38B-178 (4) BP-2022-0954
1 1 FORT ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
38B-178-001 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-2022-0954 PERMISSIONISHEREBYGRANTED TO:
Project# RENOVATIONS Contractor: License:
Est. Cost: 4500 67026
Const.Class: Exp.Date:03/23/2024
Use Group: Owner: ARNY LIBBY C TRUSTEE
Lot Size (sq.ft.)
Zoning: URB Applicant: ARNY LIBBY C TRUSTEE
Applicant Address Phone: insurance_
11 FORT ST
NORTHAMPTON, MA 01060
ISSUED ON:08/10/2022
TO PERFORM THE FOLLOWING WORK:
RENOVATIONS TO ROOM
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 TADIT
Fees Paid: $65.00
212 Main Street, P'ione(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
EV14u,c Q h
El.�iET /ft5ihe Commonwealth of MassachusettsBoa d of Building Regulations and Standards FOR
Mas achusetts State Building Codemoi , 780 CMR MUNICIPALITY
USE
To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
:. . UGPiler .tAPlication
PT°F Qu+tnrnr�+�+sP This Section For Official Use Only
NngTH
Buil4Uit...)
mg A -*D.a. Date Applied:
Qom, /2 8-10-2Oza
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
U FortS f Fa !7r
1.1 a Is this an accepted street?yes X 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 Pros ided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System
Public'l� Private❑ Zone: — Outside Flood Zone? Municipal On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP' •
2.1 Owner'of Record:
t,ilk �<Yly NeftislAkttlenA IM 14 0 I o&V
Name(Print) City,State,ZIP
i t Fof 191 1I13) 05 610 l i oycokEley400iCor✓i
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ Existing Building Owner-Occupied IT Repairs(s) Alteration(s) ❑ Acdition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: Re.1►~Olh p(& ` ceC i ' CNd t,.xt1t -�l�vt6k
DV& appp��1� l2-l•1Z (to v15v( texi..fe r v�g �,4-y , Npw DrycAall
-tct?ed Spa —ei,ec vcal opqra.ebe5 1,.. / /'
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ tter0 CV 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ '', b� 0 Standard City/Town Application Fee
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: $
00 Check No4 WiiCheck Amount:
6.Total Project Cost: $ L.1500 0 Paid in Full 0 Outstanding Balance Due:
w
City of Northampton
Massachusetts
j
- DEPARTMENT OF BUILDING INSPECTIONS it
\ 212 Main Street • Municipal Building ,VII ,�.
is (s Northampton, MA 01060 S �11a�
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. 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.
Yie14-1 (5
(1'S)
•
SECTION 5: CONSTRUCTION SERVICES
5.1.1'Construction Supervisor� License(CSL) C5,a`7a �/l t`e`7Te` p' Y('tt‘f t( License Number -mob Vz,laii
Expiration Date
Name of CSL Holder
2- Pocrie L\ f / c( ( List CSL Type(see below) u
No.and Street �Lt Type Description
Col fa.tt,\ 0/4 01396 U Unrestricted(Buildings up to 35,f 00 cu.ft.)
City/Town,State,ZIP R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
/�(zj).—a ,-„r [� ��(Z a SF Solid Fuel Burning Appliances
/5-75 e(� LV,CGS I Insulation
"Telephone Email address I D Demolition
5.2 Registered Home I rro (emeent Contractor(HIC) /g Li I p Q' 2 i L 12u
0 5A /d i i e"'"'1` hu0tt avt HIC( Registratitio(Number Expi lion Date
HIS oVcptgyName,1(IIC,,Rggistrant Name ` i t A a .,c,
No. nd Street , 04 o(,� s3� 71/ 7 Email address
t�D�f'ar`� � ��l"
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 %tL 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 J/ a.."? .4
V
to act on my behalf,in all matters relative to work authorized by is building permit xi cation.
Print Owner's Nam (E ectronic Si ture) Date
SECTION 7b:Il . '1 OR AUTHORIZED AGENT DECLARATION
By ent my below, i e. . est under the pains and penalties of perjury that all of the information
co • , -. thi. ..s`Ri ation . • - . •ccur to to the best of my knowledge and understanding.
