31A-087 (7) 16- 18 VERNON ST BP-2021-1130
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:31A-087 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Porch Repair BUILDING PERMIT
Permit# BP-2021-1130
Project# JS-2021-001897
Est.Cost:$1200.00
Fee:$72.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sci.ft.): 5009.40 Owner: BARBER ROBERT E&CAROL J EDELSTEIN
Zoning: URB(100)/ Applicant: BARBER ROBERT E & CAROL J EDELSTEIN
AT: 16 - 18 VERNON ST
Applicant Address: Phone: Insurance:
16 VERNON ST
N O RT HAM PTO N MA01060 ISSUED ON:4/7/202 10:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE AND REPLACE EXISTING PORCH
DECK AND STEPS
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 NO ' HA PTON PO VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. I I
• J'
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 4/7/2021 0:00:00 $72.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
i
m % The Commonwealth of Massachusetts
z-tii
0 o A . * , Board of Building Regulations and Standards FOR
=p " '� Massachusetts State Building Code, 780 CMR MUNICIPALITY
Dc ` . USE
0 i m i Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
z cJt — One-or Two-Family Dwelling
v v CD -.�- ' ►s Section For Official Use Only
o Building Permit Number: ,DI'!afT 3 _ Date Ap li d:
, 40„..._s 12.55
/7 Li. s-zozi
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
(�/ IS \f �. S� 3 f, — OR4 - O0l
1.1 a Is this an accepted street?yes v/ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: �•
Zoning District Proposed Use LotArea( q if) Frontage
1:5 Building Setbacks(ft) N.0 CAA_ovvt.. .
Front Yard Q 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 Zane? Municipal I°�On site disposal system 0
Check if yes
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: •
CS(E1LT. is A71.G Z C. t- e_P�I..S _17--4 NI -n"t� ?4
Name(Print) City,State,ZIP A0i OCe0
Ito \/EJ and S'r" 413- 585-8530 rf-etrayslxr47@ rut;I•cowt
No.and Street Telephone Email Address
SECTION 3:DESCRIPT ON OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building Of Owner-Occupied li Repairs(s)'21/ Alteration(s) 0 Addition 0
Demolition Er Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Descrip tan of Proposed Work':
cr\r - ciu-a c& Cs-. -2x( S Cif
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: i Official Use Only
(Labor and Materials)
1.Building $ I Z Ct 1. uilding Permit Fee:$ 3.2._ Indicate how fee is determined:
2.Electrical $ arcf rri4 e�atr7�jl�licaTion Fee
- efotal Project Costa(Item 6)x multiplier%. 4 x fitto_ (/1b
3.Plumbing $ 2. Other Fees: $__
4.Mechanical (HVAC) $ List:____
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. ticq_Check Amount: -7•2- Cash Amount:
6.Total Project Cost: $ I a rSb ❑ Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor
/License(CSL)
DWVtQ� o o. License Number Expiration Date
Name of CSL Holder
0 C � �� List CSL Type(see below)
Na and Street TY 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 ❑ 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. 2
Print Owner's or Authorized Agent's Name(Electronic Signature) D to
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.) Cp 0 (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
'SHA3/fF)3
i,, •� . 5~ .10
Massachusetts 'cam,
tDEPARTMENT OF BUILDING INSPECTIONS P,
212 Main Street • Municipal Building
Northampton, MA 01060 $1; '0"
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 c,u` .ei 1 --Q Cx "- Z 3 If e! '(-4A- -i "' 1
The debris will be transported by:
Name of Hauler: V rS 41e0.1112.iv
Signature of Applicant: Date: '1212-67—/
BUILDING DEPARTMENT
DEMOLITION PERMIT SIGN-OFF SHEET
4 2.
Date: Za21
Address: 1 VI S \eAfr svk St' Building Use: Veja-i- -4-46L-Q_ 2- -C- I L/
Owner: I` Phone: 4'1 3 -- ce 7 S - 5 3 4 Q
Owner's Address: 1 (p V -v)n s- 1 58 s - 5 0 '��`'`
C
UTILITY CUT OFF qu'k- re_j'
(Signature of Authorized Representative of Utility Department required)
As required by the Massachusetts State Building Code (780 CMR), a permit to demolish shall not
be issued until a release from the utilities is obtained, stating that their respective service
connections and appurtenant equipment have been removed or sealed and plugged in a
safe manner.
Eversource (Gas)
Signature Title
National Grid (Electric)
Signature Title
DPW (Water)
Signature Title
DPW (Sewer)
Signature Title
DPW (Storm water)
Signature Title
DPW (Tree Warden)
Signature Title
DPW Director
Signature Title
Historic Comm. Review
Signature Title
ASBESTOS REMOVAL ►t- €- Lr-(v-e-ci(
All residential, commercial and institutional buildings are subject to Massachusetts Department of
Environmental Protection (MassDEP) asbestos regulations at 310 CMR 7.15. Therefore, owners
and/or operators (e.g. building owners, renovation and demolition contractors, plumbing and
heating contractors, flooring contractors, etc.) need to determine al asbestos containing materials
(ACMs), both friable and non-friable, that are present at the site, and whether or not those
materials will be impacted by the proposed work, prior to conducting any renovation or
demolition activity.
Examples of commonly found ACMs include, but are not limited to, heating system insulation,
floor tile and vinyl sheet flooring, mastics, wallboard, joint compound, decorative plasters, window
glazing, asbestos containing siding and roofing materials and fireproofing materials.
Failure to identify and remove all ACMs prior to its being impacted by renovation or demolition
activities, can result in significant penalty exposure, and higher clean-up, decontamination,
disposal and monitoring costs.
A DOS certified asbestos consultant must be contracted to determine if asbestos is present and
whether removal/repair is necessary. If the building is a state owned facility, contact DCAM and
DOS. DOS provides a list of licensed asbestos abatement contractors and consultants. You may
wish to inquire if a contractor has any history of violations. Only DoS licensed and DOS certified
asbestos abatement contractors and consultants may be hired to perform asbestos related work
in Massachusetts.
Received by:
Print Name Title
Signature Date
The Commonwealth of Massachusetts
s,. ` ' t, Department of Industrial Accidents
4i
—t 1= 1 Congress Street,Suite 100
W%I Boston, MA 02114-2017
, > www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): l�j- ..."----T' '�-F-�t212j
Address: I V 4-g--NL( 5 1-� I O co o
City/State/Zip: 6 4CIL-n-4i c .f�}t.(, M Phone#: 4-( � 'S 8 5 - �j 5 3�
Are you an employer?Check the appropriate box:
Type of project(required):
1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Er 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.❑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 11.0 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.:
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. 'Other(2 E. p(f (.H
152,§1(4),and we have no employees.[No workers'comp.insurance required.] C1 5-fi(j D tku__, 5TE
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t��e�t Homeowners who submit this affidavit indicating they are doing all work and then hire 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 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 and penalties- es of perjury that the information provided above is true and correct.
Signature: ��� I bG -eA/ Date: 040 2-
Phone#: 415 ^58'j — 8 5 30
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#: