25C-086 (3) 12 LINCOLN AVE BP-2022-0104
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-086 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Porch Repair BUILDING PERMIT
Permit# BP-2022-0104
Project# JS-2022-000184
Est.Cost:$5000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GREGORY BOSSIE 115088
Lot Size(sq. ft.): 6621.12 Owner: DUNN KAREN
Zoning: URB(100)/ Applicant: GREGORY BOSSIE
AT: 12 LINCOLN AVE
Applicant Address: Phone: Insurance:
118 FLORENCE ST (413)296-1570 SOLE PROPRIETOR
LEEDSMA01053 ISSUED ON:7/29/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:PORCH REPAIRS
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.
n }
Certificate of Occupancy Sigiiatt ?: • 1 .A
FeeType: Date Paid: Amount:
Building 7/29/2021 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
w
c RE E
Z, The Commonwealth of Massachusetts
Board of Building Regulations and Standards
JUL MUNICIPALI
Z
� Board
State Building Code, 780 CMR
Building Permit Application To Construct,Repair,Renovate De II•lish a Revised Mar 2111
One-or Two-Family Dwelling IB PT of cur . ..
This Section For Official Use Only N""rHAr.,r+ToN r4`-A,»"h1,°1"
Buildin Permit Number: P. � . Date A plied:
rEVlk.) Ins -7 29-ZOZ)
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numb s
i • li v\C.of v`J 0-0, C, 'a 5 C. al,
1.la Is this an accepted street?yes x/ no Map Number Parcel Number
1.3 Zoning Information: I iiC� 1.4 P j opet Dimensions:
5-49
54)
Zoning District Proposed Use Lot Area(sq ft) ((jjppFrontage(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? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2. Owner'of Record: A O1 la
O 1 O(0 0
Name(Print) City,State,ZIP
2 L t ✓i cd k (". k Lit 3 33 cQ 4 cMo Q D k.an-.rva ai PALL\, Lev,,:
No. and Street Telephone Email Address V
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s)Y Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work': ` 3 p d c& _ a--' 3 rya_a t r L.9...,k t.S+, d•
ri PO c-h J
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ j t yo 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 F $
Check N4OP Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
jt 0 i,; erf-y of 4ig
City of Northampton
"? ,, Massachusetts '�4 �f �f
DEPARTMENT OF BUILDING INSPECTIONS u;
` 212 Main Street • Municipal Building vu
Northampton, MA 01060 '>
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR NEW
1 & 2 FAMILY DWELLING, ADDITIONS, POOLS, DECKS, ACCESSORY STRUCTURES,
FENCES, GROUND MOUNTED SOLAR, ETC.
I. 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. Site plan with location of proposed structure(s) and set backs.
4. Construction Debris Affidavit filled out and signed by applicant.
5. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
6. Contractors must supply a copy of CS License, HIC Registration and proof of Liability Insurance.
7. Energy Conservation Compliance Certificate (new/ replacement windows).
8. Home Owner's License Exemption Form filled out and signed by Homeowner(if applicable).
9. Note any Conservation and/or special permit requirements (if applicable). 10.
Driveway Permit (if applicable).
11. Proof of Water and Sewer entry fees paid (if applicable).
12. Trench Permit- public land by DPW / private land by Building Dept.
13. Stretch Energy Code -all new construction will require a HERS Rater Affidavit to be submitted with permit
application before issuance of permit.
14. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton.
SECTION 5: CONSTRUCTION SERVICES
5.1
Construction Supervisor License(CSL) (I costa co/3./24
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) l.)'
l8 FLoCL€A4 ck. ST
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. ft.)
LCEAD5 , r 11k otogS Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
4(3 -X96.1510 Couce. sugeforuftoestGA I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
o>R�! 1��ssKs 2c�b%L90 l L/iv /z z
GHIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
If 6 Fi o(l ce S1 404, €itAREFoRNS .oes K4
No. and Street Email address
LC-EMS itAA oioc3 N13•ZA6• !S'3O
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 No . 0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIESS FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize r tt.EC.ko P-y ^7o661‘.
to act on my behalf,in all matters relative to work authorized by this building permit application.
II��l.S 1 dlili6�/� 7(Z tO( Z
Pri 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.
Print wn 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. 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.eov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) l iJcd .4511.C.I (including garage,finished basement/attics,decks o sore I
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
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton
Massachusetts %
...
