23D-186 (5) BP-2021-2187
31 WINSLOW AVE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
23D-I86-001 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-2021-2187 PERMISSION IS HEREBY GRANTED TO:
Project# TREE DAMAGE Contractor: License:
Est. Cost: 20800 DOUGLAS GOODNOW 082188
Const.Class: Exp.Date: 10/16/2023
ROSE-LANGSTON JASON A&REBECCA J ROSE-
Use Group: Owner: LANGSTON
Lot Size (sq.ft.)
Zoning: URB Applicant: DOUGLAS GOODNOW
Applicant Address Phone: Insurance:
PO BOX 730-45 WESTVIEW TER (413)548-4561
EASTHAMPTON, MA 01027
ISSUED ON:11/17/2021
TO PERFORM THE FOLLOWING WORK:
REPAIRS FROM TREE DAMAGE
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: II JL
Fees Paid: $135.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
71 is -
+ _ Department use only
n, Cityof Northam t n �� , Status of Permit:
/<� ''`' Building Department f`' urb Cut/Driveway Permit
f ' `.. . " 212 Main Street NOV /S Seyrer/Septic Availability
, l n Room 100' 4/ W,�ter/Well Availability
Northampton, MA 91 T o Sets of Structural Plans
phone 413-587-1240 F 5c4Lt2 lot/Sife Plans
P
` -`070,,PA-Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
) i
((
3 ( (,✓////i n S t'. � AA v�— Map .�t ';�/ �Lot ) Unit
A,J 'l 7( .- 4 Al \ 1 `'l�/rt-/^� D 7 D p a
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: /� '� ^
Ta1an -D p-abccaA- SR- lands tto I-) 3 I!n S�o�/ �V 9—
Name(Print) Current Mailing Address:
��JJ�� ���eC� 413 - 6qs' " ��33
/� �� �pn Telephone
2.2 Authorized Agent: �f C.,ft d 7
, E4.ct k 64
Name(Print) Current Mailing Address:2Si atu/Ar-, it---\_. ell 3 - 5-Y --- `t 5-6 /
r Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ( ) o (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
IVA Construction from (6)
3. Plumbing ((v-2 Building Permit Fee ,/,Th
(�
4. Mechanical (HVAC)
5. Fire Protection (�C�
6. Total=(1 +2+ 3+4+5) 2�6o Check Number V "L
//JJ �� This Section For Official Use Only
Building Permit Number: b ''a 1" 7 IDssued:
Signature: ///Z / • (a Z. ',
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing Le
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[O] Other[I
Brief Descriptiop o f Proposed
d Work: 4- c (2 7/ l p ' - �-r — (-o ck /< p r
��'' r-�-p/
Alteration of existing bedroom Yes // No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes 1 No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, - 1, R Q V (a,j t DS L ' ,[�p n , as Owner of the subject
property J
hereby authorize
et
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date NU`j• 3 ? '1
l , as Owner/Authorized
Agent reby d lare that the tatements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and enalti s of perjury.
0o ) �jva (�O (rJ
Print Name '\/ �-t►
Signature of er/ ent Date AA)) ' 5.
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
�y Not Applicable ❑
Name of License Holder: L/()(�to G-DCan l O LI� 5— (fS
License Number
i
25 1029 Vt NA) I-P j2 fa11'w1thf1 70—/lo 03
Address Expiration Date
I/l3Sy - 90
Signature Telephone
fitti
kc-
9.Registe d Home Improvement Contractor: Not Applicable ❑
��c)--avin.J Coo n 5{leu C f i Orl 1 C 8 ritl
Company Name Registration Number
Address Expiration Date
fa-5 tY
16/llF) V v 11n i Telephone '/'II3 6 `f S f/
SECTION 10-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 f No 0
City of Northampton
QYn�Mp��
•
•�'' Massachusetts ��� �.. e
W
I. DEPARTMENT OF BUILDING INSPECTIONS y x
212 Main Street •Municipal Building Jti Ob
Northampton, MA 01060 SM,Y \1J
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
(Please print house number and street name)
Is to be disposed of at:
(Please print name antl location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
�-o U. 3
Signat re of rmit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The Commonwealth of Massachusetts
Department of Industrial Accidents
_ ►= Office of Investigations
_= _ Lafayette City Center
_"� 2 Avenue de Lafayette, Boston,MA 02111-1750
� • www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Qp Please Print Legibly
Name (Business/Organization/Individual): Go0OIMu) Cyis--vuc-H Oil ..14lc _
Address: y L cJ Q 5 u. n e(,e) few/Lao e
lot / i7 ,177 0109-3 Phone #: Nl aJ S-7It_ ' 2/
____
Are you an employer? Check the appropriate bo Type of project (required):
I.❑ I am a employer with 4. I am a general contractor and I (,
employees (full and/or part-time).* have hired the sub-contractors El New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. n Remodeling
ship and have no employees These sub-contractors have 8. (l Demolition
working for me in any capacity. employees and have workers'
comp. insurance.* 9. n Building addition
[No workers' comp. insurance
required.] 5. 0 We are a corporation and its I U.P] Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 Roof repairs
insurance required.] t c. 152, §1(4),and we have no / m
employees. [No workers' 13.❑ Other f�✓(
comp. insurance required.] r 4-12''''t^
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
l 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-ins. Lic. #: Expiration Date:
Job Site Address: 3� �' 1^ )(ow Au i City/State/Zip: /1 '(11\E%n1^ 44� 6'/6 6O
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify tinder the pains and penalties of perjury that the information provided above is true and correct.
�j � - 3 ate(
Signature: 9671\71- "' Date:
Phone#: 41 j 9415- - q `)- /
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority (check one):
1❑Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 50Plumbing
Inspector 6.0 Other
Contact Person: Phone#:
__ City of Northampton
c - Massachusetts '<<
d ' `I ,4 f DEPARTMENT OF BUILDING INSPECTIONS V i;
212 Main Street • Municipal Building �p\ C1
�r•'� f'.•.•„•.••,..-4
Northampton, MA 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pm-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
clone by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered.
Type of Work: .IRoUr ►2e P cc.t E /5 kr.e 1 c)c k ayeu r Est. Cost: () 1 0 , 0 L
Address of Work: 3 t ti \v.,\o\.;.) l
Date of Permit Application: ` - 5
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under$1,000.00
_Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
M2v. 3 pool/0_5 tiow
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
1/ 3Z PiLk .ec Apsz- fd
Date ner Name and Signature