23C-035 BP-2021-2159
638 RIVERSIDE DR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
23C-035-001 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-2021-2159 PERMISSIONIS HEREBY GRANTED TO:
Project# DECK Contractor: License:
Est. Cost: 1500
Const.Class: Exp.Date:
Use Group: Owner: SHAW CHRISTINE M &JUSTIN L T WENTWORTH
Lot Size (sq.ft.)
Zoning: GI/WP Applicant: SHAW CHRISTINE M&JUSTIN L T WENTWORTH
Applicant Address Phone: Insurance:
638 RIVERSIDE DR
FLORNCE, MA 01062
ISSUED ON:11/09/2021
TO PERFORM THE FOLLOWING WORK:
FINISH DECK -NEW DECK FLOORING, RAILINGS, STAIRS
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:
:,L3 . 51-11
I
Fees Paid: $65.00
•
212 Main.Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
RECEI L_)
The Commonwealth of Massachuse s
Q9 Board of Building Regulations and Sta rds FO
Massachusetts State Building Code, 780 CM NOV 8 20�1 US CI ITY
Building Permit Application To Construct,Repair,Re ovat lish a Rev ed ar 2011
One-or Two-Family Dwelling D� NORTHBI. TINGn I�.c~ 'IONS
O a c,,:
This Section For Official Use Only
Building Permit Number: of-Al' A+I tic Date Applied:
Building Official(Print Name) I Sii�ature l 0 -- e
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
to6 R 1/6fZ j10 OfZ-111.
1.la 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)
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:
akif2AS•ctil, 51'MW fu vvC61 M OI Qh)-
Name(Print) City,State,ZIP
(,3 12-\v62S1ot O2 \tk (- l3. S'-) -S 39 SNAv✓. averts-ciAk.nn w 6-A4mAt.,.cony
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 ❑
Demolition ❑ Accessory Bldg. 0 Number of Units Other 1pecify:
Brief Description of Proposed Work2: t C
(t . Bo S 11.A L Jf, 1STN1fZS
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ /50o 00 1. Building Permit Fee: $ Indicate how fee is determined:
,
2.Electrical $ ElStandard City/Town Application Fee
❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ J List: 1�,
5.Mechanical (Fire $ — Total All ee • $ 'C
Suppression)
Check NC/4, 1 Ii• Amount:
6.Total Project Cost: $ / 1 SOO. cc 0 Paid in Pull' 0 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 0 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.
Print Owner's or Au ed Agent's Nark(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"
The Commonwealth of Massachusetts
•1 Department of Industrial Accidents
r1� ire * 1 Congress Street,Suite 100
jr id � �W.Y
's( Boston, MA 02114-2017
www mass.gav/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO HE FILED WITH THE PERM17'TING AUTHORITY.
Applicant Information Please Print Leeihly
Name 113usiness/Organtzntiorvindividutll: eVeVA`, C1 Ae 5 Film‘A) 'SIJ5 W A/ tfeNc VIA 12-114•
Address: gAv 5►t OP-we
City/State/Zip: fU e /Ce MA- 4I064): Phone #: L413 ' SttB• 5 3%
Art you an employer?Cheek the appropriate box:
" Type of project(required):
to t ant a employer with _employees(full nuke part-timek• 7- 0 New construction
1 mt tl soli proprietor or partnership and have nu employees working fur me in 8. Remodeling
any capacity.[No workers'comp.iaaturantx ngruoed-1
9. ❑ Demolition
3,11 am a homeowner doing all work myself.{No workers`comp.insurance required'
4.0 tan a hsmeeuwner and will be luring oardraeturs to conduct all work on my property. 1 will Ili Q Building addition
ettalite that all contractors either hate w+urkcrs'corriptaniin maurance or are sole t la Electrical repairs or additions
proprietors with no employee
12.0 Plumbing repairs or additions
50 lam a general contractor and 1 have hired the stub-contractions listed on the attached sheet.
'these sub-r , :actors have employees and have workers'comp.insurance. l ❑RQofrepairs
6❑We are a corporation and its officers have eaentised their ngln of exemption per MCiL c. 14. Other
152,f It 1-and we hate no employees.[No workers'comp.inatuanec required.]
'Any applicant that checks box in must also Pall out the section below show log their workers'compensation poiwy mfor n ztw n
Hosncrowtsers who submit this affidavit indicating they arc doing all work and then hire outside contractors mum subnut a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the ivb-contractors and state whether or not those entities have
employees_ If the sub-corttractors hate cinpluy eea.Lite"! must provide their a irk rs•comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: _
Policy#or Self iris. Lie.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MOL c. 152, §25A is a criminal violation punishable by a tine up to S 1.500.00
and/or one-year imprisonment,as well as civil penalties in the foam of a STOP WORK ORDER and a fine of up to S250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the paths and pen fillitl of perjury that the information provided above is true and correct
Signature: C"AJi/l k 41n•( Date: 11150.1
Phone#: k\?.. — 5 7c1tu
Official use only. Do not write in this area.to be completed by city or town officiaL
City or Town: Pt-mil/License#
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
,irl Sts� rs. SAC
Massachusetts �,? ''�
1` .t. w711 4
DEPARTMENT OF BUILDING INSPECTIONS
y
0 .' ;k 212 Main Street • Municipal Building
-- Northampton, MA 01060
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.
4 10 0631Z6 I P/0 r W5iR-U a-)CAI/ DIES r,44 ti6_
The debris will be disposed of in:
Location of Facility:
The debris will be transported by:
Name of Hauler:
Signature of Applicant: ch6A--41, .5 Date: I 065 1?f
City of Northampton
0 HAM =. 0 4" gh,,
Massachusetts 41. -- <<
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g DEPARTMENT OF BUILDING INSPECTIONS h
ri. y 212 Main Street • Municipal Building y's.. �a�
Northampton, MA 01060 ssb�n, 3i%jN'�a
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
3.13lb�s
I, C`k Z i 1/v6 M , 50-A-w (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 pains and penalties of perjury on this s day of /1(0' 1 62_ , 20 1.
(Signatur )
Your Confirmation number is 20211108754616
Date of Confirmation: 11/8/2021
NOTE: When paying by ACH (Checking) it will take two business days for the payment to be debited from your bank account.
Your account number is not verified until this payment is presented to your bank. They have the right to return this payment if
unable to process this transaction against your account.
Your request for payment(s)of$68.95 has been received and is subject to approval by your financial institution. No email
was entered so a confirmation was not sent.
Account Information Payment Information
Name: CHRISTINE M SHAW Payment Type: Credit Card
Note: QUICK PAY TRANSACTION Payer Name: CHRISTINE M SHAW
Card Number:
Transaction Information
Transaction Quantity Amount Fee Payment Type
City of Northampton -Building 1 $65.00 $3.95 Credit Card
Department
Misc. QP
Permit Option: Building-Zoning-Sheet
Metal Permits
Full Name: Christine M Shaw
Phone: 413-548-5396
Property Address: 638 Riverside Dr
Notes:
Total: $68.95