32C-092 (3) BP-2021-2222
21 WILSON AVE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
32C-092-001 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-2021-2222 PERMISSION IS HEREBY GRANTED TO:
Project# ADD BATHROOM Contractor: License:
Est. Cost: 6000 ANDREW MADERA 89404
Const.Class: Exp.Date:04/09/2022
Use Group: Owner: HELLWIG CHRISTOPHER M&TARA GOLDBERG
Lot Size (sq.ft.)
Zoning: URC Applicant: ANDREW MADERA
Applicant Address Phone: Insurance:
430 ROCKY HILL RD (413)210-4014
FLORENcE, MA 01062
ISSUED ON:11/23/2021
TO PERFORM THE FOLLOWING WORK:
CREATE NEW BATH IN PANTRY SPACE
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: tnrl,t1dtL
(fs-,
•
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
09010 VW'NOldWVHlIJON I
SNOIi33dSNI timcnlflfl AO'1d30
" The Commonwealth of Massachusetts
1 Z Z A O N B 3ard of Building Regulations and Standards MUNICIPALITY
R
Massachusetts State Building Code, 780 CMR USE
i it
lication To Construct,Repair, Renovate Or Demolish a Revised Mar 2011
=1 "� pp One-or Two-Family Dwelling
This Section For Official Use Only
Buildin Permit Number: gp. en-.A.:),.7,)-. Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Prxrty Addiefss ts Ave-
1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes IC 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 ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own of Recor
LihVi 54v e Iler- gel ite,f; NdY G -k 4/14 0 to 6 D
Name(Print) I City,State,ZIP 0
„S1 C/415-Ut^ AVe- 82)9 yoI—i/6"l—/2ZO L‘1ct V16 440.v1
No.and Street Telephone Email Ad ess�
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s)K Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: GY�'�c IA[ L, YOt'l - j k 0104
e° iS-f.c-e .
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ / $$UU 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ !��U 0 Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 11 000 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. l of i c( Check Amount:I/O-
Cash Amount:
6. Total Project Cost: $ ‘6656 0 Paid in Full 0 Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
CS — °alb y- - zo
License Number Expiration Date
Name CS Holder AA
r q List CSL Type(see below) U
�Crc,
N .and Street n Type Description
[a3° HUi((
/ � U Unrestricted(Buildings up to 35,000 cu.ft.)
[[ ��f YYY//J��1 R Restricted l&2 Family Dwelling
City/Town,State,ZIP rte/Y&I,1M Masonry
CZ AM— G 11 Q G - RC Roofing Covering
WS Window and Siding
- l / SF Solid Fuel Burning Appliances
I�/3,�1° 10 i q a_BPprn 404 r' 11., I Insulation
Telephone Email address D Demolition
5.2 406/istered Home Improvement Contractor(HIC) a q 3 Imo(/� �1
✓�(�✓ ��il�Yti HI I C Registration Number Expiration Date
pany N. e or IC Registrant N e
G 0ll ghoot)► try. '1.,.. ,.
No. . o G Email `�
C. /Town,State,ZI' 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 44 cS y ,4i -J et
to act on my behalf,in all matters relative t work authorized by this building permit application.
Print Owner's Name(Electronic Signatu ) 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 is application is true and accurate to the best of my knowledge and understanding.
YpAi Aoferc--. ll'A:9- -01 (
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. 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"
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The Commonwealth of Massachusetts
e ( Department of industrial Accidents
4.
