30B-018 (2) BP 2022-1009
25 LIBERTY ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
30B-018-001 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-2022-1009 PERMISSION IS HEREBY GRANTE I TO:
Project# ROOF Contractor: License:
Est. Cost: 12600 MARK SARAFIN 053434053.34
Const.Class: Exp.Date:04/28/202304/28/2023
Use Group: Owner: GALLANT JENNIFER R& NANCY P D'BY
Lot Size (sq.ft.)
Zoning: URB Applicant: SARAFIN BUILDERS
Applicant Address Phone: Insurance:
85 RUSELLVILLE RD (413)563-92560 WCC-500-5019027
SOUTHAMPTON, MA 01073
ISSUED ON:08/18/2022
TO PERFORM THE FOLLOWING WORK:
STRIP AND RE-SHINGLE
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 VIOL• TION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
iI O _
Fees Paid: $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
•!W
SJ, The Commonwealth of Massachusetts;' b
'.-:0): Board of Building Regulations and Standkrds4 UGOR
Massachusetts State Building Code,'780 CMR 1 � 2022 ICIPALITY
USE
Building Permit Application To Construct, Repair; Re►i ova lish a Revisled Mar 2011
One- or Two-Family Dwelling r n:?rF�,ail ni '^(9PFCTio s
This Section For Official Use Only
Building Permit Number: 22,- ( Qgg Date Applied:
/Ey JO a5 /6 ' 8 h Zoz-z
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
l oI_I ID*
ss: C 1.2 Asse,sors,Map& Parcel Numulr
1.1 a Is this an accept 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
Check if yes
SECTION 2: PROPERTY OWNERSHIP'
2..1-�0wner'of g4ecor :
3tv\ C_ex 11 a.n 1- V\ooe,n .>e vab- a\o(p-7
Name(Print) City,State,ZIP
(95- L, 6e2J S4- /413 -3ga ,- IIIlQ
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 ❑
Demolition 0 Accessory Bldg. 0 Number of Units Otylt 0 Specify:
Brief Description of Proposed Work': 1-e: bv-e .e A g 1, Qac,4., ...t vis tot 11 -ec ((,cei It/
In 6.0c, .,n 511 cx\,>l ►Aic{e V•t.n A- u
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ tdb, _ 1. Building Permit Fee: $ Indicate how fee is determined:
t ❑ Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire Total All Fees $
Suppression) $ �
Check No.LPL/Check Amount:
6. Total Project Cost: $ ra1 ifoo. — 0 Paid in Full 0 Outstanding Balance Due:
City of Northampton
a s .,f !
Massachusetts •,��G
1 st iI
DEPARTMENT OF BUILDING INSPECTIONS
,..I, 212 Main Street • Municipal Building �J`
` ._;. - Northampton, MA 01060 r�j44 5VN
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.
I
• r .
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) r _a 5-3t 3q [-t—a 6 ,,)5
pv q.rz ,Z,.A. License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) U
'S "121/45seltv,ke gooD
No.and Street Type Description
-� �, • U Unrestricted(Buildings up to 35,000 cu.ft.)
O'3 '{—`.1w ',,, d�4P' cA6-43 R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry/� RC % Roofing Covering
5a,t�cAL 4s1 Q 11la tP 4 ' v' 4.WS ' Window and Siding
SF Solid Fuel Burning Appliances
2413---q93 —Qc)54 I I Insulation
Telephone Email address D Demolition .
5.2 Registered Home rovement Contractor(HIC)
.tIHIC Re ' tration Number Expiration Date,
HjCLoippany Name or HIC Vegistgt l�Ipme O, N� 4
g�j �/OSsel\u, dJ C) d ,r.se
d Street Email address
cw tAA �" MIA 4 013 413-ciO3-J9as6
City/Town, State,ZIP N 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 IV- No .0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTORA/ n APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize '�" \Wit V �W.l2w *-••••
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
contain i icat' is tru nd ac urate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Na a(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 basemendattics,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"maybe substituted for"Total Project Cost"
_ The Commonwealth of Massachusetts
I' =i,Dill f Department of Industrial Accidents
1:0 , ''t 1 Congress Street,Suite 100
• a. Boston, MA 02114-2017 •
;; •
www.mass govid,a
11 utfrers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PEIt%urwr%' ;At THUWTV.
