28-015 (9) BP-2022-0014
198 SYLVESTER RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
28-015-001 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-2022-0014 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF/SIDING Contractor: License:
Est. Cost: 15000
Const.Class: Exp.Date:
BASH ISTA MARK D& ADRIENNE G EHLERT-
Use Group: Owner: BASHISTA
Lot Size (sq.ft.)
BASHISTA MARK D& ADRIENNE G EHLERT-
Zoning: RR Applicant: BASHISTA
Applicant Address Phone: Insurance:
198 SYLVESTER RD
FLORENCE, MA 01062
ISSUED ON:01/04/2022
TO PERFORM THE FOLLOWING WORK:
NEW ROOF AND SIDING ON BARN
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: cl Is Q iirm
yQ 1 •
I
Fees Paid: $98.00
212 Main Street, Phone(413) 587-1240,Fax:(413)587-1272
Office of the Building Commissioner
/W
The Commonwealth of Massachusetts! 4.
Board of Building Regulations and,Standards Q� �� FIl'ALITY
Massachusetts State Building Code; 780 CMR „, LNIR
� SE
Building Permit Application To Construct,Repair,Renovate`Oi`-D.* . `1 Revised Mar 2011
One-or Two-Family Dwelling ��'°t,2;q o� l
,� d--1-2
Thi Section For Official Use Only
Building ermit Number: +7" ''i -I Date Applied:
ah, l Boss /12 1 I/ zozz
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address:\ �\ 1.2 Assessors Map&Parcel Numbers
`‘ y �J Y Q/S
1.1 a Ts this an accepted street?yes no Map Number Parcel Number
1.3 Zonina2Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft) E)01110.,1 L ct1.
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
r l A tiaik to } i O So'r
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Privateer Zone: _ Outside Flood Zone? Municipal 0 On site disposal system $.
Check if yeses
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
P N*. @ASLSMP c\usc,-co..• r"A o\oL'I—
Name(Print)ri 4 ]� p\ City,State,ZIP
{� a ,�( ` ^� M
i" % \ Str Its `M-Sc,'A')cam INV \LLNJ\1t S\A 11 S @ Q i\.C iii
No.and Street Telephone Email Address �+
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Buildin Owner-Occupied 0 Repairs(s))Q Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. Number of Units Other 0 Specify:
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1%I 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ClStandard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ 4/
Suppression) Total All Fees 'r'!0 Check N Check Amount:
6.Total Project Cost: $ l S CJO
0 Paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Ex•'.ation Date
Name of CSL Holder
List CSL Type(see belo
No.and Street Type Description
U nrestricted(Buildings up to 35,000 cu.ft.)
City/Town,State,ZIP R Restricted I&2 Family Dwelling
Masonry
RC Roofing Covering
S Window and Siding
SF Solid Fuel Burning Appliances
1 •sulation
Telephone Email a -ss D De •lition
5.2 Registered Home Improvement : tractor(HIC)
HIC Registration . ber Expiration Date
HIC Company Name or HIC R _stunt Name
No.and Street Email addr:.
City/Towns- tate,ZIP Telephone
SECTION 6- KERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance a ust be completed and sub i this application. Failure to provide
this affidavit will result in the denial of the Issua permit.
Signed Affidavit Attached? 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 rize s uilding permit application.
Print Owner's Name(Fie a ure) 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 d accurate to the best of my knowledge and understanding.
Mk( BA rtiA4 I+.). \
Print Owner's or Authorized A ent's Name i e ateD
g (Electronic �atur )
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. . (including garage,finish basement/attics,decks or porch)
Gross living area(sq. ft.) Habita oom count
Number of fireplaces er of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system ed Open
3. "Total Project S otage"may be substituted for"Total Project Cost"
=„'o"`' The Commonwealth. of Massachusetts
.,,, Department of Industrial l ecidents
{,, 1 Congress Street,Suite 100
'' Boston, MA 02114 2017
;'" www.mass.govidia
r '
II utters'('utnpen..atlun Insurance Affidasit: Kuilderlu("ontractor'I:Iectrician l'tunihers.
t) HI F II t I)'s 1111 1 111 1't Mli'1`t11G:U Tltt)Kl7l.
