23D-112 (2) 584 ELM ST BP-2021-1133
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23D- 112 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2021-1133
Project# JS-2021-001903
Est.Cost: $8500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 17946.72 Owner: JOSHUA COHEN
Zoning: URB(100)/ Applicant: JOSHUA COHEN
AT: 584 ELM ST
Applicant Address: Phone: Insurance:
584 ELM ST
NORTHAMPTONMA01060 ISSUED ON:4/6/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:REBUILD EXISTING FRONT PORCH
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. (� �
Xx1 •
Certificate of Occupancy signs re:
FeeType: Date Paid: Amount:
Building 4/6/2021 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
The Commonwealth of Massachusetts
iiA`i? ' 5 Board of Building Regulations and Standards FOR
f 2fl21 M1ssachusetts State Building Code, 780 CMR MUNICIPALITY
i , USE
n�
-NoRT4 J;Lr)b\ •g_. it/ .pplication To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
'�— r, ^N a,q;,,�rroNs One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: eOOa/,/,� 33 Date Applied:
fiLUiN7055 /17 Li-6-ZOZI
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Nu s
5-8y- &fin sf-, Nor--ham phi h1 AA a 070� T
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 ft) 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 0 Zone: Outside Flood Zone?
_ Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Re ord:
.dos h u a C�oksun (Jo,f+ha-rn p toil , AAA 0l a 6 0
Name(Print) City,State,ZIP
580 F�m 5 J 30?. 4309 josh va.@ f GieriseaKd fell,call
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building lE Owner-Occupied% Repairs(s)g Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work': Reb Vl Id e,x I s.1-1 n9 rd- p r f,I , Mauch Na
deck poi fs, �'oo 2 f, Cer/in9 , steps, Porch totp ri,1+-
in easureS 6 x -
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 9ca0, 0 0 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) I $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $ (�
Check No. 7 i3 Check Amount: tI'
6. Total Project Cost: $ 0 5 0� �0 0 Paid in Full 0 Outstanding Balance Due:
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.)
City/Town,State,ZIP R Restricted 1&2 Family Dwelling
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 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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: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 application is true and accurate to the best of my knowledge and understanding.
stiva C.oh�n
Print Owner's or Authorized Agent's Name(Electronic Signature) I)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
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"
..1&64.N..'4.
..—.— The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
—11'figff
* 11 Boston, MA 02114-2017
"V.,.., www.mass.govidia
WO/ken'Cempen.sarion Insurance Affidavit:Builders/Contrition/EkeirieiansiMumbers.
I(1 fik. 1 11.11)WITH THE PERMITIM;AUTHORITY.
Applicant Information Please Print Ieeibls
Name (hlusincsa,Orgamizationandavitioal): .-----7C7)S kf/tiCk Co kk-'411
Address: 5 b8 , &/#I'i s-f-
City/State/Zip:WO('hi c .fin pfo 0 /Wq- OA 9hone#: 3 v_7- io
Ate yen lell employer?Cheek the appropriate twit: Type of project(required):
i.CI 1 ,rn a employer with employees thin amkor part-time 1.• 7. CI New construction
la on a sole proprietor or pliant:11411p and have no employees working for me in 8. Ti Remodeling
,ty capacity.(Nu workers'cienp,intrimince resIturisl)
9. Demolition
XII am a homeowner doing all wurk myself,[No v•orkers to smut:nix required.)'
i0 0 Building addition
4.0 I am a Innissuistier and will be hiring taints-sours to oondiset all work on my property, I a ill
,mute that all L'untraciors either have aurkers"COMpensautin trout-ono:or are mile i it3 Electrical repairs or additions
propneturs u ith no employees,
12.0 Plumbing repairs or additions
cCi I ant a general contractor and I have hued the sub-cuntracturs listed on the anarhed 3ilect
ErThese sub-contractors hove employees and have workers'comp.insurance.; 13Roof repairs
6.E3 We are a corporation and its
officers haver iterCINCli then'right
of exemption per MOL c. 14.c3 Other
132,f 44,anti we have no crtipluyets.[No workers'comp.insurance required.]
'Any applicant thou chocks box al must also fill out the section below ahon in their workers'compeination policy infumultion.
t Homeowners who submit this atlido‘,it indicating they are doing all work and then hoe outside contractors mum submit a new affidavit indicating such.
:Cocitractoni that cheek this bus.must attached an additional sheet%busy mg the name of the sub-conitractors and mate whether IN not those entities have
employees. If the sub-eururs,:tors fuse employ era.they moo pro,.ide their workers'von",policy non 11,o
1 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. Lie.#: Expiration Date:
Job Site Address: City/StateiZip:
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 e. 152, *25A is a criminal violation punishable by a fine up to S1.500.00
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 here dffy a e the pains an "allies of perjury that the informadON provided a e is true and correct
signature: natc Li- C i -2—I
Official use only. Do not write in this area,to be completed by city or town official
(ity or Town: Permit/License a
I Issuing Authority(circle one): 1
1. Board of Health 2.Building Department 3.CityiTown Clerk 4.Electrical Inspector 5. Plumbing Inspector
h.Other
Contact PCIPMIIL
[
. , . . . . Phone#:___
City of Northampton
a 11,6b1,> w Massachusetts �4,'it s#c�er
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DEPARTMENT OF BUILDING INSPECTIONSlk
212 Main Street • Municipal Building 0%
j.+ Northampton, MA 01060 .Z •01
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10,
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 et-1Je keCtiCliki. , 2.3(t 611.s4-11.a-vv)P l01� kc�r
(VO( pfvv , MA 01060
The debris will be transported by:
Name of Hauler: gosh UOl CO LUZA 1,
( S
Signature of Applicant: Date: IZ f
City of Northampton
' Massachusetts5. - '�{
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' 'U. t DEPARTMENT OF BUILDING INSPECTIONS
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212 Main Street • Municipal Building �j, h
.a� Northampton, MA 01060 fry VO1'
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, Oo Co k 7Asl,-B
S h V 0. e-h (insert full legal name), horn (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 S day of Ar 1/7 / , 20 21.
(Sign to )
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