36-018 (7) 23 FOREST GLEN DR BP-2022-0149
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-018 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BASEMENT RENOVATION BUILDING PERMIT
Permit# BP-2022-0149
Project# JS-2022-000218
Est.Cost: $2000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 14505.48 Owner: CAIRNS NAOMI
Zoning: Applicant: CAIRNS NAOMI
AT: 23 FOREST GLEN DR
Applicant Address: Phone: Insurance:
23 FOREST GLEN DRIVE (413) 923-8099 0
NORTHAMPTONMA01062 ISSUED ON:8/9/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:RENO BASEMENT
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 ' 7-1• .
,/ •
Certificate of Occupancy Signaturg:
FeeTvpe: Date Paid: Amount:
Building 8/9/2021 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
': c -
/VG-
del kJ
14 The Commonwealth o' Mas•achu'§Ltgs
Board of Building Regul. io < i d Standards9 2Oi FOR
. II➢�y,/ Massachusetts State Buil•' :�. :: R
MUNICIPALITY
opr:Lilco, USE
Building Permit Application To Construct,Repair, • -'r8 .1!- •, ish a Revised Mar 2011
One-or Two-Family Dwelling m4 01060°NS
Thi Section For Official.Use Only
Building ermit Number: 4 -a �-�'/'I'I Date Ap lied: k
atiii•J 7Z5 , g 9-26zi
Building Official(Print Name)I
Signature Date
SECTION 1:SITE INFORMATION
1.1 Proser Address: Q O(pV 1.2 Assessors Map& Parcel Numbers
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) INI a.. Wow-tS tik_000 rs
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 be Private❑ Zone: _ Outside Flood Zone? Municipal PI/On site disposal system ❑
Check ifves❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: '
MtsyNIZA CcuA1/VS ¶Ort s\cl_ riM o 10(02
Name(Print) City, State,ZIP
2 e i -¶ dY -t _ .6.1,2iriscri c u--�anc-''a't kedhn6.co.,
No. and Street Telephone Email Address
Warp 1113:DESCRIPTION t -D rtlr.c21.eallieylU that apply)
X New Construction 0 Existing Building❑ Owner-Occupied 0 Repairs(s) 0 Alteration(s) El Addition ❑
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: 14.1.ui a, \ Let.1.14 1 pce. ..u.t IA, octlew.t,ltk-
.r vcnlpt,c.< �.sl V...e.c-Iwz,ir— I vv..v:4A C.---V43. . 4eAtdm Qu 4' 11
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ I OOb 1. Building Permit Fee:$ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ 1000 0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fee
n Check No.\ heck Amount: v, Cash Amount:
�P0)
6.Total Project Cost: $ — 1 0 Paid in Full ❑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)
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 ❑ 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 E.
to act on y behal 'n all matters relative to work authorized by this building permit application.
IVa6 ^s $11c7 (2(
Print 0 er's Name ectronic Signature) Date
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 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.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"
CITY OF NORTHAMPTON
SETBAC1,1111
ixvMAP: LOT:
u ' Isc� ko W .
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton
f11110rt• Massachusetts
Si :�` DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 4:4ra ,g't
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: 11/- Pau-5S
Location of Facility: Q,2 . c Q ocji '7 (A .c/f t e S eeIN 0.A
110 C7kex.oVate c-13, . o Co 2
The debris will be transported by:
Name of Hauler: tWin S
Signature of Applicant: Date: 94) 01,1
The Commotticealth of Massachusetts
1 , • -,_,41: Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,M4 02114-201
cf wwstmass.gomidia
,f,:-"-i....k,,,,,,,.•
- ‘A,.1 Apr:: C ompensation Insurance Affiihrit:BuilderitiCantractorsEllectriciansPhmibera.
TO RE FILED WITH THE PERNITITLVG AUTHORITY.
. . .Brant Information Please Print -
Name usmes.,- Orunizationladrviduary.
Atkiress:
City/State/Zip: -..:...• ,- IIIIIIIIIII
Are pre/1/II engdoyer?Clack the appropriate bac Type of project(reqs&ed):
1.8II ma a emapierit mak ampiejeses(fall and,or part-tuna).• 7. El New mustn't-non
2.Mi a rats ptepietor or parteerip=Alone no emplcrsses arodking dor ins m it El Remodeling
calm* pirs worken'creep inurance torpinstil
1211E(1 arz a ii=iacra-nax do....aa al:wink nivsalt[No waxier;co rap IllilLilaGa isitairod:
za
9, [I]Demolition
10 Ei Building addition
4 El I a=a hocoactrnair and w1:1 t.4 1=34 o ontracion io conittiact ail work on my proparn• :wilt
alwars that all contrartcri clam have trorian-ronipanation invtiranca or 3/41314 11 El Electrical repairs or additions
plopria=1 tania no employer:
12 El Phanbuig repauss or ackinicais
I ana a itanatal:aartrariat and I hays hand dr inh-coutractoo-i.hind ea the xitached sheet
0 Thaw suli-coarractors havaingiloyeas and havo warkers.comp dasurearat 13 Roof repairs
14 USOdier - i
6[1]Ws are a=par-anon mot its officers laws exercised their Usk of exemption'per MGL c.
132.11(4),and ere hero es emplares.[No weaken'comp.assurance rocpereill I ataAttAj W41114
An applicant that checks hex*1 mast also fa out dm section brim shames than arcerlans.camper.cacao ps:Icy information C- ILtg•
*lioreacrwaers who adman dna affidavit indicin atg tiny ant doing ail wads and the him ontside conoractors mast submit a nem dation indicatieg rack
:Costracears that:heck dos hax must attached an additional sheet alder the ease of the sub-coeurac ton and stein whether m sot dew eulines hare
amphyrnes. if the inb-coartractors have arnplcryeek they mast Foveae their nediers comp.policy=mbar
i ant am employer that is providing workers'CoPlipentselion insurance for my employees_ Below is the policy audjob site
information_
Insurance Company Name.
Polley 4 or Self-ins.Lic.a Expiraoon Date
Job Site Address: CrtviState74:
Attach a copy of the workers'compensation policy declaration page(showing die policy number and expiration date).
Failure to secure coverage 35 lryliird.under A/GI.c 152,§25A is a crmiinal violation pumshable by a fine up to$1,500..00
and/or one-year miprisonment,as well as civil penaltim 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 faded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certift er the - and penalties ofperfury that the information provided above is true and correct
) ,
Stimulate: Dec 1 C i 7_ I
I
Phan*k 1'1 1 ') ?/1:1 CI
r.....,..,................,,,... ...........”............................................. .
Official use only Do not*sue rn this area,to be completed bt city or tout!official
City or Town:
Issuing Authority(circle one): Permit License a
1.Board of Health 2.Building Department 3.C ity Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person:
. - .' Phone a:
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, pct.orto ca,U(kA (insert full legal name), born ([O(ZI (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 l t7 day of , 20 g-
(Signa re)