction❑ Existing Building far Owner-Occupied liir Repairs(s) ❑ Alteration(s) g( Addition ❑
Demolition ❑ Accessory Bldg.0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: fr-oxrn,.,,3 p R 111 c Q v NI i n
Gct34...,{.‘4,
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$1 r ,
Check No.I0✓.1 Check Amount: (/� Cash Amount:
6.Total Project Cost: $ 3,s 0 p, 0 0 0 Paid in Full 0 Outstanding Balance Due:
Oats 7icmi CGhi iC ',rn Ili/, Ye //
R;O//C, /7 g/yiail, Co#
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
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 ❑ No ❑
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
to act on my behalf,in all matters relative to work authorized by this building permit application.
/ "7 .202_/
Print Owner's Name(Electronic Signature) Date
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
✓et/lf Gt✓ F,-R/)GI .) 3' /1-202_,
Print Owner's or Authorized Agent's Name(Electronic 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
0'tH,.,, , �Mpro
t''' It', Massachusetts �`�Ss -'s,��``
Pc
1 r. . 4 DEPARTMENT OF BUILDING INSPECTIONS t9
212 Main Street • Municipal Building CD
.� Northampton, MA 01060 . 37�^1
(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: 2 3`1 E- i 6 c, H..r} „, Ia N c rjt,r...µ�,�,Y1, 040t , 01060
The debris will be transported by:
Name of Hauler: kc;^34 ,,,, 13z.>, 1d;" c CF:r- DIc-i-;g-ii
J
Signature of Applicant: Date: 3 17 Zo Z
The Coinniouty'e'alth of Massachusetts
rF__ Ile'partment of Industrial Accidents
A:ems: 1 Congress -Street, .Suite 100
Boston,AL-102114-201—
*: +rtytir.nrass.goi:rlia
ly.„t bet s'C oanpen>adon Insurance Affidavit:Builders Contractor Electricians Plumber-.
TO BE FILED t1TTH THE FERMITIPiCs ALTHORITY.
Applicant Information Please Print Legibly
Name(Business Organization.T.11diti 7I1: I kel►C fd'Ot 1)C
AddresF: 31 b 3t o c'IcSi Ct L C.—;
Circe State Zip: Pic re > , lM c. o l i;L 2 Phone=. ''113—
Are corn a■employer'Check the appropriate bet: Type of project(required):
1.0 I am a emplo}•er with empla?wes full and or part-dyne(' 7_ ❑New construction
=.DI ant a Iola proprietor or;os*ser iaip and:aave no employees working for me in S_ Remodeline
any capacity.[No worker.'comp osu.-ance teq::iir act]
3.0I am a kmnratrrrr doing all work in self.[No granters'carte in:=loots trqtin .ld f 9_ ❑Demolition
10❑Building addition
4.1x am a homeowaor and will be hiring canon:con to conduct an work on ace property. I will
ensure that all connector;either have workers'compensanoaiuzuanceorare;oh 11.QElectrical repairs or additions
proprietors with as employee: 12.0 Phaubing repairer or adaincer.
5.0 I ant a general contactor and 1 have hued the sub-icnnactor.lr;ted on the attached Meet 1 .1171RAof repairs
Bose sub-contractor.have employees and ha—e corker: comp.insurance.:
Other
6.❑yt a are a corporation and it;officer.have exercised their right of exemption per 2.1GL c 14.❑
152. 1(4).and we have no employes:.[Na w eakar:'comp.insurance regtsired.)
*Any applicant that checks box=1 must also fill ont the section below showing their worker.'caoapamsation policy information
Homeowners who submit tkis affida:•it indicates they are doing all work and then hire ouride contractors mast submit a new affidavit indicating such
:Contractor;that check this box mutt attached an additional:hew :hotline the name of the sub-contractors and:taw whether or not those entities have
employees.. Tithe sub-contractors have employee:.they must provide their worker:'comp.policy amber.
I am an employer that is providing workers'compensation insurance for air employees_ Below is the policy and job site
information
Insurance Company Name: _
Policy=or Self-inn;.Lic.a: Equation Date:
Job Site.Address: C try State lip:
Attach a copy of the workers'compensation policy declaration page(showing the policy munber and expiration date).
Failure to secure coverage as required under MIGL c_ 152. ,~A is a ritminal violation punishable by a fine up to S1.500.00
and'or one-year uvprisonment.as it'ell a:civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a
day-gn:n-t the violator.A copy of this statement may be forivarded to the Office of Investigations of the DLL for insurance
coverage verification.
I do hereby certify antler chaplains the information provided above is true and correct
Sitmztnre: - Date: ' f 7- 2 o 2 /
Phone=: !t 3 - y 4300
Official use only. Do not write in this area,to be cog leted by city or toga official
City or Town: Pertnit'license
Issuing Authority(circle one):
1.Board of Health :.Building Department 3.Citr-'Town Clerk 4.Electrical Inspector F.Plumbing Inspector
6.Other
Contact Person:: Phone=:
City of Northampton
---- yh `,,.
�,r Massachusetts ;
�." -.
,r cS'.
i i' DEPARTMENT OF BUILDING INSPECTIONS ,
212 Main Street • Municipal Building ul O�
Northampton, MA 01060 S'�frj 3,''‘''
I, as'i,'(!4- lin COIC i S (insert full legal name), born ?•q '5 Y (insert
month,day,year),hereby depose and state the following:
1. I am seeking a building permit pursuant to the homeowners' exemption to the permit requirements of the
Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a
parcel of land to which I hold legal title.
2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'exemption,
does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3.
3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2:
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or
is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use
and/or farm structures.A person who constructs more than one home in a two-year period shall not be
considered a home owner.
4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for
and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work
on my parcel, I am not engaged in construction supervision in connection with any project or work involving
construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any
provision of the Massachusetts State Building Code.
5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my
parcel,I acknowledge that I am required to and will act as the supervisor for said project or work.
Signed under the pains and penalties of perjury on this 17 day of IY/g-r, i .20.L.
(Signature)
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