17C-275 (6) BP-2022-0407
8 COSMIAN AVE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
17C-275-001 CITY OF NORTHAMPTON
Permit: Exterior Res
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2022-0407 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF Contractor: License:
Est. Cost: 42000 JACK E MORSE ROOFING CSSL 104141
Const.Class: Exp.Date:09/29/2023
Use Group: Owner: JUNG PATRICIA ISABEL & JULIA CHEVAN
Lot Size (sq.ft.)
Zoning: URB Applicant: JACK E MORSE ROOFING
Applicant Address Phone: Insurance:
2 LILAC AVE 4133749064
CUMMINGTON, MA 01026
ISSUED ON:04/20/2022
TO PERFORM THE FOLLOWING WORK:
NEW ROOF
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: 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 �
I .
Fees Paid: $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
The Commonwealth of Massachusetts
iodt, APR 2 0 2QZ2Board of Building Regulations and Standards O R
MUNICIPALITY
Massachusetts State Building Code, 780 CMR USE
L _
.,,,,,r.Huildiri P &f ication To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
NOOTHAMP t N•M A 0106
~-.- Orie-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: &0—a a"1(71 Date Applied:
40)0 6?).51 //!� y-26-24Z7
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
Lo Sim;ava 4.4 -korerrLe
1.1a Is this an accepted street?yes J 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 if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owperl,of Record:
Ai! r►c,w-p% C-"1Ure-
Name(Print) City,State,ZIP
<o S i(-w PrJ2 ��3^ GoY7-719Z
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition ❑ Accessory Bldg. 0 Number of Units Other 0 Specify: C „P1Ace_ RIOl%
Brief Description of Proposed Work2: S - c g\e..S T Ge- d- .,a A i-e r- j *fl e
\-o,nc��n �C�n� g.0q�-iMy
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire
Suppression) Total All Fees: $,
Check No.(103 I Check Amount: -44,°
6. Total Project Cost: $ L,t 24 00 0 ❑Paid in Full ❑Outstanding Balance Due:
City of Northampton
Massachusetts
frOV DEPARTMENT OF BUILDING INSPECTIONS
°' --rjity 212 Main Street • Municipal Building 0 %
Northampton, MA 01060 (`tia'
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS, ROOFS, RENOVATIONS, ROOF MOUNTED SOLAR, ETC.
I. Building Permit Application signed by legal owner and filled out
by owner or authorized agent.
2. One set of plans and specifications of proposed work(Digital and hard copy).
3. Construction Debris Affidavit filled out and signed by applicant.
4. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance.
6. Energy Conservation Compliance Certificate (new /replacement windows).
7. Home owner's License Exemption Form (if applicable).
8. Note any Special Permit requirements (if applicable).
9. Energy Code all new construction (Gut/Rehab) requires a HERS Rater Affidavit
10. Please provide the appropriate.fee in-the form of a check made payable to; The City of
Northampton.
•
J ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) l ()LA`� l "t +ZA, 2trt.3
V 2 i E License Number Expiration Date
Name of CSL Holder
a` 1\7 List CSL Type(see below)
No.and Street Type Description
C— A ). _ U Unrestricted(Buildings up to 35,000 Cu.ft.)
S R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
V 6 '.o 2 •c & Roofing Covering
V WS Window and Siding
SF Solid Fuel Burning Appliances
L t� 37'4 O(,y -�_w y1,\0 rt. I Insulation
Telephone Email address D Demolition
•
5.2 Registered Home Improvement Contractor(HIC) co Zy • V
0-0 Se HIC Registration Number Expiration ate
HIC C mpany Name or HIC Registrant Name
1 % tK. To j( 0100•dC QS`4 La
No. and trees Email address
k la( -GigCK
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 Issuan/ce 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 C.AC.,k Vt\{0 KS 2
to act on my behalf,in all matters relative to work authorized by this building permit application.
n
RetirVi Ct (o2)--
Print Owner's Name(Ele tr nic Signt-e) 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 tru d accurate to the best of my knowledge and understanding.
