31A-081 APPLICATION ON HOLD 1 1---- -E-CE-----.R/E1,-- :i-7- -I
The Commonwealth of Massachusetts
$,I c;, Board of Building Regulations and Standa 4ds DEC 3 O 2021
F R
%� Massachusetts State Building Code,'180 CILIR USE
ITY
Building Permit Application To Construct,Repair,Renovate OE,pfrliplisitmEcTsedMar 2011
One-or Two-Family Dwelling rt------J."�n oioeo
This Section For Official Use Only
Building Permit Number: GP- .7}--.13 g'/ Date Applied:
Building Official(Print Name) I Signature I ate
SECTION 1:SITE INFORMATION
1.1 Prope5 Ad ess 1.2 Assessors Map&Parcel Numbers
1.la Is this an accepted street?yes 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
i Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owne 'of cord: �i `3
Name rint) City, te,ZIP � /
Ike s' - `Jr
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition ❑ Accessory Bldg.0 Number of Units Other 0 Specify
Brief Description of Proposed Work2: 9/./Zar0/0eett
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(L and Materials)
1.Building 1. Building Permit Fee: $ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $
— 0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $Check No.aft 3 I Check Amount lIt)6.Total Pro'e ❑Paidin Full ■ • tstanding Balance Due:
lJJ►'I tom-,)' _& 4A
CIOLii
V
City of Northampton
Massachusetts off- '{
•
ta t
DEPARTMENT OF BUILDING INSPECTIONS �
212 Main Street • Municipal Building
Northampton, MA 01060
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS,ROOFS,RENOVATIONS, ROOF MOUNTED SOLAR,ETC.
1. 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. EnergyCode—all new construction(Gut/Rehab) requires a HERS Rater Affidavit
q
10. Please provide the appropriate fee in the form of a check made payable to: The City of
Northampton.
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor ' ense(CSL
License Number Expiration Date
NamedHolde
��//ee List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
IT M Masonry Restricted 1&2 Family Dwelling
City/Town,State,ZIT
V ` Roofing Coveri
Window and Siding
�� 6��� SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company a or HIC Regi ant
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 ❑ 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.
c: .„„literceritt,e
Print Owner�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.
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"
Avil
'. .
The Commonwealth of Massachusetts
ori Department of Industrial Accidents
1 Congress Street,Suite 10
„. 0
., Boston,MA 02114-2017
— . www.ntass.gov/dia
'Or raters'Compensation Insurance AMdavit:Bulkiers/Contractors/Ekrtricians/Plumbers.
tO HE FILED WITH THE PERMITTING AITHORITV.
Annlicant Information Please Print ieribiv
NitMe(Elusiness,Organuationindividual):
)
Address:
:fez4
City/State/Zip: , ( .4--7 Phone #:
Are..,nu an ritipllue!,e r`.'Cheek tin appropriate hot:
Type of project(required :
LEI I am a einploli es'wiih__ _ empio}ners(full Ilinile/pan-timel• 7. 0 New construction
1621Tant a .Ltle pruprwtcir or painnernhip and have ilu CiTiployees working for ine in 8. ci Remodeling
an,...capacity, Nu winker.'comp..inannuax regimen:LI
9. 0 Demolition
30 i sin a hoinocwitin doing all work myself[No waiters'comp.imarmine required.]'
i 0 0 Building addition
.4.0 I sin a horn/mune'and will ise hiring contractors to 01X3titlet ail*LA 0111 my property. I Wal
=NUM that an evrttractura vittin have workers'convert:whorl zusurance Cir Ate 1101C I la Electrical repairs or additions
' newts v.ith nu employees.
general 1:ono-actor and 1 have hired the sub-contractors Listed on the attached sheet.
irip
1.2.0 Plu ing repr.iirs or additions
5 am a
13 oof repairs
Thew.th-contracton,knot:anplerynnt int knave workers"tVIIIII.WIlailtrali.V.;
14.CI Other
6.0•
Vie are a,:urperlalurt and it.officers have exervised their right of exemption prr SKIL e-,
12,§1(41,and Ne have no employees.[No works:vs'comp,insurance required.]
•Allty applicant that check%bon al mug*Inn tdl Out the fieLt.i&vil betuNk mhi..744 ins their wiarlItera'curripermgiun policy infant ia-.1-1
*lioninriencrs who itkneut thia atilibiOt indicating they are downs all work and then hire ixamile saattrn:ter,must submit a r at:idx..it ir.4i....ahnF.,,i...±.
Contractors that data thia box must attached an aldttiunal about alto%ing the name,sf the sub-,:ontrackr.and date v.!tether or not those,naitica tix,e
00:-..:,..-. II L.,Lb-cantractors Isal'i,e oriplu:,inns,Lk,:anal prcoi aliit there workeri'zonal.Iv Is,,.:..,number
. ,
Jam an employer that is providing workers'compensation insurance for my employees. Below is the polity and job site
information.
Insurance Company Name: _
Policy#or Self-ias.Lic. #: Expiration Dat'------J7--(7.1/ -03__
Job Site Address: CityiState.Zip: ..
Attach a copy of the workers" compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under NICiL c. 152.§25A is a criminal violation punishable by a fine up to$1,500.00
andior one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to$250.00 a
day against the violator.A copy of this statement rriay be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby err*:under the pains am!penalties of perjury that the information provided above is true and correct.
Signature: tOile;; Dale
Phone#: /1'/it 1c ro 3.S. s
...
Official use only. Do not write in this area,to be completed hy city or town official_
City or'Foss n.: 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
i Contact Person: Phone*:
. . „.. ,1 - --— —