11-003 (6) BP-2022-0535
79 COUNTRY WAY COMMONWEALTH OF MASS CHUSETTS
Map:Block:Lot:
11-003-001 CITY OF NORTHAMP I N
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREG1STERE CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY F ND (MGL c.142A)
BUILDING PE ' MIT
Permit # BP-2022-0535 PERMISSIONIS REBYGRANTED TO:
Project# LAUNDRY Contractor: License:
Est. Cost: KUEL MCQUAID 051394
Const.Class: Exp.Date: 12/1 1/2022
Use Group: Owner: GRIFFITH M•RGARET & NINA SHRAYER
Lot Size (sq.ft.)
Zoning: WSP Applicant: KUEL MCQU ID
Applicant Address Plume: Insurance:
131 FERRY ST 41335375063
EASTHAMPTON, MA 01027
ISSUED ON:05/16/2022
TO PERFORM THE FOLLOWING WORK:
1ST FLOOR LAUNDRY RENO
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of\1 iring 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 NORTHA PTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
I. . yg . . °'1 •
I '
Fees Paid: S72.00
212 Main Street, Phone(4 13)587-1240,Fax:(413)►87-1272
Office of the Building Commissioner
ECEIVED
14AY 16 2022 ,
I
1. e Commonwealth of Massachusetts
oar of Building Regulations and Standards
MUNI RIPALITY
,��
�;, I".F BUILDING INSPECTIO SE as chusetts State Building Code, 780 CMR
'._i THAMPTON.MA 01060
But m Iication To Construct,Repair,Renovate Or Demolish a Revise Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: 6 t A?• 53 S //1Z-
Dte Applied:
Kt vl►� �," 5-I1 ZozZ
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
k 1.1 Property Address: 1.2 Assessors Map&Parcel Nura s,
71 Co-kin Ivy way ,1 fp
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 Sevage 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 Owner'of Record:
HI v,,,,r,i- Gil f-(14-1— FloreAct I M A O, O G2—
Name(P iilt) City,State,ZIP
11 (bunt-1 Way
No.and Street ! Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ 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 Work2: /? e Le..,,t^-,1y v.e:NI C;try-{- .0CD 4,7 Lek%)itr,Qc
iZOC .
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Lase Only
(Labor and Materials)
1.Building $ !l n b 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee
d O ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ -'t 0 O 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $ �
Check No.AV Check Amoui ' I a Cash Amount:
6.Total Project Cost: so 4O 0 ❑Paid in Full 0 Outstanding Balance Due:
7A-
City of Northampton
14 M T
•" ! . Massachusetts �� •ee
� 3
DEPARTMENT OF BUILDING INSPECTIONS
♦�f1r�/, 212 Main Street • Municipal Building yJ/ CDC
ram Northampton, MA 01060 SNIV 0‘1J
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR NEW
1 &2 FAMILY DWELLING, ADDITIONS, POOLS, DECKS, ACCESSORY STRUCTURES,
FENCES, GROUND 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. Site plan with location of proposed structure(s) and set backs.
4. Construction Debris Affidavit filled out and signed by applicant.
5. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
6. Contractors must supply a copy of CS License, HIC Registration and proof of Liability Insurance.
7. Energy Conservation Compliance Certificate (new/ replacement windows).
8. Home Owner's License Exemption Form filled out and signed by Homeowner (if applicable).
9. Note any Conservation and/or special permit requirements (if applicable). 10.
Driveway Permit (if applicable).
11. Proof of Water and Sewer entry fees paid (if applicable)
12. Trench Permit - public land by DPW/ private land by Building Dept
43. Stretch Energy Code - all new construction will require a HERS Rater Affidavit to be submitted with permit
application before issuance of permit.
'4. Please orovide the appropriate fee in the form of a check made payable to: The City of Northampton.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
r� � CS '° 513R /2 1112022
k����
v e--1 iv(c._ (Y J ,A License Number E onllDDate
Name of CSL Holder C.)13 ( f e-sc rj'� List CSL Type(see ow)
No.and Street Type Description
0.S arm P jA [l 0 l 0 2-7 U 1 Jill Rost (rid 1 (Buildings up to 35,000 cu.ft.)
��(/-C R Restricted 1&.2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window''and Siding
‘ SF Solid Full Burning Appliances
I03-53 7- S o63 At Qoco.dt+koet B�w �.� C
I Insulation
Telephone Email address C 0 w‘ D Demolition
5.2 Registered Home Improvement Contractor(HIC) ,
KU2[ G Cf2�a:� /66706 7 23 20Z,2
HIC Registration Number Expirati n Date
IBC+mppy Name or-ACC Registrant Name Q �/
Jac t! �J &ouA a /<oe_(
Ng-and Sheet r AA-O 1027 'T/3"S 3 7-S 04 3 Email address
City/Town, State,ZAP 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 ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLE ED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILD G PERMIT
I,as Owner of the subject property,hereby authorize /U�/ A c e v
to act on my behalf,in all matters relative to work authorized by this building permit application
r
•
M r,..�unc - G r,(-�i' -&
Print Own s Name(El e nic Si ) Date 1
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury t all of the informatio7
contained in ' application is true and accurate to the best of my knowledge and unde •
g.
