16A-020 (3) I03 FAIRWAY VLG BP-2021-1463
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16A-020 CITY OF NORTHAMPTON
Lot:-000 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-2021-1463
Project# JS-2021-002322
Est.Cost: $8800.00
Fee: $63.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): Owner: COOKE ROBERT
Zoning: URA(102)/WP(17)/WSP(15)/ Applicant: COOKE ROBERT
AT: 103 FAIRWAY VLG
Applicant Address: Phone: Insurance:
103 FAIRWAY VLG (201) 214-3731 ()
LEEDSMA01053 ISSUED ON:6/8/2021 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 NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 6/8/2021 0:00:00 $63.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
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sZ.. The Commonwealth of Massachusetts K
Board of Building Regulations and Standards ��y>�, FOR c�p��
1 Massachusetts State Building Code, 780 CMR ,N ?() 'PALM
Building Permit Application To Construct,Repair,Renovate Or Demolish a Rer "' T.II
One-or Two-Family Dwelling 6o°
N '1s
This Section For Official Use Only f
Building ermit Number: si9-�j J�43 Date Applied:
C-UIlJ 1» ,/& G-8-ZOZI
Building Official(Print Name) Signature Date
SECTION l:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
0? />
1.1 a Is this an a 6•-s ted 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: PROPERTY OWNERSHIP'
2.1 Rwper'of Record: /� AC/r�
� ,(,c .i
J ,- � G•DJ k10 Lrec,4 / A /0,1:3
Name(Print) City,State,ZIP'
/c J / •-e-wi. V/ r i AC)/ —02/`/—.3?,3I
No.and Street / ,J Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s))( Addition 0
Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify:
Brief Description of Proposed Work': 2,,_,,,,,, c_D ,J //' l
c reel/ ,..e- iv.h/Jhewr / //. ..i %,-) ,n,." .,,-+J✓. ,i.+ , , r'J4r;
Jr /• rii, r
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Item Costs. Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee:$ G3 —Indicate how fee is determined:
G O ❑Standard City/Town Application Fee
2.Electrical $ / d a V
�T'otal Project Costa(Item 6)x multiplier 9 00 0 x 7/1 o v o
3.Plumbing $ /2-0 c,% 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) �- Total All Fees:$ i
,` Check No_/383 Check Amount: 7/3
6.Total Project Cost: $ Ap6.3 ' 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) /c 699
C / •‘-/1n1
HIC Ccmpi> Name or INC Registrant Name HIC Registration Number Exp. on Date
f (, r'lG tJ c v.e
N and
��� 6/OJ'? -,2.,2/ -
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
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WREN
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 : d e to the best of my knowledge and understanding.
el)erin
Print Owner's or Authorized ATI,t'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 halflbaths
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
r'=+ ' ? Department of industrial Accidents
1 Congress Street,Suite 100
�'ii►_ Boston, MA 02114-2017
wwttr_mass.gor/dia
Workers'Compensation Insurance Afftda%►it:Builders/Contractors/Electricians/Plumbers.
TO air:FILLUwrist itti P&:R%11TiIM;AI"fNttttl"/1
Annlicaat laformatian Please Print. I.rgibls
Name t Hustness Organization tndn*dual /`d L d d C
Address: /C] r ,_
City/State/Zip:,L e r,Jr, /V ) Phone#: 2)/ a l/ , 2.3
Art yea an employee'!Chet the appr.priate toe: Type of project(required):
o I era a employer with Cmployrea!Mt omit*part-time)• 7. 0 New e'[xtw:truction
lam a auk peupricior or panattship and base no employees winking for tree in K.ORemodeling
any capacity.No wor►ers'rump,uwurantr required"
9.
30 I am honavwner&nag all wan►myself.(No outings'rump,insurance regored.(
�Demolition
I homeowner and will be luring contractors to toedoft all wort.on my property. I will 10 O Budding addition
am a•that all contractors tether bait:wutters'►smupensatnorn ut urancx m are auk I I a Electrical repairs or additions
pnrprsewrs w nth no trnplu►ty. 12.0 Plumbing repair's or additions
1r:I I am a gown!contractor and I lose bard the sub-contractors listed ua the attadntit shot I 0 Roof repairs
These anbaonuacturs Mac employers and base wurlue s'comp.in uraare.•
h.a eta are aewpuratiun and its offmts basaearnised their right of exemption per bait c. 14.0011tt'r
1S2.41(4),and we base nu ennployees.(:`io wuhen'emup,insurance regnre .)
*Any applicant dent tucks bon aI noel also fill out toe section below show tag their wurkars'cumptnsatios pulley infsumation_
li rneunncra rho submit drs afidavi;indicating g they arc doing all wort.tact then hire outside ruatrietura mat submit a aen*flutist indicating sm-h
:Contractors that diet*din boa aunt attached an arhotaoaal sheet showing the m:une of eta subcontractors and state whether to mot those entities base
employees. the subcontractors base employees.they must proside their *writers"eon".policy number.
an an employer that is proridir.R worAers•compensation insurance for sty eatp/o ors. Selow is the pocky and jab site
Information.
Insurance Company Name:
Policy#or Self-ans.Lie.#: Expiration Date:
Job Site Address City:State Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and esplraties date).
Failure to secure coverage as required under MGL c. 152.*2 5.A is a criminal violation punishable by a fink up to S I,50O 0O
sund'or one-yam impristamaent,a,well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.O0 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 ceril the prs and a ks of perjury that the information provided*bore is tree and eared,
f` /
Signature: 'l C 1� �� Date: f
Phone e: r)',,(f
Official use wily. Do not write in this area.to be completed by city or town official
City or Tana: Permit/License g
issuing Authority(circle one):
I. Board of Health 2.Building Department 3.('iiy Leta+n Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
Massachusetts `~ - `�'��
, tit'
4 t DEPARTMENT OF 'WILDING INSPECTIONS yi
212 Main Street . Municipal Building
Northampton, MA 01060 j��"-
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: V cy d� c,l i /C/,; ,_ �. /14/4
�
The debris will be transported by:
Name of Hauler: f, //,//, l L (
Signature of Applicant: Date: b^
City of Northampton
Massachusetts ' /
fct
"'IS
DSPART)NINT OF BUILDING INSPECTIONS 7E. ` to
212 Main Street • Municipal Building v'• ca
y r. Northampton, MA 01060 *DI'
OME WNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, (insert full legal name), orn_(insert
mon , day, year), hereby depose and state the following:
1. 1 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 f perjury on this lJ day of a^'t-A-- , 20 ,
(Signate)
..._ ____ _ i 1_j___________________.__---1--' _
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