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23C-080 (11) BP-2021-2127 42 BLISS ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 23C-080-001 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-2021-2127 PERMISSIONIS HEREBY GRANTED TO: Project# add roof Contractor: License: Est. Cost: 14000 TOSHI KASHIMA 060134 Const.Class: Exp.Date: 11/04/2022 Use Group: Owner: RUSCHHAUPT, MICHELEL Lot Size (sq.ft.) Zoning: WSP Applicant: TOSHI KASHIMA • Applicant Address P one: Insurance: 15 UNION ST (413)774-5402 WC231S376057020 GREENFIELD, MA 01301 ISSUED ON:11/02/2021 TO PERFORM THE FOLLOWING WORK: add roof over the patio 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: �g ► Fees Paid: $91.00 212 Main Street. Phone(413) 587-1240,Fax:(413)587-1272 Office of the Building Commissioner I NOV - 1 2021 i, The Commonwealth of Massa• usettrsar aF Board of Building Regulations an. .: ••.'s:rHAM°ToNN INSPECTIOI�� OR Massachusetts State Building Code, 780 CMR Ma 01060 MUN CIPALITY USE Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date App'ed: ' / tit ; V i Building Official(Print Name) Signature - I ' D to SECTION 1:SITE INFORMATION 41 Prodtys: _ �� 1.2 Assesesors Map&Parcel NumbO � S►��OCdat..t !?l Q�i'Z 1.1 a Is this an accepted street?yes no'-- 4 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 Wager Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public VI Private 0 Zone: _ Outside Flood Zone? Municipal Le On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' V2.1,C]wne 'of�eco . it u S {�ii cc,�e l ,� c L A 6 /O 6 2-- Name(Print) City,State,ZIP f (•�st £4 S1Z V2,6 OSItif it4A‘efile,rs 6five .c .l,,t No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units i Other 0 Specify: Brief Description\f Proposed Work2: 0 v Cr-`b a/,.,rer 40 L , -it- �f n� - S* " c . �peraa t c�►PFM1 S V-rk � . ?*th7 SECTION 4:ESTIMATJD CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) tr 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fe Check No. Check Amount: I Cash Amount: 6.Total Project Cost: $ r --*' ..''17 0 Paid in Full 0 Outstanding Balance Due: 4 Crj) SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 69- oi6 D I tVe>cf '�.r ` '�l�LL License Number Expiration Date Name OIK17171older t 5. tjLi em List CSL Type(see below) No. d Street Description © t U Unrestricted(Buildings up to 35,000 Cu.ft.) j��`'l.� R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering SFWS 4427 V-"vr`�Q�-v D(AWindow and Siding Solid Fuel Burning Appliances 13 > 4).0 I Insulation Telephone Email address D Demolition 5.2 Registered Home pr�ov ntContractor(HIC) e 7 r7 b of (ma• H Registration Number Expiratiott Date HIC Company N or HI Registrant Natpe ` A , — 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 e completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issu ce of the building permit. Signed Affidavit Attached? Yes No . 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES�y FOR BUILDING PERMIT •I,as Owner of the subject property,hereby authorize �J J � w to act on my behalf,in a matters relative to work authorized by this building permit application. N' '46 ILA-S c vp1' 05(-. (2—&P--( 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 trueand to the best of my knowledge and understanding. IA; V-e' k, 'ITV 21. 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,fmished 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 it 3. "Total Project Square Footage"may be substituted for"Total Project Cost" 1 The Commonwealth of Massachusetts . '-' .7-10 Deportment of industrial Accidents i; 1 congress Street.Suite 100 Boston, MA 02114-2017 www.mass.gor/dia Vi 04-kers'Compensation Insurance Affidavit:Buildersol:ontractorarElectrieians/Plumbers. 