A c2A.ai 22
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 wh• hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not ha e access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on i e HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be fo li nd at www.mass.gov/dps
2. When substantial work is planned,provide the information below: ,
Total floor area(sq.ft.) _ (including garage,finished ba ment/attics,decks or porch)
Gross living area(sq.f1.) Habitable room co nt
Number of fireplaces Number of bedroot is
Number of bathrooms Number of half/ba
Type of heating system Number of decks/ M •rches
Type of cooling system Enclosed Open
t 3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF NORTHAMPTO:N
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD , I
SIDE YARD SIDE YARD
MONT SL 1Lt1L11
FRONTAGE
City of Northampto
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1 DEPARTMENT OF BUILDING INSPECTION �. z
�. 212 Main Street • Municipal Building w� Cat
rsa.• Northampton, MA 01060 'rsdh, �.0
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION'PROJECTS)
in accordance of the provisions of MGL c 40, S54, a condition o Building Permit
Number is that all debris resulting from thi work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 1 1, S 150A.
The debris will be disposed of in: Va-\le-- q't-cle-1 4I
Location of Facility: NOs`LLG Ci-a-k_
MA
The debris will be transported by:
Name of Hauler:
i'LttWA- L/
Signature of Applicant: A, A dog ,u' Date: S//3 2dZZ
1
The Commonwealth of Massachusetts
Department of Industrial Accidents
ONIEMB 1 Congress Street,Smite 100
Boston,MA 02114-2017
'` www mass gov/dia
41rkers'Compensation Insurance Affidavit:Buildersl("ontracturidEleclricians!Plumbers.
11)BE FILED 14I III-I tit:PERM I l ING AI I IlORI I -
Applicant Information Please Print Lriib11
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Nance Ctiu.titeNsCNiam/atwntndntrluall: Kum l , C OUtt d _
Address: 1`3 f a' .r
So
City:'State;Zip: lcc.S-�-l.�cti,�n� 1� �1� Phone#: �3 — 537 - 6' 3 _
Arc von an caspki}Ire tAM.Lbw apprepriatr bra: lt'Z7
Type of project(required):
1.❑1:i crimp kwill..iih cngilu}eca Itrdi again prat-Un el--' 7. N• construction
' I am a wl.pr..prichii ur iwnutn.r.hir and have n emplonyia:v wurkaig Cur are in 1(. Remodeling
Jul caratat}..INu w..rkcr.'cuap.aa.urant uquiriil.l
9. ❑Demolition
I am a br.nev.wrw-r doing all work at}+ekf.11..w.iLi contr..In ux.nec rcywrcd_l
10 0 Building addition
4.0 I am a I.nicti.rw'r and w ill I•c hit mg contractitiv to conduit all wank tin ni't rattp.7ty.. I will
crnurc that all contractor.,CUNT lass worker+. c.ytq+..0 atra.ii n..urance ae arc+a.lc 11.O Electrical repairs or additions
proprietors with n..enrydo}cCS.
12.0 Plumbing repairs or additions
501 am a rt.roe-ral c.eiUactan and I kanc hued tha .nh.i nttii1unr Wed etr the attached•.hest. r
Ihe.:.uh L'+.aitrack.r.li:l.ti.iniplc.t.c.and 1u.c w.rkt, comp. al'e.• 13.t 'Root repairs
14.0 Odic"
6_0 We irs a carpwwatiun and it,utlecr,hair ctcrcn.cal then nght of cxcngNiuri per MC it c.
152.1110}.and we hams rw..-t7dovcc.. 11 a.w.rkm'comp.rn.taancc rcapmnd.
'Air}appttcacrt that chuck.bot I atu+t at.ar till.rut the.:email lr1uc.,h.owme their workers'cuurpcntattuin fetus}udiriaarrut..
Il.ntwow tiers who,ubrmt tins atttdav rt andncating they an decal:all work amiddini het unt.ld.'caaalractrrt.anus*.odnint a new affidavit indicating such.
onrtactore that click this b..t rnw.t attached as atliiioafl asset.h.rwieg lae owe oldie wl*-4. +dots w[wllr.r ur nut duo,:.nun.,have
cinplcwce... It the,uhti.nitractaw,suss etg.Joacv:..theca tier.t pta.atdc their worker.."taunt+.policy number_
I am an employer that is providing worbers'compensation insurance for m).employees:. Below is the policy anti job site
in formation.
insurance Company Name:
Policy it or Self-ins.Lie.#: Expiration Date: __
Job Site Address: ('its State Lip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under M(IL c. 152.*25A is a criminal violatitrn punishable by a fine up to$1,5(KiAKi
am d or one-year imprisonment.as well as civil 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 nray be 6irwardcd to the Office of Investigations of the DIA for insurance
coverage verification.
do hereby certi i'under the pains�and penalties of perjury that the information provided above is true and correct_
Signature.. L'vl(. (2A6 Date: 3 1 3) 2.-0 2-Z
Phone": /3—g37- ,co43 `
Er i
PI Official use oak. Do not write in this area.to be completed by cite or town official
tits or-town: Permitil iccnse#
Issuing Authority (circle one):
• 1.Board of Health 2.Building Department 3.('ity town('lerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
t'ontact Person: Phone#:
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