12C-079 (7) BP-2022-0117
20 MARC CIR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
12C-079-001 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-2022-0117 PERMISSION IS HEREBY GRANTED TO:
Project# SIDING Contractor: License:
Est. Cost: 5500 PHIL BEAULIEU 62638
Const.Class: Exp.Date:06/13/2023
Use Group: Owner: YOUNG HOLLY H&JOSEPH BIALEK
Lot Size (sq.ft.)
Zoning: RI/WSP Applicant: PHIL BEAULIEU & SON HOME IMPROVEMENT
Applicant Address Phone: Insurance:
217 Grattan St 413-592-1498 WMZ80062050
CHICOPEE,MA 01020
ISSUED ON:02/04/2022
TO PERFORM THE FOLLOWING WORK:
INSTALL NEW SOLID SOFFIT TO THE CARPORT CEILING
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:
Gas: Final: Final: Rough Frame:
Rough: Fire Department Driveway Final: Fireplace/Chimney:
Final: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
1 1 2 . 5110,
Fees Paid: S60.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Buildinc Commissioner
Fee 3 (00
Department use only
o M City of Northampt613. C� Status of Permit:
Building Department �^ Curb C.ut/Driveway Permit
212 Main SXreeeF n Sewer1 eptic Availability
f
Room 100 ,Water/Well Availability
Northampton, 01060 3 (147? TwosSets of Structural Plans
•.:4- • • phone 413-587-1240 Fa?C 4 - -1272 t Plot/Site Plans
r``�?1 n A �NgpE�r Other Specify
,1
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
Map Lot Unit
20 Marc Cir. Zone Overlay District
Elm St.District CB District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Petra Schaefer 158 North King St,Northampton, MA 01060
Name(Print Current Mailin Address:
- )1Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
2 592 .
Signature 7 Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 5,500 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
Oa
4. Mechanical (HVAC) 0
5. Fire Protection //n
6. Total =(1 +2 +3+4+5) 5,500 Check Number f` (,G ( ,
This Section For Official Use Only
.30" I f Date
Building Permit Number: �' / Issued:
P
Signature: \ '� "• a/� �1
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) i l Roofing ❑
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [1:::] Si.diwg[41/1] Other[O]
Brief Description of Proposed momminimiiimmosigin
Work:
Alteration of existing bedroom Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes x 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
I, Pe fca Sc hot e f e r , as Owner of the subject
property {�
hereby authorize P L� �L
to act on behalf, in-1 matte s relat a to work authorized by this building permit application.
� ! ..• L . . . � i0- 29 - 2/
Sign ure of Owner Date
, as Owner/•utho iizr ed
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of - -..e
and belief.
Signed under the pains and penalties of perjury.
t�► Beau
Print Name
/b 29 - Z !
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Hol. '� �sre��� Phil Beaulieu&Sons Home Im Inc.
P•,
— 217 Grattan Street,Chicopee,MA 01020 License Number
HI REG#100073 Exp.6/7/22
CSL#CS62638 Exp.6/13/23
Address Alain Beaulieu Expiration Date
PH:(413)592.1498/Fax:(413)594.6008
Signature T phone
zzi..„E"
9. Registered Home Improvement Contractor: Not Applicable 0
Company Name Registration Number
Address Expiration Date
Telephone
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 No 0
City of Northampton
atMaMpr�
‘S. :.. St
Massachusetts 5 c,�(
1 R G
VA N wr
I L vs DEPARTMENT OF BUILDING INSPECTIONS rx,
tir '� CsMain Street •Municipal Building v,^
� {r 212 G•allorthampton, MA 01060 Est TO\'‘`�
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:
AO marc C �
(Please print house number and street name)
Is to be disposed of at:
\ 6Mi 41W3h uck
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Per it 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
1. Department of Industrial Accidents
11 It 1 Congress Street,Suite 100
•%y V Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual): P
Address: all Gca}}an S}.
City/State/Zip: C r ►c 0 Pep ma 0)020 Phone#: / - 5(-7 Z - i-q 8
Are you an employer?Check the appropriate box: Type of project(required):
1.EEI I am a employer with ;t0 employees(full and/or part-time).' 7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
any capacity.[No workers'comp.insurance required.]
3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. ❑Demolition
10 ❑ Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q1Sther Sort'• l
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*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.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: A 1 m
Policy#or Self-ins.Lic.#: W 1117, 800(o a i S Expiration Date: a AI / a 3
Job Site Address: al) 1'llOxIC C i r City/State/Zip: N 0 c 1-1,a MP in,
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.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 tl pa' d n t' s of perjury that the information provided abov is true and correct.
Signature: (.gyp Date:
S J �l
Phone#: < 7 e L( ? er
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: