24D-279 (7) 161 CRESCENT ST BP-2022-0031
GIS#: - COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D-279 CITY OF NORTHAMPTON -
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:ALTERATION BUILDING PERMIT
Permit# BP-2022-0031
Project# JS-2022-000051
Est.Cost: $9585.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: BENJAMIN JOHN 112410
Lot Size(sq.ft.): 12937.32 Owner: LUPERT SUSIE
Zoning: URB(100)/ Applicant: BENJAMIN JOHN
AT: 161 CRESCENT ST.
Applicant Address: Phone: Insurance:
PO BOX 505 (413) 800-4253 WC
BERNARDSTONMA01337 ISSUED ON:7/12/20210:00:00
TO PERFORM THE FOLLOWING WORK:turn 2nd floor closet into laundry space
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 REVOIEED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
, f
Certificate of Occupancy signature . �!v`, 2ST)
FeeType: Date Paid: Amount:
Building 7/12/2021 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
The Commonwealth of Massachu.etts 1)
* € Board of Building Regulationsnd and ds J(/t F��R
Massachusetts State Building Code, 80 MR 8 20a' IeSPEALITY
Building Permit Application To Construct,Repai , '--noy4OKQ& olish a evis:d Mgr 2011
One- or Two-Family Dwelling RTNAMpToo!AJSpE
This Section For.Official Use Only.. o'o6o s
BuildingPermit Number: � o7.
3/ Date Applied:
.
la 0
J�a
Building Official(Print Name) , Signature . `)'1 - D to
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assess rs Map&Parcel Numbers
I Ct I Cresc ni- Si-. .- 13 ,7 q
1.1 a 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 0 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:
Scams Lt 42-e_r4- 00r=44--) a.—Ph)n M4 DIoceo
Name(Print) City, State,ZIP
I Lt ( C an 5h'. 1 I4-9 iq- 7efo 2 S l . .p{ r-4- 0 on-a;l .corms
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 ❑
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
ief mipti of Proposed .��a 2: 't
C�D0 • , c....c-k49 c.. wo- L rs.
SECTION 4:ESTIMATED CONSTRUCTION.COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 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: �y. s. kIlLt6
Check Ni Check Amount: Cash Amount:
Kotal$DrolPctli®os $ �CJ� ❑Paid in Full 0 OutstandingBalance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
• �.... CS- /124110
St.n'' ct.m 1 r1 . John License Number Expiration Date
Name o�•CSL Holder
0 80 x List CSL Type(see below)
No.and Street Type Description
acrn at. i-er Df 337 U Unrestricted(Avifdin$s up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry •
RC Roofing Covering.
WS Window and Siding
}3—$�,� ,� SF Solid Fuel Burning Appliances
6) b(1j(di-Q.('.,tDM I Insulation
Tele1hone Ema nddress D Demolition
5.2QRegistteered Home improvement Contractor(HIC) I
+� %. (JUJ I HIC Registration Number a Expiration Date
'IX'Company Name or MC Registrant Name
r o• do X .5rls— Gen 13r bt&1! taus.cctat
No.and Street Lail address
City/Townt 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 Ise No Cl
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 13.e.r3o.tK i r1 1.. '361^►r1
to act on my behalf,,in all matters relative to work authorized by this building permit application.
0.—rm (- _14 -7lCo' / z-
Pr►nt Owner's tame(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.
(3.e.,41 a.nM1 r, g, doh r, -T/ci /2—(
Print Owner s or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. 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 ggi 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.masa.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
r' r_ Department of Industrial Accidents
le —_At
1 Congress Street,Suite 100
i_= �Y Boston,MA 02114-2017
www mass gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electrleians/Plumbers.
TO BE FILED smut THE PERMIrrING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): g e 3 r 1 d-_("S
Address: . (o X �i 5
City/State/Zip: aer n ct +On t N of 337 Phone#: ff t 3- Soo -- V2 S. 3
Are you an employer?Check the appropriate box: Type of project(required):
Lai am a employer with employees(full and/or part-time)
7. El1 Nemodelitruction
2.0 I am a axle proprietor or partnership and have no employees working forme in $, rL�,',�`�emodeling
any capacity.[No workers'comp.insurance required.]
3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. ❑Demolition
4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet
These sub-contractors have employees and have workers'comp.insurance.t 13.0Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MOI.c. 14.Q Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
•Any applicant that cheeks 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. lithe 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 and fob site
information.
Insurance Company Name:__44)' 3.L._.�...tZ�-1r
Policy#or Self-ins.Lic.#: W CV O A-4$90Q Li Expiration Date: `-/ it( ( 2o 2.Z_
Job Site Address: I Ce I C,r CQ.f'i t" } . City/State/Zip: N D t O J-Y P+`-) M 14 bloc,
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 ce . and r the sins and Ities'Sfpe►jury that the information provided above is true and correct
Date: Z /Ce (
//2
Phone#: el/3— Soo-P2s
Official use only. Do not write in this area,to be completed by city or town oiciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
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• Atlantic Charter Insurance Company VDAC
NCCI Co. No. 29211 Policy Number WCV01484001
1. INSURED: Prior Policy Number WCV01484000
BRJ BUILDERS LLC Producer:
Bearingstar Insurance, Inc.
199 BALD MOUNTAIN RD 375 Airport Road
BERNARDSTON, MA 01337 Fall River, MA 02720
Federal ID Number 001421546
Business Type: Limited Liability Risk Id Number:
SIC 1521 -236118 Residential Remodelers
Other Named Insured: Other Work Places
2. POLICY PERIOD: The Policy Period Is From: 02/14/2021 To 02/14/2022 12:01 A.M. Standard Time
at The Insured Mailing Address
3. COVERAGES:
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states
listed here:MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of our
liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100,000 each employee
C. Other States Insured: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B
D. This policy includes these endorsements and schedules:
See WCE105
4. COVERAGES: The premium for this policy will be determined by our Manual of Rules, Classifications, Rates&
Rating Plans.All information required below is subject to verification and change by audit.
Code Premium Basis Total Rate Per Estimated
Classifications Co. Estimated Annual $100 of Annual
Remuneration Remuneration Premium
See WC 00 00 01
Minimum Premium: Deposit Premium:
$500 $5,290
Total Estimated Premium $6,718
Interim Adjustment: Annually Surcharge(s) 223
Servicing Office: Total Premium and Surcharge(s) $6,941
25 New Chardon Street
Boston, MA 02114-4721
Issue Date 01/26/2021 Countersigned By: ' C � C.A.J; JIe-1 Date
Copyright 1987 National Council on Compensation Insurance Form:100mvnt4
City of Northampton
S` . s
;9 ; ;. Massachusetts S' .. ��'r
` i DEPARTMENT OF BUILDING INSPECTIONS a
212 Main Street • Municipal Building 9:. 31
Northampton, MA 01060 s'' ••......
,�P
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: 5 5- rf ay_ 3+ • ems(d 04 4- 6J63$
The debris will be transported by:
Name of Hauler: kQ S-h �l•t.C�c.ir cj
Signature of Applicant: Date: 1/ 21