12C-076 (4) BP-2022-0743
15 MARY JANE LN COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
12C-076-001 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-2022-0743 PERMISSIONISHEREBYGRANTED TO:
Project# roof Contractor: License:
Est. Cost: 11000 RICHARD PALM ISANO CSL89485
Const.Class: Exp.Date:03/05/2024
Use Group: Owner: HUNT CHRISTOPHER M&OANH Y TRUONG
Lot Size (sq.ft.)
Zoning: RI/WSP Applicant; BAYSTATE EXTERIOR RESTORATION INC
Applicant Address Phone: Insurance:
87 SHATTUCK RD (413)374-2719 6HUB-6B21339-4
HADLEY, MA 01035
ISSUED ON:06/22/2022
TO PERFORM THE FOLLOWING WORK:
STRIP AND RE-ROOF HOUSE AND SHED
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
4 ,2 . 7301T
Fees Paid: $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
A 11
' I
I I
•
RECEIVED
JUN 2 2 2022
The Commonwealth of Massachusetts
Board of Building Regulations and Standards=PT.OF IUILD!N(INS F , -FOR
V):
Massachusetts State Building Code, 780 CMR r'oRTHAnnrTON.MA�i �CIPALITY
'. USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
BuildingPermit Number: 2 p—,�3 • "743 Date Applied:
k/z J;� � O' 3 J/'l� 6-22.202Z
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Ad ress: s 1 ( 1.2 Assessos��Map&Parcel Numbs?
1.1 a Is this an accepted treet?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❑ Private El Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
�Caroc k r�s( 4 .. , . . 0(tea- _
Na e(Print) City,State,ZIP
L(t)C) //[A S. P‘3—D-9% TCC Ki2.n x,sQ a)L4lak. C-07 ,
No.and Street Telephone Email Address
SEC IN 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building!' Owner-Occupied 0 Repairs(s) 0 Alteration s) 0 Addition 0
Demolition 0 Accessory Bldg Number of nits Other,Specify:
Brie Description Proposed / r� k 4-
Q �4
�, ,
L., A-&crf- 4 A,.-ii,1
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ / / Ovv 1. Building Permit Fee: $ Indicate how fee is determined:
/ 0 Standard City/Town Application Fee
2.Electrical $
0 Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All F s: Si, 11
l
Suppression) i, V
Check No. (,J Check Amount. Cash Amount:
6.Total Project Cost: $ t (I 00 0 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
Constructio Sup sor License(CSL) 3 b5--/P-1
License umberN Expiration Date
a e of CSL Holder
^ 5 k u .. List CSL Type(see below)
No.an, Stree Type Description
=e ' f\-- D / U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,Z i' M Masonry
RC Roofing Covering
WS Window and Siding
51/9 SF Solid Fuel Burning Appliances
alpaail,L1,41/4, ,bi.e.,,,,,--- I Insulation
Telephone Email address D Demolition
5. Registered Home Impr vement C actor(HIC) 13C)61(9 . AW1
i S 1 a4'S1W, isjA— HIC Registration Number Expiration Date
HIC Com ny Name or I-IIC Registrant Name -�
No.and Street . 7"E afn it address
City/Town,State,ZI 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 CONTRAC R APPL F R BUILDING PERMIT
I,as Owner of the subject property,hereby authorize �c1C, Q� /1/4A,4 -0-A6
to act on my behalf,in all matters relative to work authorized by this building permit application.
...- 74-i''— 1C-C-4-41k:ttS 6 De..)4-D--
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
co . -d in this ap li ti is true and accurate to the best of my knowledge and understanding.to
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"
City of Northampton
✓ `� Massachusetts a�' ... ?,-
\ � l � y • A DEPARTMENT OF BUILDING INSPECTIONS y. z r
\ r, � l 212 Main Street • Municipal Building J`, `
y,' Northampton, MA 01060 14 .. 00
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: k, Q, RCA)c , 'e,
The debris will be transported by:
Name of Hauler: NI.7\ -------1 1 c--/A
/11* 00
Signature of Applicant: ( I P iJ i.�., ., I Date: /36)();)—
\
The Commonwealth of Massachusetts
t Department of Industrial Accidents
1 b11 mom
1 Congress Street,Suite 100
., mi
Boston, MA 02114-2017
' .�_; www.mtass.gov/dirt
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
l't)BE FILED WITH•I`uW PERMITTING AUTHORITY.
Applicant Information ,(�lC� Please Print Legibly
Name 4Husines&Organization/lndividual): ��t.� 7 t
Address: '2'- vaTr ttt—
City/State/Zip: 4 Oi o 3s Phone#: S /9 --/v 7/
Are yor an employer?Cheek the appeniiriate but;
Type of project(required):
I. 1 am a employer with employees(full and or pan-time.L. 7. New construction
- I am a sole proprietor or partnership and have no employes working fur me in 8. 0 Remodeling
any capacity.[Nu worker'comp.insurance required.]
30 I am a hotiseowner doing all work myself.[No workias'cony_monor a required.).
9_ ® Demolition
0 Q Building addition
30 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'cons}w_-nsation insurance or are wile I I.o Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
SO I am a general contractor and I have hired the sob-contractors Gated on the attached sheet
Idr1a' .t frepairs
These sob-contractors hate employees and have workers`comp.insurance.:
6.0 Vie are a corporation and its officers have exercised their nght of exemptionper M(iL e.
14_®Other
1'2.§1(4).and we bare no employees.[No workers'comp.insurance required.]
'Any applicant that checks box a1 must also till out the section below show ing their worker,'compensation pulw-y'information.
t ttorneuwrcrs who submit this atlid:isit uudicatrnu they are doing all work and then hue outside contractors.must submit a new affslat it indicating such.
1.Cuntructurs that check this box must attalsed an additional sheet show ing the name of the suhreontraetu s and state whether or not those entities have
ennpluyees. If the sub-contractors have employees.they must provide their workers'comp.polity number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site
information. ��S
Insurance Company Name:
Policy#or Self ins.Lic.#: 10 (A.8 -- (96 a-__( 339 - (I Expiration Date: 7-3( (Oa-
Job / � (&t:66CX)
Site.Address: t5 � �� `—N City/State/Zip: k �/�
Attach a copy of the workers'compensation policy declaration page(showing the policy number and a piration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a tine up to 51,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day agains e vi.lator.A •j. of • statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage rifle •n
I do hereb c ''r ;,; Id pen of perjury that the information provided above i true rid correct.
1 ,6
Signature: ( /� t / Date: 36
Phone#: I 3 /p� / '�)t
Official use only. Do not write in this area,to he completed by city or town official !
City or Town: Permit/License 4
Issuing Authority(circle one):
1. Board of health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
b.Other
Contact Person: Phone#: