43-026 BP-2021-2225
551 PARK HILL RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
43-026-001 CITY OF NORTHAMPTON
Permit: Addition
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2021-2225 PERMISSION IS HEREBY GRANTED TO:
Project# ADDITION Contractor: License:
Est. Cost: 65500
Const.Class: Exp.Date:
Use Group: Owner: BACESKI BRIAN A& TANYA L
Lot Size (sq.ft.)
Zoning: WSP Applicant: L BACESKI BRIAN A&TANYA
Applicant Address Phone: Insurance:
551 PARK HILL RD
FLORENCE, MA 01062
ISSUED ON:11/30/2021
TO PERFORM THE FOLLOWING WORK:
ADDITION TO INCLUDE BATH,LAUNDRY AND REROOF EXISTING 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: ! 1 )2 3)
Fees Paid: $426.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
. .RECEIVEC Gpoil
va-'�.� �rz G,v-ayi,�
1 The Commonwealth of Massachusetts
(° NOV 2 2 m2itrd of Bui ding Regulations and Standards FOR
G Massacl-usetts State Building Code, 780 CMR MUNICIPALITY
1) t i ,> • tion To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
__ NORTHAMPTON.titA 01060 One-Or Two-Family Dwelling
nn This Section For Official Use Only
Building Permit Number:'Ij 0- I -• 222.6- Date Applied:
Building Official(Print Name) Signature l -� e
SECTION 1:SITE INFORMATION
1.1 Prop rty Address) 1.2 Assessors Map& Parcel N tubers
551 it th II Pt1 1-Oale-acl
1.la Is this an accepted street?yes V no Map Number Parcel Number/6_ozi-coy
1.3 o g Information: 1.4 Pro er Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone:• Outside Flood�Z�$ne?
Public Private❑ Check if yesG Municipal 0 On site disposal system -V
Wilk
/� `1 SECTION 2: PROPERTY OWNERSHIP1�,/ y��/� /�
2.1„Owner'icue�o1 Wilk 1°U�)C 9tA �OAV,0 1 Jt t 1( 1P 01 OtQd�
Name(Flint) (�l /1 J City,State,ZIP
DY L \ 413-ticraidriA8 TL P 6ft6eim lE Lont,)
d Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building 0 Owner-Occupied tie' Repairs(s) 0 Alteration(s) 0 Addition I
Demolition 0 Accessory Bldg. 0 Number of Unitst Other 0 Specify:
Brief Description of Proposed Work-': 'L/_I 11 6 At 1(le twit' cr11�1.Q,tf, �-ID
if s ,1 to 1 r �crsi rr.o .�J
to if1C.�Q Q�� teyv lei ii V1, OVl R�.
C�
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ (Ca WO 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee
1 ❑Total Project Cost- (Item 6)x multiplier x
3.Plumbing $ )--15002. Other Fees: $
4. Mechanical (HVAC) $ 5a) List:
5. Mechanical (Fire $ ,_.
Suppression) Total All Fees: $
Check No. /5 _Check Amount:g0(� Cash Amount:
6.Total Project Cost: $ (J t 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 C'onstruction 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 L'SSURANCE 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 .V 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.
11 2`3�
(b�ric� 610.G:A 1
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 '9. 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
SETBACK PLAN
MAP: LOT:
LOT SIZE: . 61561:),
REAR LOT DIMENSION: vL Uy
REAR YARD 140
SIDE YARD 0v 1 SIDE YARD le(_'
Tfalt
111
esrhoj
hakSti
FRONT SETBACK '15
FRONTAGE ��
City of Northampton
ow",,"F 4, S'
1. S
rt.," Massachusetts 4v �-
t G'
v M
U ';I ;r O $t DEPAR2S'NT OF BUILDING INSPECTIONS 2.
G �
. "' 212 Main Street • Municipal Building �a
SOS"`'�`_ Northampton, MA 01060 sf-,y 3 �
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:
Location of Facility: NIOdk\ `0U\
The debris will be transported by:
Name of Hauler: Ur' IRA QICUA
-6/C(44i-
Signature of Applicant: UUC Date: tit
=tr _
The Commonwealth of.Massachusetts
t Department of Industrial Accidents
l congress Street,Suite 100
:i-j Boston, MA 02114-2017
www.mass.gor/dia
UWurkers'Compensation Insurance Atfidinit: Bui dersl(bntractors/Electricians'Pluinhers.
TO BE FILED WITH THE moll i`I'I\C At THOM I'l.
Applicant Information Please Print I.eeibls
Name 1'uh111,,,l)1.4.lfiliJ11Ut1 I114.1i1k1U.li►: ,anOfti 1 beKti
Address: 051 cla,fflii r t �
C'itv'State/Zip: �P G�,,— Phone 4: 13 V I **--!D-
+re.«as etapioyer?Cheek re appropriate boa: Ty pe of project(required):
1.0 I am a empdiiyer Nith employee%(full and or part-tin 1• 7. p Nev. construction
I am a suk pn,prxtcx or partnership and have no etrployee%Narking tot me In t(_ O Remodeling
any capacity (No Norler.'ctmtp imurancx roomed]
9. ❑ Demolition
1�I am a homix,Nner doing all work mys It (No%orkcis'comp insurance minuet]]
`, i 0 Building addition
4�l am a bunko%nee and N itl bb hinny,.untradurs to conduct all N ark on my property I N ill
ensure that all curttraclurs either have%%Moe s etprroat,on insurance or an wle I I a Electrical repairs or additions
proptuisIrs N nth no employee-.
12.0 Plumbing repairs or additions
<79 J general
I am a geral contractor and I have hire su n.d the b-contrcctu Iited on tb.attached,txet. 130 Roof repairs!hex whtuntraeturs have employee^%and have*cxktrs'comp insuranc.
h.Q N e are a corporation and its officers have execiscd then nght of exemption per Mt,L c. 14. Other —152.;1141.and vs have ni ctnplu}ets.(No iso ktrs'comp insurance required
•My applicant that.ha ks Ixix a mint alai till out the section helots%hocing them Norkers'compensation piney information
Homeowners vsho auhnnt this affidavit indicating they arc doing all is ink and then hue outside cimtractors mint iuhnut a nets aitida%it Indenting larch
:Contractors that clack this bo%must atta-lsed an additional sbeti shots Inc the name of the sulrconZractors and state vs hither cx not those entities have
employees It the sub-cuniractixs have enrplo}rts,ttcy trust pre+vide their conkers'sonip.pokey nunnhrt
I am on employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
informatwn.
insurance Company Name:
Policy or Self-ins.Lie.#: Expiration Date:
Job Site Address: City State Zip:
Attach a copy of the workers'compensation policy declaration page(shussing the policy number and expiration date).
Failure to secure coverage as required under .LiGI_ c. 152. *25A is a criminal violation punishable by a tine up to S1,500.(X)
and or one-year imprisonment.as well as cis penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a
das against the s iolator.A copy of this statement may be tilrwarded to the Office of Investigations of the DIA for insurance
cov;:r.tcc verification.
/dot hereby certify under the pains and penalties of perjury that the information provided above is Sr e and correct.
' v3 1-
Signature: Date �c l
Phone '.J- LA -)i 1
Official use only. Do not write in this area.to be completed by city or town official
('its or Fosse: Permit/License#
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3.City fossn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone 4:
City of Northampton
' Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building cs�
Northampton, MA 01060
•
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
12.
I, b(0(1 &Oat (insert f it 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 qualifij 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 13 day of `( ,20 2,/.
(Signature)