07-015 (2) 372 NORTH FARMS RD BP-2021-1198
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:07-015 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPAIR BUILDING PERMIT
Permit# BP-2021-1198
Project# JS-2021-002003
Est.Cost: $7000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 56628.00 Owner: MINSKY LAURA
Zoning: RR(I00)/WSP(100)/WP(53)/ Applicant: MINSKY LAURA
AT: 372 NORTH FARMS RD
Applicant Address: Phone: Insurance:
372 NORTH FARMS RD (917) 841-7273 ()
FLOREN CEMA01032 ISSUED ON:4/20/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 5 REPLACEMENT WINDOWS,
REPAIRS TO SIDING, DEMO CHIMNEY
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Budding 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.
1 1
T ,1 .10
Certificate of Occupancy Si2nature: I
FeeType: Date Paid: Amount:
•
Building 4/20/20210:00:00 $65.00
• 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
. i_ _
The Commonwealth of Massachusetts R
, Board of Building Regulations and Standa ds APR 2 0
�0z11 I
UNI IPALITY
Massachusetts State Building Code,780 C vIR SE
Building Permit Application To Construct,Repair,Renovatt ' 01060
eviseqi Mar 2011
nnTHAh?PTpN MA TI NS
One- or Two-Family Dwelling _______ .
This Section For Official Use Only
Building Permit Number: 6/1 A)4. 1Jq 0 Date Applied:
I '55 1-1'Z Z6Z.
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property,Address: 1.2 Assessors Map& Parcel Numbers
?) )1 0rrithe ILA no rzila- MROIQIPL. 0-70/6
1.1a Is this an accepted street?yes no Map Number Parcel Number
13 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 Record:
t ran fr. 1AJt I soy` A- Ltc,urot 1.n s 11 "noir.vtc.,2 f11 A o tot:,1._Name(Print) City,State,ZIP
'31'l NJ ftvlvt S [Zei 703 Ia. l 5D' b► e.h m w. is crri L g rn ..r i-caw‘
No.and Street Telephone Email Address
SECTION 3 DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building Er Owner-Occupied Repairs(s) III"[Alteration(s) 0 Addition 0
Demolition l3" Accessory Bldg. ❑ Number of Units 1 Other 0 Specify:
Brief Description of Proposed Work': -.pi Ace 6 t.utn a(Ows Clap wood 1e.Dal(S,
-(Ake down def,nc. r.,nderhloc u,tm,r-tpA r, l-t;u-o2 028
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $t.l 000 1. Building Permit Fee: $ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa (Item 6)x multiplier x
3.Plumbing $ — 2. Other Fees: $
4.Mechanical (HVAC) $ — List:
5. Mechanical (Fire $ Total All Fees,;,, //
Suppression)
�b
Check No. Check Amount:
6.Total Project Cost: $ 1 000 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.)
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 .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 Ora ncr'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
sts application`is true
�and accurate to the best of my knowledge and understanding.1
IrA L`^ `�`" kiN MuArc,V. �i 2 v21
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"
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 021.1 A-201
: www masx.gavldia
Iv oilers'(`ompensatlon Insurance Affidavit: luilderaFContractorsfElectric€anstFluinber'.
TO tel: FILED WITH THE PERMl1TING AUTHORITY.
Applicant Information A
} ' Please Print Leen
Name(F3usiricss ilrganizatiantlttdividual): 3 M �t(�'" 1- 1._. '- t� 1 'YV 1 I n S
Address: Mgt . 1 a N ail, * ►vi s 12oc,4i
CityiStatefZip: °revile Y1(1 A 01 Ob2 v 3 L DZ. I S O
Phone#: '? 1
,ire yet an employee Cheek the appropriate Aar:
Type of project(required):
1.Q I am a employer with .. s'erigiloyeea(full andforparvtime)_' 7. 0 New construction
:fl 1 am a sok proprietor or pane hip and have mu employef working for ME iii $. 0 Remodeling
an opacity.[No workers'camp.insurance moaned.] `t.. -'�
l I art a homixtwner doing all wet£myself.INo workers`coratp.insurancere quired_I'
►. Q Demolition
-f. 1 am a hoax tans and will be hiring corm-actors in conduct all work on my property.. 1 will 10 Building addition
ensure that all c^nnaractors either have workers'eutiveniaiion insurance or axe Sole 1 I 0 Electrical repairs or additions
prupttetom wait nu employees.
1 2.E1 Plumbing repairs or additions
I am a ge5netal contractor and 1 have hired the sub-cnntrecbattc listed on the auadxed sheik ] [ "l Roof repairs sub-comma-ors have employees and have workers'comp.insurance.;
�t..J
6.0 We are a csntxaratian and its officers have exercised their right of exemption per MGL e. l 4 'Jt ei�� r
�
152,§1 f 41.and we have no exuplarees.[No workers'comp.insurance required.] l�el e.k°., Viloi .t t
'Any applicant that sheds box al most also till out the aeu on below showing their wotkera'conipencexian policy information.
t Homeowners who submit:this affidavit indicating they are doing all Mori and than hire outside contractors most tiutmttit a new at ulavit indicating Such
;Conttartcras that cheek this box muse an ailed an additional shot showing the name of the Solt-cct+itractoes and stale whether or nor those a ititie?i have
c-mpinyeiy_ It€be stib-coltracti rs he a exrrplogees,they!toil proti w idc their orkers comp.piney number.
I am an employer that is providing workers'compensation insurance for my employer=,. Below is the policy and job site
infotmadon.
Insurance Company Name:
Policy#or Self ins.Lie.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy ot'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
arid!ter 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.
f da hereby certif t under the pnain�and penalties of perjury that the Information provided above is true and correct
sires.. lum ` ,��J Date: l,\n 3 i 2-0 2-1
Phone t#: `(f)2 LSC`i
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permiiil.icense#
Issuing Authority(circle one):
L Board of Health 2.Building Department 3.City/Town('lick 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone 4:
City of Northampton
Massachusetts ��2� ' {e
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DEPARTMENT OF BUILDING INSPECTIONS ��`` Pl.,'
212 Main Street • Municipal Building �,t,., t"
� Northampton, MA 01060 'yy ‘y0
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:
The debris will be transported by:
Name of Hauler: 54 -Tvo..6411
Signature of Applicant: 0/W) Date: 0 3 1 2-02-1
City of Northampton
94' ESRNP O SAS' .c.
Massachusetts .`c
..
► "� DEPARTMENT OF BUILDING INSPECTIONS4: g
• 212 Main Street • Municipal Building Lr, (ti
Northampton, MA 01060 l'4 ON�
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
LA.)' (insert full legal name), born (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 activihj 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 ' day of �wf _\. , 20Z-1 .
(Signature)