31A-110 BP 2022-1040
75 FORBES AVE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
31A-1 10-001 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-2022-1040 PERMISSION IS HEREBY GRANTEI TO:
Project# REPLACE STAIRS Contractor: License:
Est. Cost: 3000 MATTHEW KOZUCH 106644
Const.Class: Exp.Date:09/25/2022
Use Group: Owner: JOHNSON JOHNSON SYLVIA & ER :ST JERRY
Lot Size (sq.ft.)
Zoning: URB Applicant: MILL RIVER DESIGN BUILD
Applicant Address Phone: Insurance:
6 HIGH ST 4133418893 WC2-315-624269-010
FLORENCE, MA 01062
ISSUED ON:08/24/2022
TO PERFORM THE FOLLOWING WORK:
REPLACE STAIRS
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:
•
10 • y9 7-
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
"____FQL.F -
The Commonwealth of Massachusetts-' AUG 2 4 �022 OR
Board of Building Regulations and Stan rds
Massachusetts State Building Code, 780MRFa MUSEITY
T o`nun ---_.
Building Permit Application To Construct,Repair,Renbval$Df''_`F3tlttrte 4 Np° Man 2011
olos
One-or Two-Family Dwelling ''— '�_
_ This Section For Official Use Only
Buildin Permit Number: .&P 2 . " lid Date Ap lied:
k;Lh4 ) ` JCOSs //' Q Zy Zoiz
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property A dress: 1.2 Assessors Map&Parcel Numbers
-T i Ilorloes A - a\h - 11 p --001
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
ll,KL Zi, WI-- I•Z0
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
t\)/A N/ VA J/A N�� N/
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Informati n• 1.8 Sewage Disposal System:
Zone: _ Outside Flood e? Id
On Private 0 Check if yes[ Municipal I On site disposal system 0
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: r ( ' ..
Syl,�ih.. ' llle5'I— aso^ Aferfl,LA A 0(C26O
Name(Print) City,State,ZIP
-7)- Fotto-a5 ,A.It. 413 2 Ig 40I t -7--S li V'It Oi11lsOJke I,Calk
No.and Street Telephone EmaiYAddress
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building❑ Owner-Occupied 0 Repairs(s) 0
Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other Specify: ref�k.c.e. S�
Sp q,►
Brief Description of Proposed Work2: (�P,O _ L2j rt i l (_C
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ '1 r 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:^$
Check No. 1 Check Amount: 46 Cash Amount:
6.Total Project Cost: $ .3 I< 0 Paid in Full 0 Outstanding Balance Due:
r 4 �=7j�C_� license Number Expirati Date
Name of CSL Holder
,, '�, �� List CSL Type(see below) l
No.and St Type Description
Pore+lL e MA- 01061, (U) Unrestricted(Buildings up to 35,000 cu.ft.)
Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
if 3 V1Je-IJo-zc e ac, .cC ' SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(WC) t 11-1 q Z
�- HIC Registration Number Expiration to
HIC ompany Name or HIC Registrant Name II
t‘. MI C lJer ZYe ckikkaii, l CAI
No.and Street \\ Email addres
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 Er.-- 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 1 ui 1 D. { L L
to acton my behalf,in all matters relative to work authorized by this building permit application.
E
Print Owner's Name(Electronic Signature Drne
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.
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"
The Commonwealth of Massachusetts
Department of Industrial Accidents
F I Congress Street,Suite 100
71 Boston,MA 02114-2017
www mass.gov/dia
11wirers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED%VII H THE PEltsilTIINC Al:'I'IlOW-1'1'.
Applicant Information ( Please Print Leeibl%
Name taus loess:Organizationlndnidual):_M f'L N1\s1 be5.1 5 \Jt 1 • --
Address: I elk S _—_____
City/State/Zip: f O O/ ? Phone#: (4)3 - /-(f - g 3
•
Are you an employer'('heck the appropriate bat:
Type of project(required):
l.Iaam a urlploytx With employeca(full and ur part-trnrl-' 7. New construction
.1:3 1 am a auk prupnctur ur trartnenhip and have nu employee.working for nu:in N. Remodelin
any capacity_(No W urktrs'Bump.insurance rcquucil)
9_ 0 Demolition
30 1 am a humcu ucz doinr all uurk myself.[No Nuri:ca>'comp.insurance n-quucdj'
10 0 Building addition'
4.0 I am a humeoi ne-r and Will be birine eosin-actors to conduct all work on my property. 1 will
ensure that all conirtctun either have wutkcn ccxapcmatron insurance or arc sole 1 1 0 Electrical repairs or additions
proprietors N ith no employee..
12.0 Plumbing repairs or additions
30 I am a ec-ncral contractor and I h,%a hoerl the aub-contractors!fated un the attached duct
130 Rtwf repairs
These orb-contractors have employee.and Izarc Wuhcn'comp.insurance.-
6.0 We a corporation and its officers have exercised their nght of exemption per Mti&c. I u
n-a
132 *1 i 4 f.and we have no arsployeca.[No ourkca'comp.insurance rcquued.l
'Any applicant that checks box a 1 mug alau till out the.section belu.shoo ing thou Nurkcrs'compensation policy information_
t Ilutricum nnen Who submit this aurora's it indicating thin,are doing all N oak and then hoc outside contractors must aubnut a nc'affidavit unlio tug such.
Contractors that check this lox roust atta.lred an additional sheet alum ins the name of the'ub'cuntracturs and mimic N nether or nut those armies have
employee-.. If the sub-comtractors have employee...them must provide their %wrier.'comp.pu)icy ntunbcr.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. �(� i t
Insurance Company Name: 1.—[to 2 r 1 t 10 TJ a 1
Policy#or Sell-ins.Lic.#: JC1'3 IS—6 b(I Expiration Date: ,57/i 7 7
Job Site Address: 7 5 l ��P� /VQ l^ ,v.41,J '14 CitydStatelZip: �'`t 66
Attach a copy of the workers'compensation policy declaratln page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c_ 152. §25A is a criminal violation punishable by a fine up to i1,500_00
an&or one-year imprisonment,as well as civil penalties in the firm of a STOP WORK ORDER and a fine 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 certify and r the pains and penalties of perjury that the information provided above is true and correct
Sienature: ' I Date:
Phone»: 1413 3141 $113
1 d
Official use only. Do not write in this area.to be completed by city or town official
City or Town: Permit/License#
Issuing Authority (circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
•
City of Northampton
• ...A'_"i,..
Massachusetts
- i DEPARTMENT OF BUILDING INSPECTIONS
. .• r, 212 Main Street • Municipal Building J�• :C1
. Northampton, MA 01060 ssN •• ,1�
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: '1)a1 tQ 2 c c1/A ci
The debris will be transported by:
f ,
Name of Hauler: ,1i ' to
Signature of Applicant: '�� 4, vt,i I Date: ,