36-259 (14) BP-2022-1039
131 MAPLE RIDGE RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
36-259-001 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-2022-1039 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF OVERHANGS Contractor: License:
Est. Cost: 5800 MATTHEW KOZUCH 106644
Const.Class: Exp. Date:09/25/2022
Use Group: Owner: T MCGRATH JOHN E &NANCY
Lot Size (sq.ft.)
Zoning: SR Applicant: MILL RIVER DESIGN BUILD
Applicant Address Phone: Insurance:
6 HIGH ST 4133418893 WC2-3 1 5-624269-0 1 0
FLORENCE, MA 01062
ISSUED ON:08/24/2022
TO PERFORM THE FOLLOWING WORK:
BUILD ROOF OVERHANGS OVER BACK DOOR SLIDERS
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 . 51-1 1 el
Fees Paid: $65.00
2l2 Main Street,Phone(413) 587-1240,Fax:(413)587-1272
Office of the Building Commissioner
*-7C----------s"-----
'"'_11:„__—QPI 1 - -----
if
sL., The Commonwealth of Massachusett.(0) s
Board of Building Regulations and Stanciar OR
Massachusetts State Building Code,780/Clew 2 4 202 CIPALITY
, Z (USE
Building Permit Application To Construct,Repair,R Demolish a Reviled Mar 2011
One-or Two-Family Dwelling r ° Ha 11 Dina;inISPFCTIply
This Section For Official Use Only �" so
1----Buildin Permit Number: a P -3 a- " l0 31 Date Applied:
EV & // 2 8111-202Z
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: a 1.2 Assessors Map&Parcel Numbers
1 1 ett(t �AiJ /e_. { �� ZSI—c(
1.1 a Is this an accepted street?yes i/ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
S' 1-{Lf ff 31 740
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
,
Front Yard Side Yards Rear Yard
Required Provided R uired Provided Required Provided
1.6 Water upply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal
System:
Public 1 Private❑ Zone: Outsi Flood Municipal On site disposal system b
Check
if yes
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: f� In,,
oi(\i\ A)A k� n &ra+� Vort-lik,s1/1 ICA ►' 4 D /o EckName(Print) l City,State,ZIP
1 3 I ` _ ki Kd 3 3cft 6ekS rtf�su, 5-LA c' 1,NI-
e - ��
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction d Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 AccessoryBldg. 0 Number of Units Other 0 Specifya.ii .� n roc
g � � �
Brief Description of Proposed Work': (,,) �tl '
, }-.0 coe ®v 0 f(,9 s 0-MC Le ckr 1‹. c)n M
SI-,dc,r..
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ _S-800 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All F:: :�• y
Check No. I 't Check Amount. Cash Amount:
6.Total Project Cost: $ 5-4300 0 Paid in Full 0 Outstanding Balance Due:
(_ -1V6(oliti Y /Z)/Zz—
��eL 4 u-Z,�C License Number ExpirationDate
Name of CSL Holder
cqc 4 List CSL Type(see below)
No.and Street,'' ,' J Type Description
f )o i e,C e �-1 t t /� a'0 6 2 c.0 Unrestricted(Buildings up to 35,000 cu.ft.)
1Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
c SF Solid Fuel Burning Appliances
LfI 3 3 LI► �R 4 gi 1 I d`1 J er ZS e )►a „� ,CcM I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) t 11
l I W i
�-VMS- HIC Registration Number Expiration to
HIC ompany Name or HIC Registrant Name
.\. M IC lJer ZS- 'ecINkC111, (Cal
No.and Street `'s \\ Email a
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 E(' 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 I Y 10. l L t Y L
to act on my behalf,in all matters relative to work authorized by this building permit application.
A ( Ce-i 7-2--/-2._- ___
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.
)'\0. 'h0ZQC\ q-Z,2427___
'
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
?o0.Y H M_p i
��.._. 4 i. 5‘5..'». S Cs,i 1•? Massachusettsdik
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6 k',a »! DEPARTMENT OF BUILDING INSPECTIONS
' 212 Main Street • Municipal Building yvl.. ' 5
Northampton, MA 01060
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:
`V�
Location of Facility: oi(� e c c ll A
The debris will be transported by:
Name of Hauler: , ;11 kiJeC Sr ai iti'10
Signature of Applicant: / -�, ��" Date: Z- _
The Commonwealth of Massachusetts
Department of Industrial AccidentsFJ 1 Congress Street,Suite 100
Boston, MA 02114-2017
www.mass.go►/dia
1$ui leers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
To BE FILED WITH THE PEILMI n INC Ai.rlivw r>r'-
AuuGcant Information ( Please Print Lt iblk
Name l HHusiness•Organization.lndty ieit>stil: ( 1I LJ\ijQ 1 • v%1 �_
Address: t 5%#\ &F —---
City/State/Zip: F10{' IkC..Q- AM ()/C ? Phone #: qi 3 -3'I/ - a?3
Art yeas an employer'Check the appropriate hex: Type of project(required):
1.Iaam a employ is untr entpluyzcs i foil and or pant-tine►.• 7. tg"ew construction
20 I am a sole proprietor ur partnership and bare nu employcca wutkine fur me in S. 0 Remodeling
any capacity_[No workers'comp.insurance required!.) r—�p
9_ L_1 Demolition
3.0I am a twmevunr-r doing all work myself.[\u isorkias comp.aauemcc nyuiril.j'
10 0 Building addition
4.0 1 am a Noncom nee and V.ill be hiring euarraeturs to conduct all work on my property. I will
cnatue that all contractors either have winders'compenaatxm insurance or are sole 1 10 Electrical repairs or additions
proprietor w ith no employees.
12.0 Plumbing repair.or additions
50 lam a several contractor and I have hued the sob-contractors listed on the au—Idled sheet
13.,,0 Root-repairs
These b-contractors have employers and have works•comp.insurance.:
k ✓O so
6.❑ n We a a corporation and its officers have exen-ised then right of-exemption per Ni(,L e. I ��� 3 et ' iS
132:1141.and we have no cznpluyecs.[Ni uurkcrs'comp.insurance requind.j
'Any applicant that ehecks box-1 must also fill out the secuon bcluu show ing their work exs'compensation policy information.
t Homeowners olio submit this atlidnvii indicating they are doing all work and then hire outside contractors met subnut a nevi.affidavit indicating such.
Contractors that check this box must atta.:lied an additional sheet shim iag the name of the sub-contractors and state w holier or not those entities have
employees. lithe sub-contractors base employees.they must provide their %oilers'camp.policy'number_
l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. �M
Insurance Company Name: Lilo Z.r 1 t 1>> 1"../c.
Policy#or Self=ins.Lie.#: WC2 31S-6 2'-f 26 9 a 11 Expiration Date: ,�'s1�3/4 z-
f� ( � �(� +
Job Site Address: I 1'l CkP IA 10 SQ (k_e) I"r1orett,c. / City,State:Zip: CVO 6
Attach a copy of the workers'compensation policy declaration 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 tine up to SI.500_00
anchor one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a tine 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 ofperjury that the information provided above is true and correct.
Sienature: 4� �/wC Date: L� ZZ--
Phone Y: 14(3 341 t) l 3
Official use only. Do not write in this area.to be completed by city or town ofciaL
City or Town: Permit/License#
- 1
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
c.3
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