11)El FILED WITH'IRE PERMITfINC AUTHORITY'. Aonlicant Information Please Print Legibly ..----....„ . ...r.„, Name(HusinessfOrganizationilndieidnal).: k- S-Ak'-,.. -fx..4",,e/YtA,.. Address: 1:&--- U ilk\, ("if\ Sk.cP2r2-1— City/State/Ziparlitie1 qv 000( Phone#: t---... .).„....7-, ... Art yam as employer?Cheek the appropriate hats: Type ol project(required): 1.0 I am a employer with ..)......_ renpluy.e.es(full aril part-tirnel.* 7. liff New construction 2{73 I am a sole teuprictur or partnership and have no employees working for me in K. 0 Remodeling any capateify_[Nu workers'comp.insurance InguiredA 0 30 1 urn a humoowner doing all wart myself.[No workers 9. Demolition'cum.insurance required.]" I 0 El Building addition 4.0 1 urn a homeowner and will&laircia osintracturs to conduct ail work on my property. I will ensure that all contractors either have workers'compensabcm inmiransx or an sole I la Electrical repairs' -or additions proprietors with no onployees. 12.0 Plumbing repairs or additions SCII I am a general contractor and I have hired the sub-cootractors fisted on the ans.-bed sheet_ 130 Roof repairs These sub-contractors his employees and lis‘c workers'comp.insurance.; ther ts.E1 We arc a corporation and it officers have exercised Eheli right of caemption per kIGL c. I 14.00 ---— 152,ti 114).and we base no employees.[No workers'comp.insurance reouired.] I *Any applicant that ehs.a:ks boa.1 must also fill out du:section below showing their workers compensation policy information_ *Homeowners who submit this affidmn Outwitting they are doing ail work and then hire outside contractors must suhnin a new affidav it indicating such. teuraractors that cheek this boa must att.a:hcd an additiunal sheet show in the name of the suh-eoranictors and state ic holier or not those entiries haw employees. lithe sub-curaracturs have employees.they must pni5 de their workers-ocump.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and Joh site information. ‘. I ---...Insurance Company Name: t )S N..„0 V.it\. 14t .... WD CA.le.tiMt,S Policy#or Self-ins.Lic.#: kA.,) C.- 7,.. .?) I '. 7.60 -70P,etation Date: 0>/2.-3/ ---____ Job Site Address411-- VS 1'%'....S-5 1--- CAINAL.-- CityState/Zip7q VS,PetAtili..—(ht..CA ,.. Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).---..2detp. Failure to secure coverage as required under MGL c. 152, j25A is a criminal violation punishable by a fine up to S1,500.00 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 co erage verification. 1 do hereby certify under the pains'and penalties of perjury that the information provided nbore i.I.true and correct. .. ,., igrizifure: 4- ------- -1‘` i ,/. % Da te:(17672'W:72 / Phone#: 44 ) t,.-722,----l- i ( -.4> Official use only. Do nor write in this area,to he completed fry city or town official ('itv or Town: PermitiLicense# ' Issuing Authorip, (circle one): I. Board of Health 2.Building Department 3.Cityrfown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: CITY OF NORTHAMPTON SETBACK_ PLAN ^ MAP: " Y,L LOT: 1.7 400 LOT SIZE: C �Q REAR LOT DIMENSION: REAR YARD / SIDE YARD SIDE YARD 44-1- FRONT SETBACK J XI- FRONTAGE .a City of Northampton 0r ti sus .:s, Massachusetts �4?. { o DEPARTMENT OF BUILDING INSPECTIONS 0 V. 4 212 Main Street • Municipal Building is, a Northampton, MA 01060i� ye 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: k) -all Location of Facility: L iALIffZ'v%_ �tI �� tit, 01 '6 The debris will be transported by: Name of Hauler: 41,a•-s,-- -5i ��+�'� �t-ce.,',.._ C Signature of Applicant: (' / �'�--a- Date: at/2`` < r1 -1 ,Z--- 1'N\ ... i-X , I. Q 5,?a (, ---0-- --(\,1 p.):0Q p ' - • ,,,//) I . , v.53 ..___- __24 2,-,....), a \ `<-/- ) 7.7 477 + i ir,' _ tn./ Lts-)4,27x--',v---,1-_-(1 . - i 1 7,Q 9 > ci _. �_-_.