DEPARTMENT OF BUILDING INSPECTIONS
ar
212 Main Street • Municipal Building
Northampton, MA 01060 4.11i°I.%°''
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: \,1Ru (A.mNc1
The debris will be transported by:
Name of Hauler:Signature of Applicant: Date: ` i;.-S
pp 7
-'1‘.,•,..,,,_
,a......N, The Commonwealth of 31assachitsetts
{4?, Department of Industria1.4ecidents
1 Congress Street, Suite 100
-og Boston,AL-1 02114-2017
',, §1
or omte.ntass,gorfdia
— Workers'Compensation Insurance Affidavit Builders.fontractorstrElectriciansflumbers.
TO BE FILED WITH IllE PERMIiTENG,AUTHOItt rt.
ADDlielint Information Please Print LeLliblt,
Name illusinessinizationilndividuatt: A .mix.,„,,,,t,9,1.)6,5 i fly ..DE" ..pilLe t—OILINIS
Address: 015 FLA>V— (4 c:s1"
City Stale Zip: Ls6OS ,KW, 0‘05-3 Phin, ::: LI •2-ct 4• /3-1•C,
— ..„ .
Are you an taiiplar!cr?t:betk the Apriruprene twit:
i l', 1)-1:ii 1 priliect'required):
1.C3 I ant a emplover!illt eumloyet"s ifidt and:or part-innei.* 7. 0 New WrIgIrtlettrUld
2411 am a sok proprietor of parim.lesaip sod have no employees working for in g: is Remodeling
any e2tFecifty.fNo workera-'camap.insusuper requirmq
9. 0 Demolition
30 I aan a homeoknt_r titian all work myself.INe welit..- 'comp..insurance required"'
properly. will
10 0 Badding addition
4.0 Isla A ittUIWWIttl and will be hit*euraraelors to emir:Met ail work on ray 1
ensure that all ernaracturs either:Mote worke nsation insurance or are sole 11.0 Electrical repairs or additions
proprietors:with no oriploymes.
12.0 PIUMbing repairs or additions
siN I sin a general ematractor and I have hired dre subwiontracr(Yts listeid on the reared sheet.
131:Roof repairs
These soh-mantrartors have employees and have worke&corrals,insurance)
6.0 14,°Other we are a corporation and its.officers have exercised then right of exemption per Ii4GL c_
152.k 1141.and we hese no employees.[No workers'eonip.insurance required.]
*Az:,arrIlczt:iliat cit,:ck.tvA..,":,1 meta also fill out the scetion below;show-nig then-workers'eorripermation policy inforrearrion.
*bliatrierwriers who NU:031311 IlliS airteavit imilicaring die re eking all work mini the hire outside contractors must submit a new affidatit railieatMe suck
:Comm:ems rim!'L-.1%.1.4..tht,k:'1..must artaelliest sn addatiotrai sitell shisikine the mem of the.&i113.-C-131rgrarbi:Eri•amrd Ante whetlacr tar not those=laic%havc
cmplo:,ze, I i AI,:,LI, 1: y11:habit errarloyees,teal isaa, pro,idle their workers'corms policy member.
I am gut employer that es providing ri•trrikers•compensatiem itraatratAttd fur my emph.tyees.. Below is the pulley and job size
information_
Insurance Company Name:
Policy#or Self-iroi.Lic.#: Expiration Date:
Job Site Addre , City/State/Zip:
Attach a copy of the workers'compensation polic declaration page(showing the polio number and expiration date).
Failure to see are coverage as required under NIGL e. 1.52. 25A is a criminal violation pool-that-le"ny a tine up to SI„.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 again t•I z.tc ,..ioiaior. A copy of this statement may be forwarded TO the Office of Investigations of the DIA for insurance
r,1..."...-
/do hereby certify under the pain:),WI ef penaltio of perjury dun!the infOrmation provided oho re'iA true and correct.
Silmatcrc: 6 i),:.:
/41-5 • 6• IS IC'
e ,/ -,..------
Offiekil ItNe oill5. Du ilirt*Prue it this areu,.to he completed by city tit toroth OffiCial_
City or To it: Permit/License
Issuing Authority (circle tote):
I. Board of Health 2.Building Department 3.City,Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
I
City of Northampton
Massachusetts `!r
4,4)s 1 DEPARTMENT OF BUILDING INSPECTIONS ?z
sa
212 Main Street • Municipal Building
Northampton, MA 01060 11`a
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, J� (insert full legal name), born (insert month,
day, year), hereby depose and state the following: 91 i5k (0i
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 O V day of 't"" —1 , 20 24
(Signature)
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