=.4� 1;
i 1 Congress Street.Suite 1011
r; .1i Boston.MA 02114-2017
-' ,,..- www.mass.go►e/dia
%%urkers'Compensation Insurance Affidavit:Buildersi("ontractorttl'E:kctrician 'Mumhrrs.
it)1W E'ILE:I)VC fl n i ttE:PE.R11iITIN(::O TII0KJ I' .
applicant Information Please Print Legibly
Name i lia.inx�ts�()ru:rtalr, itttn ttult3ittuul►: C r-- i1Vtl�1�/et Q(� o
Address: "l 50 1Lc /,4'I L / `s"
City/State/Zip: CNGL Ot°60- Phone#: Iy'o1.L U '.._G U /L
Are you ate csttmI.yet?('heck sir appropriate hut:
"1"ype of project(required):
1.0(am a ctrpektwtT wills 0 employees thud andurpart-ileac►.• 7- jNew construction
_'.. ( Jill a sok prupnctur or pustncr dap and hate:no etip'Irytes workmc tor me in I(.ORcmtidelin1
any capaaeett..!No*seeders'coupe.mturance required"
9. ❑Demolition
t.j I ant a hot:w ones doing all wick entself.rte.we.rkei comp_notimnec required.("
l0 0 Building addition
(a i ass a lnsnux.ttme and%ill he hair mg ctngraeturt K.teunJuct all stork on my wormy_ I w ill
ensure that all contractor,either limit Muskets'compensation eet.utautl eat Mt:Melt II{3 Electrical repairs or additions
pragnwturs wail teen tTsepintc.
12.0 Plumbing repairs or addition.
rf:j I am a tranaTal eantrackar and I hate hued Ilse sateunteack.rs listed on the attached'hod_ I 1 11 Root repaua
Ihce tube-crastrJek+ra bite cmpil pms mid lima:weeks'comp.Insurance.
tilD W.:air a wp d.rerrtion and its offm-ems hate exercised them fight e.t etcntpenwt per M(il..e. I _ ,t)dlitt
I y2.§1(4).and%c hate no employees.[No workers'wimp_insurance requned.l
'Ant applicant that eltceks box r,I mutt also till out the scciw.n lido%,have tap their winters'compensation poircy usfduneatnen.
♦Illimeoitnno tabu submit this Juniata indicating they'arc doing all%ails and then line outside contractors Trutt submit a new alfuhrt it rtmdmcating suck.
IC irnuaclots dust cheek this but must attached an additional shed showing the m:une of the sult-anntraruus and state whether or nut dome amities hair
employees. IfIlhossib-cor®tratknl fuse aeq.t„etc,they tearst rn.ttdc lhcir %urkcrs'centrp.paelrc.c ntnui+er
a
i am an employer that is providing workers'compensation insurance Or my employees. Below is the policy and job site
information.
li.ur.uti.*.('ottiparis' Name:
Polies ::or Sell-ins.Lie.all: Expiration Date:
Job Site Address: City=State-Lip:,
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage tt_s required under MGL c. 152.425A is a criminal tittlatitnt punishable by a tine up to Sl.5(I0.01
and ur one-year itoprisonn eat.as well as civil pc:rubies in the antic tit a STOP WORK ORDER R and a tine tmt tip to S 5(l.(lll a
day against the violator.A copy of this statement may be forwarded to the()tlice of Ins c'.tinattons of the D1A for insurance
cot erage verification.
I do herein-certiff. ruder the pains and penalties o f perjury that the information provided above is true and c urrect.
SiSntature: Date: !'�-�� t7"" 1
Phone:: i 3 _P2t0 -go 11
Official use only. Do not write in this area,to he completed by cite or town official
('its or Town: Permitil icrnse it
Issuing Authority (circle one):
I. Board of Ilealth 2.Building Department 3.('illy;lossn Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
('outset Person: Phone#:
City of Northampton
.c Massachusetts
,< DEPRRME T OF BUIS DING INSPECTIONS ,.
,a.' t
212 Mein Str•ot x Municipal Building
"� Nartharaptar�, MA 01060 �Tt`y
CONSTRUCTION DEBRIS AFi WAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40,554,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.
i
The debris will be disposed of in:
U. (2
Location of Facility: C ,/ ,
The debris will be transported by:
Name of Hauler: �, Hof
1
Date:
Signature of Applicant
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