23A-125 (6) BP-2022-0291
24 MIDDLE ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
23A-125-001 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-2022-0291 PERMISSIONISHEREBYGRANTED TO:
Project# REPAIR Contractor: License:
Est. Cost: 2000 MATTHEW KOZUCH 106644
Const.Class: Exp.Date:09/25/2022
Use Group: Owner: SEILER MARGARET L & LEONARD MELNICK
Lot Size (sq.ft.)
Zoning: URB Applicant: MILL RIVER DESIGN BUILD
Applicant Address Phone: Insurance:
6 HIGH ST 4133418893 WC2-3 1 5-624269-0 1 0
FLORENCE, MA 01062
ISSUED ON:03/24/2022
TO PERFORM THE FOLLOWING WORK:
REPAIR PORCH 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:
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:
Fees Paid: $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
l N , r 1 ..
The Commonwealth of Massachusetts
•V Board of Building Regulations and Standards MAR 2 4 „ JNLITY
FOR ;
Massachusetts State Building Code, 780 CMR E ? IUSE
Building Permit Application To Construct,Repair, Renovate Or DeiiJ --a fevise11 Mar2011
One-or Two-Family Dwelling ,' !1,`N J
pp This Section For Official Use Only
Building Permit Number:6t A.)-" L"l / Date Applied:
410.) c).55 -3_zi_i_z027_
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property A dress: 1.2 Assessors Map&Parcel Numbers
Zii M.11016) S4-. 234 12S-a)
1.1 a Is this an accepted street?yes 7 no Map Num 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
I.5 /7 15" NA 2.0 Ai/A
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public H Private❑ Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O ner'of Record:
o.ictace,\ ,_,e._1 I e C F\O(cAce MA 6166z_
Name(Print) 4 City,State,ZIP
V-I ;aa k 5-\--. 4113-261 (4974 ,Mt'XiSglaI l.A&edit(
No.and Street Telephone Email'Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building❑ Owner-Occupied 0 Repairs(s) —❑ Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other Q' Specify: K E e ot oaf PHf c
Brief Description of Proposed Work2: (<,.e pcit(- f ofeh 4\4 ar -free_ Col i of ,÷.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ - Jl 1. Building Permit Fee: $ Indicate how fee is determined:
�\ 0 Standard City/Town Application Fee
2.Electrical $ 0 Total Project Cost' (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $ `f
Check No.1.143I Check Amount: LA gl Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
CS, Ic66iiii 2-
Z`Ic License Number Expiratio Date
Name of CSL Holder
List CSL Type(see below) V
tSt'No.and Street Type Description
o r,rc e 1 AAA aIn6 (� Unrestricted(Buildings up to 35,000 cu.ft.)
r c� �f Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
l.((3 3 g I �R ` Ml L I CJYtA4t I ,CC/tip I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) '1_t,j tol I /1 /Z
:,,. Me- T l ! . .
HIC Registration Number Expiration Date
HIC ompany Name or HIC Registrant NametAA, C `J e C Zs-- e Q l (cm
No.and Street `� `\ Email addr
City/Town,State,ZIP 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 .❑
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 (A Ar K)2 c)c L
to act on my behalf,in all matters relative to work authorized by this building permit application.
Se,I 2-r 3/-2-3/z
Print Owner's flame(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.
McAk 0-ZeL/C..\r 3/a. /Z L_
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 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
.iHaenF„
/f Massachusetts
iv t
t -.ETI ! DEPARTMENT OF BUILDING INSPECTIONS .:
isr /:; y
212 Main Street • Municipal Building
_— Northampton, MA 01060 ssy 'N�
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: VoL1 tQ�` i2 c�c/ ii_
J
The debris will be transported by:
l
Name of Hauler: in/t ;I( kiJeC tJeSr v1 iu%/0/
Signature of Applicant: /7//.1V, Date:
/
""� The Commonwealth of Massachusetts
1 f .-' t Department of Industrial Accidents
iro
• :/1�= I Congress Street,Suite 100
a
• ?`a= Boston,MA 02114-2017
'-. z�— ter
.. `,, www mass.gov/dia
%%others'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
to BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information (� Please Print Letibb
Name Ii3usmess:Organizationlndtv�idual):_1t' _ NlS)Q.l e'1.r'\ vt�()
Address: Ca A t el S-� ____
City/State:Zip: no i'e_f—C' -Y4 0/0G2 Phone#: qi 3 -3q I - F ?3
Are yea as employer?Cheek the appropriate but.
Type of project(required):
l.Iaam a employer with 2.__ employees(full:awful.part-timer.' 7. 0 New construction
20 1 am a sole prupnetur or partnership and have no employees winking fur me to H. O Remodeling
any capacity.(Nu workers'comp.insurance required.)
9. ❑ Demolition
3E:1 I am a hon 'owner doing all work myself.(No wurkexs'comp.insurance rerurrced.J'
4.0 la a homeowner and will be hiring exrntracturs to conduct all work on my property. I will1 Q 0 Building addition
m
ensure that all contractors either lure workers'compensation insurance or are sole 1 I.a Electrical repairs or ad
proprietors with no employees-
I__a Plumbing repairs or ad
:50 1 am a cxneral contractor and i base hired the sub-contractors listed un the attached sheet
These sub-contractors terse employees and hascworkers'comp.insurance. 1 Roo frepairs
6.0 we arc a corporation and its officershasr exercised then right of exemption per ht4L e. 14. Other
1$2.;lt4l.and we have no anpluyecs.[No workers'comp.insurance requited_I
'Any applicant that checks box al must also till out the section below shuns ing then workers'compensation policy information.
t Homeowners who submit this atlidasit indicating they arc doing all w uric and then hire outside contractors must submit a new affidavit indicating st
:Cunuacturs that check this box must attaidual an additional sheet showing the name of the sub-contractors and state w lu:thct or not these entitles has
employees_ lithe sub-cuntraetors have employees.they must plus ide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job.
information. rr 1 M y
Insurance Company Name: LA Z r --, 19 1 t1 TJ c
Policy#or Self-ins.Lie. 4: �/C2-3 rS`6 Z Z6 7 -V I I _ Expiration Date: 6115
Job Site Address: CitylState:Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration
Failure to secure coverage as required under MGL c. 152. §25A is a criminal violation punishable by a fine up to S 1,50
andkor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S25
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insur
coverage verification.
I do hereby certify and r the pains and penalties of perjury'that the information provided above is true and correct
Signature: �l ' Date:
Phone#: Li 13 341 fl 9 3
Official use only. Do not write in this area.to be completed by city'or town official
(City or Town: Permit/License t
Issuing Authority(circle one):
i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5. Plumbing Inspect(
1 6.Other
Contact Person: Phone#: