38B-164 (2) 24 FORT ST BP-2022-0133
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:38B- 164 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-2022-0133
Project# JS-2022-000238
Est.Cost: $9240.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10062.36 Owner: GUILFORD JOSHUA
Zoning: URB(100)/ Applicant: GUILFORD JOSHUA
AT: 24 FORT ST
Applicant Address: Phone: Insurance:
24 FORT ST (517) 980-0119 O
NORTHAMPTONMA01060 ISSUED ON:8/4/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR FRONT PORCH
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 signatnr L___ _ .
FeeType: Date Paid: Amount:
Building 8/4/2021 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
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The Commonwealth of Massachsett ��G �\ 0
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Building Permit Application To Construct,Repair,Renovate a t'n�N` Revi ed Mar 2011
One-or Two-Family Dwelling t4A0'sn70Ns
This Section For Official Use Only _
Building ermit Number:
J ,--Date Applied:
Eu s i/:Z B-Y- 2ozj
Building Official(Print Name) Signature Date
_ SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
24 Fon.T Sr- 3g a 3YR- 1 6q
1_la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
3$ g - u2.e uRB -1-, 350 Fr 2- 60F
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 ca. Private 0 Zone: _ Outside yesyes Zone? Municipal Jl�'On site disposal system 0
Check if ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Jo c d+ h N(t.1-7-0 M po o J A Il Aide ,ts1 part.- tovtirro N 1 144-4 010 6 O
Name(Print) City,State,ZIP /
2' F°►+.-T S+ A S, -7--9 -d1/1 Jorhtt.4 tit'C/,�i&94t44'L•
No.and Street Telephone Email dress CJ
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) jet Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg.0 Number of Units_ Other 0 Specify:
Brief Description of Proposed Work: R.a kl vt. 0 F Few w'T f*4-GM . 1Z i t-R-G3 pvtAwr"_
o F po RC a( 90 lr.A3 T j Rir t.A-r.tr rt t.g'at cif' Pori,c�k F-ir ; R t-p L
c'r rtic0- V r} R Ir. 1-A-c4 Wt..4vi/r 01' fr..4_,t_bf /? La Ar4 .
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Buildingo'v 1. Building Permit Fee: $ Indicate how fee is determined:
$ ��I I/ 0 Standard City/Town Application Fee
2.Electrical $ — ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ — 2. Other Fees: $
4.Mechanical (HVAC) $ . List:
5.Mechanical (Fire $ _�
Suppression) Total All Fe s:A 06,6
6.Total Project Cost: $
!/
do Check No. Check Amount: Cash Amount:
��Z '1 d, 0 Paid in Full ❑Outstanding Balance Due:
sQ t (
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 35,000cu.ft.)
City/Town,State,ZIP R Restricted 1&2 Family Dwelling
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)
yosI IwlN I RLt-AP.o/MO tlfODy 1 MAn1 LLB
HIC CR S $ S�"pT• 2aZ3
J Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
2 Nf, S i. it,a.,k.u r\dl N w�,a-t1,W wt,0- Q ov4-4 t C1 k• Go L
No.and Street J
AAA-1-1- l Wt a. 0I o0 2. (Li13) 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:OWNER1 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.
1419 11 14,t(--Frw`j $'- 3 - 2
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. 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.sov/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"
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton Y
eggi. oA y,5 . sr,,
s '''` Massachusetts A. - %f
;" U.
:tr. DEPARTMENT OF BUILDING INSPECTIONS 41 x-
212 Main Street • Municipal Building
~" ' Northampton, MA 01060 �shit 4o,��,
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, 554, 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:
✓q-L Lt 12 C L.I KR-)
Location of Facility: �- �"G
The debris will be transported by:
Name of Hauler: y°S( /J 1 wl 14 I
Signature of Applicant: Date: $- " 2
` The Commonwealth of Massachusetts
`� a Department of Industrial Accidents
' 1 Congress Street,Smite 100
' : Boston, MA 02114-2017
;,, wwwi mass.igovldia
1luskers' t'ompensation Insurance AMA%it:Builders/ContractorslElectriciansiPlumbers.