0-ac, 4414 L 20 24 L2
Print Owner's or Authorized Agent's Na (Electronic Signature) Date I
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
0= .. Department of Industrial Accidents
Yi-
Si.irl�_ l Congress Street,Suite 100
4 Boston,MA 02114-2017
;,,,....,.,, ww►t.ntass.gov/dia
Workers'Compensation Insurance.tfftdas it:BuiIders/Contractors/EkctriciansiPlumbers.
TO HE FILED 411 I li l'HP PERMITTING A1'THORIT'i.
Applicant Information Please Print Legibly
..----
Name(Busness:`C7tgatsizatiotta Itidividtia!Y. , G.c*L C
Address: 2- \ t Lu. I-
r--
CitylState/Zip: tV - ► ,/..) r\A- veotcpix,tic. 4: L'l 13 - ) S{, — L0
Any..in employee Cheek the Appropriate trot:
Type or project(required):
iii
t 0 i am a employer with or partnership u, e%klull anifor part-time[_' 7. ,J New construction
ir p no cnipk Veer working for rise in g. D Re midEling
t _J
any capacity [No worker'comp.iiesurantx required"
30 lam a homeowner doing all work myself.[No workers'curial.insurance required.]'
9. Demolition'
I 10 0 Building addition
4.0 I am a humeownrc-r and will be hems einur ciors to conduct all work on my property. I will
pure that all cixntraC'turs either have warmers'eonsperteai2on tnsurasux in are sole 11.0 Electrical repairs or additions
pnnprict rrs w ish no employees.
12.0 Plumbing repairs or additions
50 I ant a iaeneral contractor and I hake hired the sub-contractors listed on the attailied sheet 13E1 ROt?fte repairs
Chest sub-contractors 1 a'.e employees and base workers'eetsnp.insura ICC.
6.0 we are a Lxisperatnon and its°triter%have exereiaed them right of exem rtion per WA_c. 14. Othe �I€.v �Q(�I'-
152,§1t41,and we have o e llployeea.[No*orient'comp.insurance renamed.'
`Any applii=itt that e'htc:ka box 4l mmtt also till out the section below stuw ing their workers'compensation pokey information
f Homeowners who mahout this affidavit math:alma they are doing all work and then hire exttside centractors must submit a new af3idLo i.rsdicaung such.
� .
*Cuntrsc'urs that cheek this box must attached an a.tdiGon:d sheet,keno tsitt'.tic::tam;of rite ittb-c[uttrcr::[Rxa:ntcl state whe'tttrr or trot.tio-.c _nt:tie,hatie
our!, ,:,_, II':1.... •Li,;,.'F.::_.c.ors hale empiceyecs.they must Flo.,id,t1,is .a.I1,crs':.crop.pullet number.
I ant ten employer tluet is providir{;t►'orAa r.s'compensation lnrurunce for my'emploreea. Below i.s the polio.and job.silt•
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/State'Zip:
Attach a copy of the workers'compensation polio declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MIGL c. 152, §25A is a criminal violation punishable by a fine up to$1.5:00.00
artd or one-year imprisonment,as well as cis it penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 err -•under the pain% and of perjury that the lisforaratlon provided above is true and correct
Siipiature: Date: 4, L. A-C 2 0Z- -7-
Phone#:
7`1 — go6't
Official use only. Do not write in then urea,to be compkted by city or town official
("its or Toss a: Permit/License 1#
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.('itylTown Clerk 4. Electrical Inspector S.Plumbing Insltrrritr
6. Other
Contact Person: Phone 4:
I
City of Northampton
` "' Massachusetts 4- -b- rF
DEPARTMENT OF BUILDING INSPECTIONS
IP 7
212 Main Street • Municipal Building E N
Northampton, MA 01060 �'rt ��
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:
The debris will be transported by:
Name of Hauler: A-IA,he r R^'VC,I'�-I
Signature of Applicant: Date: iM 11 i 6 L2)LL
City of Northampton
Massachusetts ' --
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building v4,
a�
mac.. Northampton, MA 01060 3y al.'z'
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, (insert fill 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_.
<,
(Signature)