Annlicant Information Please Print Leiibis
Name tHusincsstlrpw.a attion Was-1Ju.th: ii Qc\` (1A,(\.5`A
Address: \tl�6 S 4tcss ._.cw
City/State/Zip: . \ta_sc,..fig, (`'Y\ 0`o(}-- Phone#: Lk VI— SC-)o — S N S''C:t
Arc yoga ran eatpiattif('lad tin appraprtatc hot: Ty pr of project(required):
L l ant a cit larycr V. �n dame..thud and to pant-nine t
❑ �' �' �' 3. � New.construction
_.D I ani a Male pr'p%tote it ptattncrshir and Itat.no curio!.it:.'aorktne Loot nit an S. ❑ Remodeling
ant.3 ut ait [`o*t+rier, comp In%utance n uirtai.l
9. ❑ Dcinolition
.�I ant a tt/rnotrtsowl doing ale nigh arryaett..lN'umlauts,'coact to atrratu:.act real.00'
�/►�y� it)J Building addition
-i�t ,I:ant a to moron mt and ss all he hiring'aYtntl:f.2Urs to eonduct Ail%stick on net prop rty. I v.III
•"C.reuse•that all contraction,.echo hate sorbet's<.ng..n+ata at tnsuxancc ae anesoli: I I.I Electrical repairs or additions
inty,ItLttta+Asti%no curioycc .
12.0 Plumbing repairs or addition.
'. I ant a general contractor anti I hake hoed the,uh-canna-tarn listed on Ow attach.-d shed
♦� 13. Rt►ot repairs
!!laps.anh-auntta.tan'.11%;$ :.nttpdtly.- and%ak a,t titlan!k canna..nt,UUatrac.' -
14.$-1Q(Ithei S', ..;,ys
s.D K c arc a corwtseatton and tt,ottaccrs has c cactca,.d tlwtt richt art cl.ntrnort i,aT V(,L a
l't`_.,*'II-)t_and vs hake an'crurltry.cs [tit,atnk.n'corny,.nisutaxa.0 rcyutn.cd.
':Ytty applicant that.haY 1.tktat"l truest alga fill anal the as nano%dt.lott shouting then rt orkaT, .glop etn'ataaan part%.%ntti oration
' Ih..oneontiers*Iry slalom'this atiiJa6it Imaicatinff dun.are%%tarot ail wt.rl and then tine outside cimtinractoc,Itaur,i,ubmiit a ni..t attwtaoar.rttltaatrnar.uuh
-t a r racta,xa that check this Moot ntunl atta.laul it additional,titter shstn-n anti`'the naarr.ot the su -ernntr:utttr,and,tat.ttttab.r ter rt,..t tdieNi aittnitc,tank.
.nop?lny.... It the soh-contractorsl o' curly:.4.:1-t,tuck moot Tut+kid,th.Ir warrkcr^."aion-rd,.t.tiltcy nunrttlr.
1 ant an employer that is providing,t orAers'compei:sation insurance fur my employees. Belot-is the policy and job.site•
information.
Insulanai:l'oinpan% Nance: _
Policy#or Self ins. Lie. r i Expiration Date
Job Site Address: Cats State Zip: ,__
Attach a cups of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure cos erage as required under \KiL t:_ 152.*_'SA is a criminal s halation punishable hs a line up to SI.5(K)1K)
and ear one-year irnpristmm nt.as well as civil penalties in the Harm of STOP WORK ORDER and a tine of up to$250.00 a
alas against the violator.A copy of this statement may be forwarded to the()Alice of Investigations of the DIA for insurance
Lotcrage terlticatitttl.
I do hereby certify and the paint and penalties of perjury thief the information provided above it true and tarred.
Signature: i 1)ate. 13\1Zf4'` -1
Phone»: ail— SC. c‘1 S�
Official use only Do not write in thin area.to he a atrophied hi'city or loon official
('its or Town: 1'rrntitrl.icenset)
Issuing Authority.(circle one):
I. Board of Health 2.Building Department 3.Cityarl oss n(7erk 4. Electrical Inspector 5. i'lunibing Inspector
6.Other
('ontact Person: Phone#:
[M M_
City of Northampton
k Massachusetts �� 7 '<<.
Y`. ' w ►.
i • .. DEPARTMENT OF BUILDING INSPECTIONS �`• A" x'
y07
v '-212 Main Street • Municipal Building .
y,._ Northampton, MA 01060 rfln, . �`���
CONSTRUCTION DEBRIS AFFIDAVIT
(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.
The debris will be disposed of in:
Location of Facility: v A QIA Rtc�c� l�o I'�A
The debris will be transported by:
Name of Hauler: ' inkk - Q0
Signature of Applicant: 0)\ ------.' Date: 13\- —\ .\
City of Northampton
Massachusetts was r'<<
DEPARTMENT OF BUILDING INSPECTIONS
`�(-1--
v �
212 Main Street • Municipal Building
Northampton, MA 01060 psi 4/91
�41
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, 0.1(4(.. ,\O c (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 .�, day of , 20 a\.
(Signature)