24A-191 BP-2021-2078
23 JACKSON ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
24A-191-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2021-2078 PERMISSION IS HEREBY GRANTED TO:
Project# 2021 ROOFING/SIDING Contractor: License:
Est. Cost: 10000
Const.Class: Exp.Date:
Use Group: Owner: HELEMS CLARENCE R &LANA M
Lot Size (sq.ft.)
Zoning: URB Applicant: M HELEMS CLARENCE R& LANA
Applicant Address Phone: Insurance:
23 JACKSON ST
NORTHAMPTON, MA 01060
ISSUED ON:10/26/2021
TO PERFORM THE FOLLO WING WORK:
1 ROOM ROOFING/SIDING TO HOUSE
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.
Signature:
ir I 2 CS-4 1
II
Fees Paid: $100.00
212 Main Street, Phone(413) 587-1240,Fax:(413)587-1272
Office of the Building Commissioner
11111
1V -L�
OCT The Co onw lth of Massachusetts
e13oai Bu' ding egulations and Standards10 FOR
Far Massachus-v s Sta a Building Code, 780 CMR1NIUIPAI'ITY
D
SE
OP , - 0 'cati n To onstruct,Repair,Renovate Or Demolish a Revised Mar 2011
°N•P,'a 0-,?'C�1tg-or wo-Family Dwelling
-.. This1Section For Official Use Only
Building ermit Number:0 P Z(}2(l20?3 D to Applied: (O/2 /V?Z(
EVIrJ(Z55 V ZL Z6z)
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
IIIIMM_Address: , ,1 1.2 Assessors Map&Parcel Numbers
"ib`�01,� 1 ' $ 24A -141-ool
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
URA
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:
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Description o
1 rvv,rl ►FDA q Si 4V
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 $ Total Ales: $
Suppression) yy p.,
Check o. Z6�' Check Amount:0/00 r-
6. Total Project Cost: l �• 0 Paid in Full 0 Outstanding Balance Due:
I
p
City of Northampton
Massachusetts ' 'd
gg
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 14
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS, ROOFS,RENOVATIONS,ROOF MOUNTED SOLAR,ETC.
I
1. 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. Construction Debris Affidavit filled out and signed by applicant.
4. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance.
6. Energy Conservation Compliance Certificate (new /replacement windows).
7. Home owner's License Exemption Form(if applicable).
8. Note any Special Permit requirements (if applicable).
9.Energy Code—all new construction(Gut/Rehab) requires a HERS Rater Affidavit
10. 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)
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 Masonr
y
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
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 0
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 accurate to the best of my knowledge and understanding.
of er s or Authorized Agent's Name(Electronic Signature)
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
r=11,4 Department of IndustrialAccidents
1 Congress Street,Suite 100
. /' www.mass.gov/ttio
1iothers*Compensation Insurance Affidavit:Euilder CMantractur./F Ie*tricians/PIurnbe .
TO BE F11F0%%rfl1 THE PERMITTING At:tlit)ltl"1'I.
Applicant Information Please Print I. it
Name(Basle ti»x 'ltlei l)
Address:
City/State/Zip: Phone##:
Are you an employee t'heck the appropriate liar: Type of project(required):
LC]I am a.employe with _.. . .. employees.(full andier part-tizre�k:*' ',. 7. El New aanstraidtiall
2.13 I am a Jane propriena or partnership and have au employees worker ha Era in 8.a e paeity.(No workers'e rep.iat•wira required"
required '
ill
3 i ama a heath �° ar a �a myself[No workers*u€ _;+air •=a s nall"
9. Demolition gi
10 ElBuilding addition
ant a homeowner and will he hams oinataittorsto conduct ail work on tiny property. I will
Man:but all eentractors either have walkers*taninettaation insurance te are sale 11 Ci Electrical repans or additions
rtikiviletari with no ermploye _
12.0 Pluntbing repairs or additions
1 am a general emmanetor and I have hired the aab tr more listed on the attached sheetpa Roof t repairs
Mese.intisiormacts rs leave employees and have workers'comp. earaacu;u.=
6„0 Vie area corporawit and its officers have exacised their right of exemption per SK L e„
14.0 Other
I .2.,31t41,and*chase no employees,[ 'entry.ansuranee required,'
'Any applic rat that:losiks lam al fill each doe section beleaw showing their work 'een. ratan penisy infannaticm.
a Homeowners who submit this affidavit milienting they are doing all work and then hire outside eoritraetam must submit a yvese affidavit indicating sueli
t^C itractcara that check this boat mast atmehed an additternal suet showing the name rat"the soissaimraithes.and e,re whether er or not creme entities hate
employees It subsiontraetc Ve employees.they provide their workers'gip.policy nsmmber..
I am an employer that is providing warfi ra'ce apencarion insurance fin.my emplo ee. Below is the policy and Jab site
information,
Insurance Company Name: ..._
Policy#or Self-iris.Lie. Expiration Date:
Job Site d C'ity/Stale. ip: ..__
Attach a copy of the vs tickers'compensation policy declaration page(showing the policy number and expiration date).
Failure to pure coverage as required under M€L e. 152. §25A is a criminal violation punishable h> a rite up to S1,500.00
arid-or one-year imprisorinient,as well as ivil penalties in the form of a STOP WORK ORDER and a tine 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 i ILA for insurance
I do hereby certi weeder the paths and penaltks of petinty that the inf rnuuinar provided abo►ee is true and correct
d
Official use only. Do not write in this area.to he completed by e or town official
City or Town. Pernnit)'Lirense
Issuing Authority(circle one).
I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6(Other
Contact Person: Phone
City of Northampton
Massachusetts a,:' r!c
j DEPARTMENT OF BUILDING INSPECTIONS 4
}� 212 Main Street • Municipal Building y,,y -t,.
Northampton, MA 01060 W�
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIII
I, L h e 0 a FI e !-)e/eln..s (insert full legal name), born (insert
mont , day, year), hereby depose and state the following:
3 )
►� 43
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 ha
Signed as the supervisor for said project or work.
Signed under the pains and penalties of perjury on this o4c. .day of kik Z/
411,A IP Aild./1414
(Signature)
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 \'`y
CONSTRUCTION DEBRIS AFFIDAVIT Raw
(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:
The debris will be transported by:
Name of Hauler: bi)Oi (� liZAtlyitt/ej
Signature of Applicant: icritR" Date: /6' ) A1-2 `