23C-080 (10) 42 BLISS ST BP-2021-1236
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23C-080 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Bath reno BUILDING PERMIT
Permit# BP-2021-1236
Project# JS-2021-000908
Est. Cost: $22300.00
Fee: $145.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 17685.36 Owner: RAUSCHHAUP MICHELE
Zoning: URA(I00)/WSP(100)/ Applicant: RAUSCHHAUP MICHELE
AT: 42 BLISS ST
Applicant Address: Phone: Insurance:
42 BLISS (413) 478-3137 O
FLORENCE ,MA01062 ISSUED ON:4/26/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:RESIDE SECTION OF HOUSE AND RENO 1ST
FLOOR BATH
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 NORT AMP N f. VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. I •
. I '
Certificate of Occupancy Signatu e:
FeeType: Date Paid: Amount:
Building 4/26/2021 0:00:00 $145.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
,4! APR 2 6 2021 he Vommonwealth of Massachusetts
Bo d oBuilding Regulations and Standards FOR
MUNICIPALITY
�_ M sachusetts State Building Code,780 CMR USE
• tinRTsiiiimi lr l^1sP,
aingrY rAf5pli ton To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
- --One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: _AA. a 1 Z 3Co Date Appli :
Building Official(Print Name) Signature 1 1a,
SECTION 1:SITE INFORMATION
1.1 Pr Addr 1.2 Assessors Map&Parcel Numbers
44-2 to 0ss frreet
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: PRc RTYt WNER; P'
2.1 wner'ofRecord:
Alichce WI-LSC Chi" tzp1- ; 10►'e-vtcc MAD l 66
2_.
Name(Print,(L�/ J- City,State,ZIP
! Z '/, s f'-re 5/2-v2.6 -egzr r'v chok ,-,1&/ /vucf, c oet-,
No.and Street Telephone Email Address
11111111111111111111.11.111RN OF PROSED WORK2(check aIMIMMINI
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s)l0 Alteration(s) 0 Addition 0
Demolition CI Accessory Bldg. 0 Number of Units Other Specify: S'e: n9
Brief Description of Proposed Work2: RCs,dc, ,e4-1 oi ex-fer.ow- i✓,W, ceder.' Shi•J/es
I5 7t -1 a6'' b to o..,. ,'•e/1 0 — moo-ficrrwE' 4, r e,,.„.1,,t ,S'Girit P
•CTION 4: 'IMATED CONSTRUCTION COSTS
Item Estimated Costs. Official Use Only
(Labor and Materials)
1.Building $ /1 S-O O 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
0 Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 3/ Q D 0 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $Suppression) Total All Feg /
Check Nod!!�' Check Amount b
6.Total Project Cost: $ cy �S )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.)
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 Owner's Name(Electronic Signature) Date
OCTI i 7b:OWNER'ORAUTHORIZEl1 1GERIFDE,
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.
4'f' Gtie /RJc� iGz-c-' r Z(o/off. /
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
=1.0n 1; : Department of Industrial.Accidents
_�011 i — 4r, 1 Congress Street.Suite 100
'•a.= I Boston MA 02114-2017
6.7
'%�; www ntass.go►/dia
)%urker 'Compensation Insurance A ida%it:BuiWrrsicontr'setors/Eleet iciaas/PIu nbers.
It)BL FILED VI 111H THE:PL:KSil"rrlNG AIITHURIT11.
Applicant Information Please Print Leeibh
Name I Business Organization 1ndntdllal►:
Address:
City/State Lip: Phone#:_
Art dun an tmploaar'l hrrk the appropriate.hot:
Type of project(required):
1.0 1 ant a etiplot et with enaFMt ecs t lull:rid to part-tine I.• 7. CI New construction
20 I am a irk patron tarn as punntrship aril hate no cnrptanttis wotkinn lot me in 8. 13 Remodeling
art .apacttt. [No workers'cheap.insurance rryturti!_l
9. ❑ Demolitiona Iionwvwi doi
ng all work tnttclf llS vo
miters'oke s'comp.its :u urtcc n-almrcal..)'
10 a Building addition
a trrmcarwtrr and%ill be hiring ttiracrtatrs Itt conduct all work on ma prupertt. 1 win
ensure that all contractors either hale woikcn compensation insurance et an:sole 110 Electrical repairs or additions
proprietor wrth no eitttdarlices.
12.1:1 Plumbing terrain or additions
S0 I ant a gc-ncral c'ntraclor and 1 hate hued the soh-camtraelots listed the attached sleet. 130 Roof repairs
These soh-camtrattarn hate empk. ..oi and lute workers'comp.ut,L.r.tocr.
14.0Other
6.1:11 we an:a corpora nisi and its officer hate exercised Chen right of c.trntptwn per MC&c. ----
152.§144).and we hase no trnplotccs.[No wailer't:t np.insurance rc guise .)
•Ant applicant that shocks boa=I most also till out the idiot helow allow rig then workers'compensation polio. eniirtnatioa.
' Ilosneowncts who submit this arhdas it trudicaitng then are darni:all worts and then hue truest&contractors rust submit a ttcw atti.t:aa it indicating such.
:Contractors that cheek this box must attached an a lditrortal skeet showing the name of the soh-ear irntt.rs and slate w Becher as not tlaosc unities has.:
t-inplotres. It the sub-contractors base cmplot ees.dirt nrusi ,rt..ids ihco ,aorlrrs'comp.Folic)manna
I am an employer that is providing workers'compensation insurance for me.employees_ Below is the policy and job.site
information.
Insurance.Company Name:
Policy#or Self-ins.Lie. =: Expiration Date:
lob Site Address: City State Lip:
Attach a cup'.of the workers'compensation policy declaration page(showing the polity number and expiration date).
Failure to secure!overage as required under MGL c. 152,425A is a criminal a tolatiun punishable by a tine up to S I.500.(N)
and or one-year imprisonment.as well as civil penalties in the tone of a STOP WORK ORDER and a tine of up to S250.00 a
ciao against the violator.A copy of this statement may be forwarded to the Office of Investigation of the DIA for insurance
co%crag:verification.
I do hereby certify a er the pains and penalties of perjuty that the information provided above is true and correct.
/z4 / -/
Phone#:
Official use only. Do not write in this area,to be completed ht'city or town official
( it or Town: l'ermit'l_icense#
--
Issuing:authority (circle one):
I. Board of Health 2. Buildingi Department 3.('its Joon('Icrk 4. Ekctrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
?oaY MnM jo g`S ; • .f r
L. Massachusetts A4, ':G
ii ' lic.....V !
DEPARTMENT OF BUILDING INSPECTIONS S
r. 212 Main Street • Municipal Building �� �D
' Northampton, MA 01060 ssill, -4l`1'
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:
c
Location of Facility: i c /( c Te yc%ri�
The debris will be transported by:
Name of Hauler: /k1he c,-) �a- '"7L1
ASignature of Applicant: Date: 91/4 6 /2 /
City of Northampton
00,6, - o. �S • •
: ::: :: : :
achet i��5 <<
G
DEPARTMEN O BUILN ISPECTIONS j4
... 212 Main t • Micpa Building yvy cD-
\N .,,,, _�.' Northampton, MA 01060 JSI, '‘'.
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, � 6-A e% /?h 7�USct� ha r /'�� 3
i L�/ � (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 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 2-4 day of 14-/v,,/ , 20-/
----)1k ;....&2
(Signature)