1 O 13H. I I I_H. i NS ITH'rui:PERMITrt.N(.At 1HORi'TY.
Applicant Information Please Print Leitibhc
Natnt. I13usincs,{)rsr.anrza4tion-Individual►. JQSH let,l(..-Felet)
Addess.: 2- LI j°"-i gr.
Citv'Staie %i 01660
1 /l/�iY� TNv�r� f� IM A' Phone#: S 1 - q ' - O l f `l
Are sau an inipin+rr.'t hark the sppirriwiamtlbut:
Tape of project(required):
t.0 I.in a,rnpio+,r Attic _Etttpinyeeu(full mcbor part-titres 1.• 7. O New construction
20 I am a suk proprietor or pmtnervinp and have nu enipIo ecs ss orktny tar me in 8. 4 Remodeling
any capacrt) [No*Laker,"camp.tnaurance required.1
[—� 9. [] Demolition
;0 I am a bun r doing all,hark myself.INu worker*.comp.rrxwrarwe rexiwred.l'
10ID Building addition
4.M 1 am a hunnovs net and*III he birme cu n€ractora to conduct all work on my property. I will
einure that all contractors either hair%VASTf compe'tla;rtion otaurance or are%ale I I.3 Electrical repairs or additions
prupruto:3 with no cnrkeycc%
12.0 Plumbing repairs or additions
5C:1 1 am a genctal conoa-tor and I has c hard the nab-contractors listed on the attached sheet 1 34::::1 Roof repairs
Their sub<ur:uac .•tars ha.. cmpir'ycc,and have*wirers'coanp.uuuranrc.•
6.0 We are a corporations and it,officer,hale emu-creed their n bi of exemplum per Wit_r l .C:1 Othlcr'
152,f 1(41,and we have no ertrlu}era. [NO*t./AM Limp.inztranea rayun+d.1
°Any appihaal that chss.1%bon nI must atia 1111 out Ow tenant ball"showing then workers'car'npentsatian porn,infrwination,
*illitannawnani who sutnnu this affi,lasrt utdreatsntt they arc donng all w ark and Own hire uunkie contract mum;.,ahem'a new affidavit un heating rrurb.
tenitenrion titan check this boa mum antes;b d an.wldrtioral shut sham ins the name,af the sutreortina•ior,and state+l it irnr of.not those enirtirs have
etnpl,•ycc, If tt.. .a;l , e_tr..,t,a• I.i,_,1 a'l,,.., .16:, ino,1 pros isle then wrkcrs ,lacy.prltse rumbzt
I urea an employer that is providing workers'compensation insurance far my employees. Belon-is the polity and job site
information.
Insurance Company Name:
—
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: CityStatefZii►: __._. ___ ....
`
Attach a copy ar the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MCI_ c. 152.ti25A is a criminal violation punishable by a tine up to S 1,500.(X0
and or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tint of up to S2500►a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for Insurance
cps cr.it c t erifield ion
I du hereby certify under t e pain+ and penalties o/perjure that the in/terntution provider!ribose is true and{urrert.
Stt_ta.tiinc: (---2r>_.:, — 3 - 2I
P .e>r.: . c i 1 1 D"' — a I 1
Official use only. Do not write in this area.to be completed by city or town official
('it', or Town: Permit/license is
Issuing Authority(circle one):
, 1. Board of Health 2. Building Department 3.City/Town Clerk 4.ERctrical Inspector 5. Plumbing Inspector
G.Other
('ontact Person: Phone 4:
City of Northampton
Massachusetts �� - 'rE,
1*4 DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building 3 .b
Northampton, MA 01060 sVA' AO.
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
s 4wt LFGi'i ? (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 'ns and penalties of perjury on this 3 day of AA-4 GfAT , 20 2-1.
(Signature)