4 .,4A1A
P-***k. ' 0- er'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 arbitra ion
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
=ra.E Department of Industrial Accidents
t..-.
1 Congress Street,Suite 100
•=. Boston,MA 02114-201 wwittmass.govitlia
us kers Compensation Insurance .‘tridas it:BuiLdersiContracturs;ElectricianstPlumbers.
It) Bk. FILL!)N11 LII I IlL Pf.RMITTING .1,1 I 110RI IN.
Applicant Information Please Print 1..egiblv
Name illusiness;Organizationlindividual): tAt.. 1.1 / CAP-17-VtA, 112.46gA*6(-4/1-4,-"?
Address: ZPc4kt4L (?4
City/StateZip:L 0 1346 Phone #: (.4 ,) (
Are 011 an emplot er?Cheek.the apprtiprtale tptt%: 1 Ty pe of project(required):
1.D I am a employ...7 utth employ Neh itu.IIImsltsr part-urnet.• 7. j New con.strixtion
2...10 I am a sole proprietor or partnth o- ip and bate no e empbo in yeea workg for me in 8. vi Remodeling
any varaelty.[No workers'comp.insurance reqinrcd.]
9. EltM0iftiOtt
30 I am a hanneowner Joins:all work mvself.[No workers'corm. uranee moire&j
ICI CI Building addition
.41:1 t am a hattnenutuer and will be hums:C lirat.lursiOconduct all work on my proctnty. I will
entatre that all 4::netractura either have -ornpensation insurance or age sole .f Electrical repairs or additions
proprtetors with no employes:2i_
12.0 Plumbing repairs or additions
50I am a general cut:Ara:tor and I have hired the nits-contractoni listed on the attaiiied sheet
13 ROO I*repairs'
fhcae sub-contractors have employect and have workers'comp.nuitarance.:
14.a Other
6.C3 w'e are a corporation and offieers have exerciaed then right of exernpinnt per SiGL e.
112.§I i 4).and we hate no erripinyees.[No workeni'comp.insurance tCqUtreti I
'Any imp/h.-ant that cheeks NIA al Mira A6.0 all out dime sectium Itch APCi,a1 kin policy information,
Horricoiktaers who submit this atrickivit indicating they are doing all i ork and then tun:outiode,a.ettraeturs must..tuhrtut a new atfidat ii indicating such.
:-Contractors that check this box must attached an idditional sheet showing the ozone vf the sub-eeettractors and state whether in:11.1 LIIUNt!*MLIEICh kart
employers. tithe sub-contractors Lai,:citirInv ei.N.they must provide their is!A It Ir.mimes number
am an employer that is providing workers'compensation insurance fOr my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.4: Expiration Date:
Job Site Address: City/StateiZip:
.tttach a cop, of the viorkers' compensation piolic declaration page(shoeing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation palish:1We by a fine up to$1,500.00
anikor 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 riolator. A copy of stat t may be forwarded to the Office of investigations of the DR for insurance
cos C nfic. c. .
ft
I do hereby c,,, fru re . t allies of perjury that the information provided abo !rum°and correet.
SnInature: I ,
[Pah: p .2 2
Phone 74/5 ,
Official use only. Do nut Write in this area to be completed by city or town official
City or Town: Per-mitilicente
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3.City/Ton Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone*:
City of Northampton
41N
Massachusetts
! 4 DEPARTMENT OF BUILDING INSPECTIONS !
F 212 Main Street • Municipal Building a�
,st Northampton, MA 01060 s41* �
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permi
Number is that all debris resulting from this work shall be •isposed 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 )� ZCAfdt Facility: Di ( O(.l iesc.411-(tAy
The debris will be transported by:
Name of Hauler: nc ix( (el
,--
Signature of Applicant: Date: tin 2
City of Northampton
f 4 �, s�rl
Massachusetts �, c
DEPARTMENT OF BUILDING INSPECTIONS
A 212 Main Street • Municipal Building 91/4„�
to s Northampton, MA 01060
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, (insert full 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)