17A-099 (11) 27 GRANDVIEW ST BP-2021-1258
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-099 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: ' Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Stair BUILDING PERMIT
Permit# BP-2021-1258
Project# JS-2021-002087
Est. Cost: $500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 9365.40 Owner: HALE DAVID
Zoning: RI(100)/URA(100)/ Applicant: HALE DAVID
AT: 27 GRANDVIEW ST
Applicant Address: Phone: Insurance:
27 GRANDVIEW ST (617) 398-1327 ()
FLORENCEMA01062 ISSUED ON:4/29/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:INTER RENO ON STAIRCASE
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.
I a cgl
Certificate of Occupancy Signature: ' I
FeeType: Date Paid: Amount:
Building 4/29/2021 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
The Commonwealth of Massach etts 'G-:(--�� '-'"
WBoard of Building Regulations and tan ds QPf? F Massachusetts State Building Code 780 MR 2 8 (10 l SE ITY
Building Permit Application To Construct,Repair; oj,olish a evis/dMar 2011
One-or Two-Family Dwelling ryq;n°'Nc 1Z-
This Section For Official Use Only ?N 44A oTos.20NS
Building Permit Number:bQ. al.. `.161 Date Applied: ---.. I
4i/J(Z, 1/4-.1 11-n-ZOZI
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numb
tly
o7 &A4.J.)J(ET-J J>_ I o/frz cmA G7i t'
1.1a 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 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:
Name(Print ` City,State,ZIP
�,7 G` JJ.Z)v'E..) e(t 39:/...,)3.'7 J f^k,to /c �oa_<oA2
P
No.and Street Tele hone Email Ass
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building lEt Owner-Occupied X Repairs(s) 0 Alteration(s)% Addition 0
Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify:
Brief Description of Proposed Work': A t io 44 Cl='of T/f r , G L IN a .fry;fe c,4S,
,4 -
, 7.Q B e,J,f6 L A Ri-►iiT�r , fl-1 (6taL ,er p b-6 ,A,c-ror
_ A 'a,J -T2✓�✓ ! L c,)114cCi�o TJ 4 920.i.-Aied is.)
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ g-DO 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:$ •
Check No. Y14 Check Amos: 0 V)
6.Total Project Cost: $ �0O 0 Paid in Full 0 Outstandmg 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,. est and-. e pains and penalties of perjury that all of the information
contained in this application is tru- .1 i ur. - • the best of my knowledge and understanding.
D.fL)L NA(C ;�' / c(7x-1/X,0;),1
Print Owner's or Authori -. Agent's Name(El: 1 'c 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
L= .fit
.V.4.01= I Congress Street,Suite 100
;! =4 Boston, M 4 02114-2017 •
ww s mass.gov/dia
1larkers'(Compensation Insurance Affidatit: Builders/('ontractorsiElectricianstPlumhers.
1'0 BE: FILE()N 1111 TBE PERMITTING AUTBORft•la.
Applicant information Please Print Leeihls
Name i Business'organixatiorrindivicluat 1: -DAN)11A l I/A(),'
Address:_ /
City/State/Zip: � � Phone
Are you as employer?Cheek the appropriate bats' i'4 pe of project(required):
If]I am a employes with employees tall and'or part-time).* 7. a New construction
20 I am a sale prtipractitr or partnership and ha.c no employers wanking fur nse in 1i. o Remodeling
any capat'ity.[No workers'Romp.insurance required_]
1.g am a Borers owner doing all work myself.[No worker'comp.insurance tequirrd_j` 9_ Demolition
10 0 Building addition
4.n I am a humrraowm-r and r�it I be hiring contractors to conduct all work on my property_ I will
c�---++ensure that all contrutura either have workers'compensation imuniricc or are sale 11 Electrical repairs or additions
prupncturs with nu employees.
12.D Plumbing repairs or additions
s fj I am a general contractor and I have hired the Nub-contractor.listed tin the attached sheet_ 13 Roof repairs
These sub-contractor.In* employee and have wMer%•comp.rnaI lnce.1
6.0 Yi't cr are a cueporielun and tts ut$ica have exercised their nghl of exemption per MGL e. 1 Outer
1S2.t tl4),and we have no employees.[No winters'comp.insurance required]
*Any appticani that checks box 01 must Aso lilt out the section below show enig then x oti.tts compensation puke., inforrnatietn.
Homer wnersa who submit this affedaart indicannu they an:doing ail work and rhos hire outside contractors must submit a new affidavit indiealing such.
ktontractors that check this box must attsi:hcrl an aalditiunai sheet showing the name of the subcsxttractors and mate w Maher or nut those entities have
employees. lithe sub-contractors have employees.they must provide their porkers'comp.pubcv number.
I am an employer that is providing►s°orkers"compensation insurance for my employees. Below is the polity 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!AGE c. 152, §25A is a criminal violation punishable by a line up to S 1.500.00
andlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
cuaerugc Verification.
I do hereby cc'rti • to the tins penalties of perjury that the information provided above Is true and correct.
tit�tt(clot . Date: c1.4.
Phone =:. ‘i x2
Official cial use only, Do not write in this art'++. to be completed by city or town official.
City or Town: Permit/License A
issuing Authority(circle one):
I. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
(Contact Person: Phone#:
City of Northampton
•
Massachusetts 4}o " f'{
DEPARTMENT OF BUILDING INSPECTIONS r
212 Main Street • Municipal Building yJ. ca`.
Northampton, MA 01060 �SNjy ),1ar
ti1
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: "A '- 7 Ararc L1.-)6 _
The debris will be transported by:
Name of Hauler: of- '`S& (-11 � ` `6
A��Signature of Applicant- Date: ��
City of Northampton
\ Massachusetts -
g ,r c
DEPARTMENT OF BUILDING INSPECTIONS y r
212 Main Street • Municipal Building Jti,. Ca
Northampton, MA 01060 s81 `^°
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I ✓ h. (IAe�� ll�a2 l
(insert full legal name), born_ (t sert
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 un t in and alties of perjury on this 2—) day of #-1 L- , 20
( igna e)