36-159 (6) 1 112 BURTS PIT RD BP-2021-1442
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36- 159 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2021-1442
Project# JS-2021-002397
Est.Cost: $8000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 10497.96 Owner: BURROWS BARBARA M&MICHELLE D KWASNEY
Zoning: Applicant: BURROWS BARBARA M & MICHELLE D KWASNEY
AT: 1112 BURTS PIT RD
Applicant Address: Phone: Insurance:
1112 BURTS PIT RD (413) 587-9952 ()
FLORENCEMA01062 ISSUED ON:6/2/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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: (j k (p-g Z i k i)e
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND RE U IONS.
Certificate of ,/ / Signature: t
FeeType: Date Paid: Amount:
Building 6/2/2021 0:00:00 $40.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
1112 BURTS PIT RD BP-2021-1442
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36- 159 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2021-1442
Project# JS-2021-002397
Est.Cost: $8000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 10497.96 Owner: BURROWS BARBARA M&MICHELLE D KWASNEY
Zoning: Applicant: BURROWS BARBARA M & MICHELLE D KWASNEY
AT: 1112 BURTS PIT RD
Applicant Address: Phone: Insurance:
1112 BURTS PIT RD (413) 587-9952 O
F L O R E N C E M A0106 2 ISSUED ON:6/2/20210:00:0 0
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 ,2 cs-)a ,
'
Certificate of Occupancy Signature: I'' try
FeeType: Date Paid: Amount:
Building 6/2/20210:00:00 $40.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
k
ECEI E
JUN 2 - 2021 Th Commonwealth of Massachusetts
oard f Building Regulations and Standards FOR
assa usetts State Building Code,780 CMR MUNICIPALITY INSPrCTI
Buirdiitf$�_ to t A USE
pp cation To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
_, One-or Two-Family Dwelling
This Section For Official Use Only
Buildin Permit Number: M"d►1 �� (y 2- D pplied: (o—2, 2d1�J
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Number
1 /2. ecwzr pig 2090/ 3Cp 11
I.1 a Is this an accepted street?yes f 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? Municipaitl,On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
/Vicic,G fclJ /Ve.A. j/Dnt�GW/fDN n�S
Name(Print) tty,State.ZIP
i/12 1,' r pi 12-0 Rd '113- � �o- rills
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work: 2N STALI QI/( 12001' , -17.1110 Re- Sdis
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item (Labor and Materials) Official Use Only
1.Building $ �POO 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee
0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $
Suppression) Total All Fees:$
6.Total Project Cost: $ Check No.'DO� Check Amount: ash Amount:
600 ❑Paid in Full 0 Outstanding Ba ance Due:
Lam, .� ‘6 �f� ^ '/0 �a r(�-
4'
City of Northampton
Massachusetts
s
`l ,24 DEPARTMENT OF BUILDING INSPECTIONS S ' %
212 Main Street • Municipal Building vS ��-
�, Northampton, MA 01060 sfJn S'7.1�`
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS, ROOFS, RENOVATIONS, ROOF MOUNTED SOLAR, ETC.
1. Building Permit Application signed by legal owner and filled out
by owner or authorized agent.
2. One set of plans and specifications of proposed work (Digital and hard copy).
3. Construction Debris Affidavit filled out and signed by applicant.
4. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance.
6. Energy Conservation Compliance Certificate (new /replacement windows).
7. Home owner's License Exemption Form (if applicable).
8. Note any Special Permit requirements (if applicable).
9. Energy Code— alI new construction (Gut/Rehab) requires a HERS Rater Affidavit
4'
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(RTC)
HIC Registration Number Expiration Date
HIC Company Name or MC 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 wner'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.
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. I42A.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 taww.mass.aov!dns
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
17—
Department of Industrial Accidents
i_ ' 1 Congress Street,Suite 100
V= 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 Leeibly
Name(Business/0 bganization/Individual):
Address: /// Z nun r Pi f R.o tad
City/State/Zip: No 4.1/ "?°ir 4/ Phone#: L/<3 -S-7d-5-O/
Are you an employer?Check the appropriate box: Type of project(required):
I.0 I am a employer with employees(full and/or part-time).* 7, 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.0 I a homeowner doing all work myself.[No workers'comp.insurance required.)t
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.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.sRo of repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.0 We are a corporation and its officers have exercised.their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
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 andjob 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 of perjury that the information provided above is true and correct
Signature: Date:
Phone#:
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):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
r
`4.01Prat 4 The City of Northampton
`
ft6,, `*Li 4�.. .(to` Building Department
:;' 212 Main Street
OR"'Eoy111-�' Northampton, Massachusetts 01060
Phone (413) 587-1240
Fax (413) 587-1272
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVAT ION PROJECTS)
in accordance with the provisions of MGL c40, 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, s150A.
i
The debris will be disposed of in: )1/wtr5 rd -
Location of Facility / /r2 Rc'n.-r Pit /og, NOit-fiAi/-tiv /114c-/
The debris will be transported by:
Name of Hauler ( /7
Signature of Applicant: I Date: .-••?- '2 o /
City of Northampton
��HaMjyr. _r
0 0 �c JI
e .- tis Massachusetts
y'V,"11;tiEsrE @ C DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street doy,Municipal Building v.;. �>
Northampton, MA 01060
•
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, K ,t'cj6/74i /0Gi,S/VO4/ .(insert full Iegal 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 lwnieowners'
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 Z day of i O*• , 20 0/.
X IYA.eiLtitt„ 0-- .6^1 Gt4vy
(Signature)