25A-040 (3) 16 SWAN ST BP-2021-1263
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25A-040 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 repo BUILDING PERMIT
Permit# BP-2021-1263
Project# JS-2021-002096
Est.Cost: $13000.00
Fee: $85.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 7623.00 Owner: DERSHAM DAVID H&MOLLY A WATKINS
Zoning: URB(100)/ Applicant: DERSHAM DAVID H & MOLLY A WATKINS
AT: 16 SWAN ST
Applicant Address: Phone: Insurance:
16 SWAN ST (413) 923-1860 O
NORTHAMPTONMA01060 ISSUED ON:4/29/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:BATH RENO
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 NORTHAMPTO UP VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
• . . AIR
Certificate of Occupancy Signature:
FeeType: - Date Paid: Amount:
Building 4/29/2021 0:00:00 $85.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
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SZ, The Commonwealth of Massac'hus;u 2
Board of Building Regulations and Stanc ,�dso 9 � 'OR
W Massachusetts State Building Code, 78OCIPALITY
r ,N USE
Building Permit Application To Construct, Repair,Renovate Or oN srt 44,s R- ised Mar 2011
One-or Two-Family Dwelling °
This Section For Official Use Only
Building
Permit Number: a i-,c3 /.2.03 Date Applied:
K.:.-.VP-/Z:> /47 it 29Z7-4
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
L/Properly Address: 5� 1.2 AsA.5A Map& Parcel Numbers ow
1.1a Is this
iss an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: ., l
l f!i(>Ct,1�Lt InS%,[�4tll t� ,(JPr 7I �d(— 'ieta-v)'1 / //4 O iOff)
Slame 'nt) ! City, State,ZIP
ji0 3117 I/ 04013 -<&003 c'5?-13e ►vt I. e ehi
No.and Street Telephone Email ndtjriss
SECTION 3:DESCRIPTION OF PROPOSED/WORKS(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 12 Repairs(s) ❑ Alteration(s) 63/1 Addition ❑
Demolition 0 Accessory Bldg. ❑ Number of Units Other 0 Specify:
Brief Descripti of Proposed Work':
k 1. room rerYt od e.-(
coo 1 arc-� -Tv to Gcy .$ k o t.c.)--C.2
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ I I. Building Permit Fee: $ Indicate how fee is determined:
����� DO 0 Standard City/Town Application Fee
2.Electrical $ o p_9 t , p 3
0 Total Project Cost (Item 6)x multiplier x
3. Plumbing $ LI 0D0 . 00 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ •
Suppression) Total All Fees:
/ Check Not ' Check Amount: " Cash Amount:
6.Total Project Cost: $ /3 pop,00 0 Paid in Full 0 Outstanding Balance Due:
- 1
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) /-71' /( a
pay(' C0 Il t'n 5 HIC Registration Number Expi ion Date
HImpan,v Name o HIC Registrant e
Vet- (eu- CI v c{-gym. &OD tLI S be S 403 es ap4taztI, cc44..
N d S et R Flo—aZ�l�"— Emaddress
i sr - Aidne id� edoI
City/Town,State,ZIP 1.14 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 Iss of the building permit.
Signed Affidavit Attached? Yes No .❑
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.
MO 11 WI--k; a.s'it(
Print Owner's/or Authorized Agent's Name(Electronic SignaturXe) I
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"
City of Northampton
. >
Massachusetts 4 �
r' "^ DEPARTMENT OF BUILDING INSPECTIONS
r
212 Main Street • Municipal Building !
Northampton, MA 01060 44 °- ,11'
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: rh hLt
/ Signature of Applicant: Date: Li(.2%--1 02
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co, 214,00ria= I The Commonwealth of Massachusetts
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Department of Industrial Accidents
. „
1 Congress Street,Suite 100
Boston, MA 02114-2017
.,'....17.
www.mass.gowilia
Workers*Compensation Insurante Affidavit BuildersiContractorsiElectriciantalumbers.
TO BE FILED WITH THE.PERMITTING AUTHORITY..
Applicant Information Please Print Legibly
Name ilinatiet&Organizattoreindoactuall:11_014_,4:1/41 i-4-,,,,HtA5 11. 1,), et cie— L.),e -r-,,,.. 114 qi_ _
Addres: / 4; •:5.4.0 e).4 AA__
CitylStatelZip: 4;1 ' " )1- A /1 Phone #-, Li/3-- 92 3 —Y003
. ,
Are you AU employer?c heck the appropriate hoc Ty pc of project required):
10 i 4=A employer with__ niuyirirs deli mita.pi-um ' 7. 0 New construction
20 I sin ii Wit proprietor or partacritop wad haw an tapluyea working tor me in L CI Remodeling
arty capacity Nu winters'comp,nothattee respired'
0 Demolition
3iii(i sio s homeowner doing al work myself IN°workers"tt4t*,itift.inaricX resporal*
RI 0 Budding addition
4.C3 i ain a hinaseowiliet and will he hums cosdractori to aoudad ait wok on inty property I will
mare that all contractor*tither Italie*lotions'compraciatiusi ineairanix Ot we*We I LE)Electrical repairs or additions
proprietors with no eittfdi*etti.
12.0 Plumbing repairs or additions
I am a genera connector intisi I hot hired the tuabwardrament Wed iv the attached And_
BC]Reeri repairs
Thew sulinurinacturs bow outploycimi and ha&e workers'coast at)
14.CI other
tED w.rue a isiipariniat and its.othoess have exercised their right of exemption pet.MCIL
152,f 1,(4i,arid we haw ne exployeert.[No wakes*"coop rinerrancerequireal
Any applicant that ditch*tot di MAI ettet fill cat the section tiekrw showing their worker*"eomperwation policy rotannation,
1 wisest*hi>ttuintit*it allititrilt illattafir4 they sire doing nit work anti thou hire ohisaile contractors hued stianit a new affidavit indicating such.
;Contractor&that check this hot it attached au additional sheet showing the mum of the nitbmciaanictors ail Atille*holler sir not those entities&we
employer& if d'w,u1,--,kumactotN he employee ,thrN iit pros,itic their workAT4'4,7110tp,1$011Cy Mita/wt.,
.i..... ,...=,,,,, ...,—. ..,..,,....,
I am on employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information,
Insurance Company Name. _
Policy tor Selfitis.Lie.a: Expiration 1)ate:
Job Site Address: City Statalip:
Attach a copy of the workers'compensation policy declaration page tshossing the policy number and tipinttion date).
Failure to secure coverage as required under MGT.c. 152,§25A is a criminal violation punishable by a fine up to$1„500.00
andior onelear imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$25001 a
day against the violator.A copy of this statement may be forwarded to the Of of Investigations of the DIA for insurance
coverage vecation
I do hereby col a, , r the ins a d penalties of perjury that the infOrmation provided above is true and correct
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Siptiltiare.:: 1 • r ,41
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Phone#:Lii,3-- ,9. 3 -7 CC
Official use only. Do not write in this area,to be completed by city or town Vida
City or Town: PermitiLicense#
Issuing Authority(circle one):
I. Board of titan 2.Bonding Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
i (intact Peron: Phone a:
City of Northampton
ff. Massachusetts _
z
€_ " DEPARTMENT OF BUILDING INSPECTIONS S' 4
212 Main Street • Municipal Building ,d. „
Northampton, MA 01060 j:1 .1
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, rn a I L W �� 'r°S (insert full legal name), born l" 1 5--100(insert
A 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 J- day of 4 pv, i , 2071.
)( '74)—W(A"--
(Signature)