25A-131 (15) 51 DAY AVE BP-2022-0014
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25A- 131 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-2022-0014
Project# JS-2022-000021
Est.Cost: $4500.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 39683.16 Owner: MIHEVC NANCY T
Zoning: URB(100)/ Applicant: MIHEVC NANCY T
AT: 51 DAY AVE
Applicant Address: Phone: Insurance:
51 DAY AVE (413) 585-9011 ()
NORTHAMPTONMA01060 ISSUED ON:7/7/20210:00:00
TO PERFORM THE FOLLOWING WORK:RE-ROOF GARAGE
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 1 �
Certificate of Occupancy Signature:I
i ` , • )2 • TA)-Na
FeeType: Date Paid: Amount:
Building 7/7/20210:00:00 $40.00
2 I 2 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
The Commonwealth of Massac setts 1/
F
Board of Building Regulations any Stan ds/(/ OR
Massachusetts State Building Co,e, 7 CMR `6 PALITY
FaT SE
Building Permit Application To Construct,Repair, ' ,,'. : Demo a Revi••d Mar 2011
One-or Two-Family Dwelling tigMp°j o,A,...
This Section For Official Use Only Mq o,crio0 Ns
Building ermit Number: P-ca.).- I Date A lied:
CulrJ( ) _______717/ 7 7 Zi
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
51 Day Ave 25A 131
1.1 a Is this an accepted street?yes x 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 OWNERSHIP1
2.1 Ownerl of Record:
Nancy T Mihevc Northampton, MA 01060
Name(Print) City,State,ZIP
5.1 Day Ave 413-313-2024 mihevcn@comcast.net
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building al Owner-Occupied III Repairs(s) ® Alteration(s) BI Addition 0
Demolition 0 Accessory Bldg. 10 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: Re-roof existing garage
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 4500 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 0 0 Standard City/Town Application Fee
0 Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 0 2. Other Fees: $
4.Mechanical (HVAC) $ 0 List:
5.Mechanical (Fire $ 0
Suppression) Total All Fees:
4500 Check No. Check Amours : O
6.Total Project Cost: $ 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 l&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 0 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 IV
...Li'
to the best of my knowledge and understanding.
Nancy T Mihevc %. v rLi' 7/6/2021
Print Owner's or Authorized Agent's N (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
1.1 - Department of Industrial Accidents
: ,
1 Congress Street,Suite 100
j--' ,` Boston, ,tfA 02114-2017
;t" www mass.gov/dia
)1 ut kers'Compensation Insurance Affidas it:Builders/Contractors/Electricians/Plumbers.
to BE I li.E:t)'%1TN TIIE PERMITTING A1`TIIORITt'.
Applicant Information Please Print l.en_ibls
Name(Husincsstkgamratton'Individuall: Nancy T Mihevc
Address: 51 Day Ave
City/State/Zip: Northampton, MA 01060 Phone#: 413-313-2024
.are yam an employee!l hrck the appropriate but: Type of project(required):
I D 1 am a employer with . enhpluyees(full pad or put-time).• 7. 0 New construction
2.01 am a sole proprietor or partnership and hose no cmpkn cos working for ns in g. Remodeling
any capacity-Ito workers*comp.hnwranct espousal.)
9. ❑Demolition
3I I am a hansoms net doing:all work myself.[No wor►oTs comp.atsur.usx required"'
.1.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will It)Q Building addition
ne
ensure that all can traatuts maser have winces'connlnnsatart utlurant-a+r an:sole I 1 a Electrical repairs or additions
proprietors w nth no employees.
12.0 Plumbing repairs or additions
30 I am a atcneral contractor and I lane hard the sob-contractors listed tat the attached shed. 130 Roof repairs —E C 2 0o it:--
These wb.:untrxwrs Lose a-tnplatyces and hose wax►en'corm.irsutancc.•
60 We arc a a-imputation and its officers hate cwatised they right of eaemption per NCI c. l 4.Q Other
152.1t 1(4).and we hose no employees.[Nu workers'comp.insurance required)
*Any applicant that checks boa ill must also fill out the section below showing direr warier;compensation policy information.
Ilurreowrsrs who submit this affidavit indicating they are doing all work and then hire outside contractors rust submit a new affidavit indicating such
:Contractors that cheek this but most attached an additional short showing the name of the sub-asrmactors and state whether or not those entities Luse
employees. If tic sub-contractors have employes.they must provide their workers comp.policy manlier.
1 am an employer that is providing workers'compensation insurance for my employees Below is the policy and Job site
information.
Insurance Company Name: _
Policy#or Self-ins.Lie.#: 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 S1.50(1.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 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
coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: Nab T M i.l��v� Date: 7/6/2021
phone#: 413-313-2024
Official use only. Do not write in this area,to be completed by city or town official
. ('itv or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3.('itcllown Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
t�tirr.�_r{r„.ti Sy...�" .s��
• "jj Massachusetts ztt/ i�
' A' • wr ;.
4 DEPARTMENT OF BUILDING INSPECTIONS Di
� "`� 212 Main Street • Municipal Building
—^� Northampton, MA 01060 'rsNiy, 0
Q
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: Glendale Road Transfer Station, Northampton, MA
The debris will be transported by:
Name of Hauler: self
Nava y T M(,1,ewc 7/6/2021
Signature of Applicant: Date: _
City of Northampton
AMP n ` 1 t1
12, Massachusetts aj .��c�
SIR '� H
DEPARTMENT OF BUILDING INSPECTIONS ? �°
212 Main Street • Municipal Building 6,1*
Northampton, MA 01060 1.°
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, NancyTheresa Mihevc 3/2/46
(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 6 day of July , 20 21.
Na-0-.cy T M ilt-e
(Signature)