Applicant Information Please Print I ibll
Name(BasinesslOrganiratiotu'individual): 504-11.4w.e%..- .."\ `-<
Address: Pc Ql c k v,,\'e 9 LO
City/StatelZip ` w0a,-\\ \y3 W a\b-43 Phone 0: t-t13—'5*(Q 3—1 *.0
--
Are yea a.eatp1.yre°!Cheek the aminiprizne hot: Type of project(
gyireilt
I.dlam a cmpIn t with 9; employees(full aodbr part-ti►ne).' 7{ 0 New construction
20 lam a ale proprietor or partnership and have no employees working for urc in S. n Remodeling .
any capacity_[No workers'comp.rewraner mutated]
u
Ej30 l am a Iromcowint doing all work myself_[No wruke s'comp.imrrawe rveqirerd_[° 9. Demolition
d{J c►nr lam a bcown a r and will be hiring wuractors to conduct aft wort on my property_ I will 1 Building addition
ensure that all cinmalors either have workers'eump►rn:N,um msur mt or are rode I I.0 Electrical repairs or additions
proprietors*ids no employees_
12.0 Plumbing lira or addition.:
SinI am a general contractor and I love hind the arb-contraol►ra listed on the attached sheet.
TheseI 0t1f repairs
sal itioniraetors love employees and ce love wariums'camp.irwrran _; , i��''
6.®We anc a rumination and its officers have cxtxired their right of ctennp nm per A/t;L e_ 14. Other
MI,¢1(4),and we have no cngoloy er:s.[No wurkcts'comp_insurance requital
'Any applicant that chocks hot AI rauat also till out he section below showing to.*wurkers'commission policy information_
tiumeownea who submit dam affidavit indicating they are doing all work and then bit outside contractor.must submit a new Wilda*,it indicating suck
k'oatraclra that check this box must attached an additional semi showing the manic et the iai►comirrcturs and stale whether or not drays amines have
employees_ if the sub-corlrac.rs have en,loyucs,they mast provide their weariest. sump_polity rider.
I am an ealpluyer that is providing workers'c mpettsation awnaace for any emplo}eres. Below is the policy and job site
information.
Insurance Company Name: A k VV1
Policy#or Self--ins.Lic.#: WQC. -'So$- 45 a'' 0)0cPa Expiration Date: 1" t`a
Job Site Address: 9-5- L, be 4-- City/State/Zip: GQ 1e 1 VA-
Attach a copy of the wokkrt s'con ion policy declaratan page(showing the policy number and eipiralion date).
Failure to secure coverage as required under MGI.c. 152,*25A is a criminal violation punishable by a fine up to$1,500.0()
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fore of up to S250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certi e s n pen i . of jury that the iafineratiow provided above is tome and correct
Signature: Date: 8^ 1.4-.2 ?
Phone#: 44 13`-(p S -COS-4
Official use only. Do not write in this area,to be completed by e'er or titan official
City or Town: Permit/License#
hsmi.g.ttrthorit.) (circle one):
1.Board of Health 2.Building Department 3.('ityrlrawn Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Perm: Phone#:
City of Northampton
0. H Me.
#°
Massachusetts 7�?�• 'c•
lt
r, 1 DEPARTMENT OF BUILDING INSPECTIONS 101 ;�
212 Main Street 40Municipal Building 0� :Cam
Northampton, MA 01060
ill
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: AtN2- LwA L
The debris will be transported by:
Name of Hauler:
•
Signature of Applicant: Date: g-1 ^