17C-166 (11) BP-2022-0381
48 HIGH ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
17C-166-001 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-2022-0381 PERMISSIONISHEREBYGRANTED TO:
Project# INSULATION Contractor: License:
Est. Cost: 8000
Const.Class: Exp.Date:
Use Group: Owner: OTT MILES Q&BENJAMIN D CAPISTRANT
Lot Size (sq.ft.)
Zoning: URB Applicant: OTT MILES Q&BENJAMIN D CAPISTRANT
Applicant Address Phone: Insurance:
48 HIGH ST
FLORENCE, MA 01062
ISSUED ON:04/12/2022
TO PERFORM THE FOLLOWING WORK:
APPLYING FIRE RETARDANT PAINT TO INSULATION
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: I if
• . CS-11 •
I
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
The Commonwealth of Massachusetts =Y 1.. ;
1Wft Board of Building Regulations and Standards -a FOR
Massachusetts State Building Code, 780 CMRA PR MUNICIPALITY1 2 2022 , USE
Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling "? r.,;,`n --,- _ 1
This Section For Official Use Only1 `"'`' ^ %r�' �c' rn
Building Permit Number4ao- 1 - 39/ Date Applied:
gU% �I�Q55 1/P q"/G'0ZZ
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
'�\�� 5 •` ck0( -e IvGa M pc 1.2 Assessors Map& Parcel Numbers
17c
1.1 a Is this an accepted street?yes I no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system 0
Check ifyes❑
aIIIIIIIIIIIIIMMIMIIIIMIIII
2.1 Owner'of Record;
hi 'es oft L ccA.fS-tr"'i �=- 1o4- hee M p% o ( 062
Name(Print) City,State,ZIP
Lk$ 1--\ C•31,‘ S-t,• 'tic -203- ?'5 ' r,.ieS_Oft)alv......n:.bre..,r..ed✓
No.and Street Telephone Email Address
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work': p f Ll z F t re r t<ti,r d2. -s4-t p' : tit - o
4pre-L1 4"1611. jti_S✓ L vtkvV
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $
❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Q ,90°
Suppression) O Total All Fees:$Check No.Lk1�Check Amount: td6
6. Total Project Cost: $ 5i 000 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction 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 l&2 Family Dwelling
City/Town, State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 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 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 0 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
By entering my name below, I hereby attest under the pains an enalties of perjury that all of the information
contained in this application is true and accurate to th be of owledge and understanding.
M 0
Print Owner's or Authorized Agent's Name(El ctronic Signatur 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"
The Commonwealth of Massachusetts
1` .VI 'i!,' Department of Industrial Accidents
?� -• 1 Congress Street,Suite 100
=ilii= 7' Boston,MA 02114-2017
www mass.gov/dia
11 pikers'('ompeasation Insurance Affidas it:Builders/Contractors/Electricians Plumbers.
TO BE HEEL)With i•111 PERM1I11•1riG Al THORI`fl'.
Applicant Information Please Print Ixeihls
or Name(Business anI2atioa"tidividuall: ►qn` 1 1.f S 0't.--C--
Address: `h I k-k VCV1 c
Cityf'StateiZip: 10( t V\C•G V`1 r D t fl '2 Phone#: 1-k. 15 — 25D' -7,65 E
Art yw as wrpilwi1?Check tit appropriate hos: Type of project(required):
10 I am a employer with errip aryea's{full array part-fiend.• 7. 0New construction
_s0 1 am a sole proprietor or partnership and haw no employees gees working for me is $. Q Remodeling
any capacity..[No workers'comp.innsuranec required"
Or a homeowner doing all work myself.[No workers'comp_insurance ample Ll• 9. 0 Demolition
1119.
a homeowner and will be hiring contractors to conduct all work on nay p epetfly_ I will 10 El Building addition
c'7nuR that all contractor,ember hose worker`compensation unurancc ur we aide I I.L Electrical repairs or additions
proprietor,w nth no cetrploycca.
12.0 Plumbing repairs or additions
Sf0!am a general contractor and I hose hired the sub-contractors fisted DO the attached sheet. i 3 Roof repairs
these sub-contractors lose employees and lore women:comp.anurance)
14_MOther ( K Z vet `(re l rcotilt a )
&LI N c arc a corporation and its officer,hasc exercised their nee of exemption per M(.L c.
152. 10).and we have no oanpliwees.[No workers'cotter.mooring required.'
"Any apphcau that checks box?TI must also fill out the section below showing their worksiss compessuleian policy infatrtnatiin_
+l iotoatwnen who submit this affalas it indicating draw arc doing all work and then hire outside contsactura mint snnhxmt a new al dos II indicating such.
:Contractor,that check this box must attached an additional short showing the none oldie.sub-c-ontracturs and stale ss bother or not those.sire..-.have
employers.. If the sub-contractors base emplosoes.they must provide their workers`comp.policy nsnnbcr.
I am an employer that is providing workers'compensation insurance for an employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Sell-ins.Lic.#: Expiration Date:
lob Site Address: CityStateZip:__
Attach a copy of the workers'compensation policy declaration page(showing the policy number and eepiratioa date).
Failure to secure coverage as required under MGL c. 152.§25A is a criminal violation punishable by a fine up to S1.500.00
andor one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a
day against the violator.A copy of this statement may be forwarded to the Otlice of Investigations of the DIA for insurance
coverage verification.
I do hereby certify and the _ s t d penalties of perpny that the information provided above is fate and correct
0 q ' 121 Zv-Z Z
Phone 4: 5^ 2n3 r 510
I t
1 Ofcial use only. Do not write in this area.to be completed by city or town official
(-its or Town: Permit/license#
Issuing Authority (circle one):
I. Board of Health 2.Building Department 3.City.'Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
_ City of Northampton
oat--Mvr' 5S... .. StC
! '� Massachusetts �4,? -- 'ee•
� : �` �`
( % DEPARTMENT OF BUILDING INSPECTIONS a' �`
°r. ;.. r_ A-' 212 Main Street • Municipal Building v�;.
,.� Northampton, MA 01060 ‘PSI-iv .-v,o
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.
We akre o (7 '1 ,� 'F � � �' r � ��.f� ��` �� fit ,
t.)D sou_v, f t—s ct ,'t k1/401 rct-k-e.k,
The debris will be disposed of in:
Location of Facility: V1 Pt-
The debris will be transported by:
Name of Hauler: \I h
Signature of Applicant: AJ-A----V----------
Date: 1 Lt ( ( f WZZ
City of Northampton
a�HRMP>
O\ -I..
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"� Massachusetts
Si DEPARTMENT OF BUILDING INSPECTIONS C.
�` 212 Main Street • Municipal Building v`, �.�
Northampton, MA 01060 fsdiy goi•,
0t/214 /(CC7`1
S 01.—t (insert full legal name), born A (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 pai and ties of perjury on this tZ day of ttP'i ` , 20 ZZ—
(Signature)