44-018 (2) BP-2022-0647
1 l 1 OLD WILSON RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
44-018-001 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-2022-0647 PERMISSION IS HEREBY GRANTED TO:
Project# KITCHEN RENO Contractor: License:
Est. Cost: 31882 THOMAS MALONE 055236
Const.Class: Exp.Date:01/18/2024
Use Group: Owner: BECKER TESINI JANICE M & HARRY
Lot Size (sq.ft.)
Zoning: SR/WP Applicant: RHI CONSTRUCTION INC
Applicant Address Phone: Insurance:
128 RYAN RD (413)885-9038 7PJUB 1 K060384
FLORENCE, MA 01062
ISSUED ON:06/06/2022
TO PERFORM THE FOLLOWING WORK:
KITCHEN RENO
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 >2• g I
Fees Paid: $207.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
/' 2Y
of Massachusetts JUro
� The Commonwealthassacl* -
62
Board of Building Regulations and,Sta CO ?2
-. 1 Massachusetts State Building Code, 780 OOP RFc;41,1 F SE LITY
Building Permit Application To Construct,Repair,Renovate Or- 1rK►, §tT7 evil Ma-201i
One-or Two-Family Dwelling a ____°vs /
This Section For Official Use Only
Buildin Permit Number: 3 0- a? 0(-/7 Date Applied:
=vik) 6-G-ZOzz
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 s
`'� rs Map&Parcel Numbers c�
t\\ ,ulR�S C/1 - Q / b
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 systeri 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: `w p ^r�1" nn 6A0 6 O
Name(VN 'ern "(ic \V J w,
t) City, State,ZIP
\ 1 012, t> i,'V L4A.,- •,1k s --S L--t{z
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 Addit on C
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: -__
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS _
Item Estimated Costs: Official Use Only
(Labor and Materials) __
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determine(
❑Standard City/Town Application Fee
2.Electrical $ % L -'0 ❑Total Project Cost'(Item 6)x multiplier x _
3.Plumbing $ 'UU 06 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: do (Cash Amount:_
6.Total Project Cost: $ '31 TT?`1 r 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)
TNo.and Street Description
C U Unrestricted(Buildings up to 35,00(1 cu.ft;_
V LU(°' R Restricted 1&2 Family Dwelling
City own,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding _
1 SF Solid Fuel Burning Appliances
`di\ -Z1�C(d5' ��: ��/ yy�� f e.A I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
., HIC Registration Number Ex irati on Da e
HIC Compan_y Name or HIC Registrant Name
Berm(Q111 4.t�1e�vc_�rt
No.and Street Email address
C'W-twc- fr - 01uG.-L \ 5—eve3
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 .❑
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 r-\\4Q.Ary\c.� (1'�
to act
on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(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.
T \I% PC-VA/AI ZZ_
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered coutractur
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitratior
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be f.iund;It
www.mass.govroca Information on the Construction Supervisor License can be found at ww ..mass. w\-'dp.
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
Massachusetts
t": )'I • j DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 r9frn ifp�1`�C
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 Df 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:
Signature of Applicant: `//� 7/4 / Date:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
"-1 Boston,MA 02114-2017
l www.mass.gov/dia
%linkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumber!.
TO BE FILED MITI THE PEIoil'CI'INC AtITHOR1T .
Annlicant Information Please Print ,l.c. l!I_
Name(BusiatesvYhgranization/Inditidual): g}i.-:- -
Address: t--3i.-iLL04, ` y
CityiState?Zip: Iy\(Ns' Phone#: t -S---cl(
..._.
Are sou an employee Cheek the appropriate bat: Type of project(req aired•
1.0 I am a employ-is with, ,__.____employees(full and'ur part-tinsel.* 7. 0 New construct on
2.1:3 I am a sole proprietor or pamiership and have no engsloyeea w irking fur me in N. 0 Remodeling
any capacity.[No workers'comp.unuranu required.]
9. ❑Demolition
3 fj 1 am a hunrcawmr doing all work myself_[No workers'currip.nisur m.e nquired.l'
4.0 I am a bonito*mr and will be hiring waradurs to conduct all wink on my property. I will
10 0 Building additinn
ens. '
12.0 Plumbing repairs or tdditions that all contractors either have workers'conmematninl mw'ur.mix eE are sole 11.0 Electrical repairs or tdditions
dots with nu employees.
5 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. I ID Roof repairs
These sub-contractors have employees and have workers'romp.insurance.:
6.0 Vs a are a corporation awl its officers have exercised clan right of exemption per MIL.e_ 14.❑Other
152.§44 and we have no employees.[No workers"comp.insurance required]
•
'Any rpplu-anr that cheeks box 1,1 must also till out the section below slowing their workers'compensation policy information.
r Homeowners who submit this affidavit indicating they me doing all work and then hire outside c'tnttractors must submit a new adinlm it itslioum} such
1.C'untracturs that check this boa must attached an additional sheet show ing the name of the sutrcuntriettas and state w holier ur not those entities Is five
employees. If the sub-contractors have employees.they must pros ide their workers'comp.policy number-
am an employer that is providing workers-'compensation insurance for my employees. Below is the policy and-ju h site
information. n
Insurance Company Name: (. ..c`-1 _lLc. 1 _._—
Policy#or Self=ins.Lie.#: Expiration Date:
Job Site Address: \\\ 4 Q_. t \ (N.. c\f>.--- City State1Zip: .32,r,A _ C)t
Attach a copy of the workers compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MC1L c. 152.§25A is a criminal violation punishable by a fine up io S I..it!()00
andJor one-year imprisonment,as well as civil penalties in the ft ni of a STOP WORK ORDER and a fine of up to S.!51.1.10 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for ins..ranee
coverage verification.
I do hereby certif'under the ins nd pent lties of perjury that the information provided above is true and corral.
Signature: �� Date: 6�l`��� —.._
Phone#: L-V\y -e-drS t-
Official use only. Do not write in this area,to be completed bycityor town official I
City or Town: Pernik/License# ._-
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City./Town Clerk 4.Electrical Inspector 5. Plumbing'!nsper for
6.Other
Contact Person: Phone#: