08-007 (10) BP 2022-1033
906 NORTH KING FT COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
08-007-001 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-2022-1033 PERMISSIONISHEREBYGRANT I TO:
Project# 2022 BASEMENT & BATH Contractor: License:
Est. Cost: 27255 AE REMODELING 068078
Const.Class: Exp.Date:07/06/2024
Use Group: Owner: ANN JENKINS MARY
Lot Size (sq.ft.)
Zoning: HB/RI Applicant: AE REMODELING
Applicant Address Phone: Insurance:
PO BOX 291 413-658-4192 SOLE PROPRIETOR
HAYDENVILLE, MA 01039
ISSUED ON:08/23/2022
TO PERFORM THE FOLLOWING WORK:
BASEMENT RENO
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: ( , ' '
tt )9
Fees Paid: S354.00
212Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
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The Commonwealth of Massachus s AUG 9 2 Board of Building Regulations and St dar F
W Massachusetts State Building Code, 7 0 C 2� IUI E'ALITY
DFpT
Building Permit Application To Construct,Repair, tba $ R ised ar 2011
One-or Two-Family Dwelling Mr�T°N.Mq oi� o^ts
This Section For Official Use Only
Building Permit Number: q. 2 01 "(0 ., Date Applied:
%� : v., g, . lb g 03 Z
g
Buildin Official(Print Name) Signature 1 �Dat�
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
qoC /l/_ ic; 9 .' NgrTh uAi pTQ h
1.1 a Is this an accepted street?yes V.
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 Zone: _ Outside Flood Z9ne? Municipal liOn site disposal system 0
Check if yes W
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'ofR�o'n rdl(re s„ &5 NO .^ V %J DK)\ O` U
cii (Print) City,State,ZIP 1
Lk\5 Q31.S9:03 AgeAtZ40(flea4A- C_SAV-1
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK' (check all that apply)
New Construction IN" Existing Building IS/ Owner-Occupied 2' Repairs(s) 0 Alteration(s) ❑ A ition 0
Demolition 0 Accessory Bldg. 0 Number of Units I Other 0 Specify:
Brief Description of Proposed Work': (3u ld 2&Lir 4/co l 5 ;in , hi c t
crco-re 3 roow+5. 6aTh, STa'r'�_ •
2Y1 Sroc.f/ 511 {cT rock 1 f c M�r zin 5 �t/i jv' W i.11 h,.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ gib 2.,S5•pQ 1. Building Permit Fee: $ Indicate how fee is determined:
7 0 Standard City/Town Application Fee
2.Electrical $ yJ (oOO ❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ £jJQoo 2. Other Fees: $
4. Mechanical (HVAC) $ J y Q c) List:
5. Mechanical (Fire $ Total All Fees: $ ���
Suppression)
Check No. Check Amount:
6.Total Project Cost: $ 7 u;5-, 0 0 0 Paid in Full 0 Outstanding Balance Due:
City of Northampton
Massachusetts /� - �`',4,
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DEPARTMENT OF BUILDING INSPECTIONS 7
212 Main Street • Municipal Building% �
�- Northampton, MA 01060 � •.,, �'1��
•
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. EnergyConservation Compliance Certificate (new/replacement windows).
7. Home owner's License Exemption Form (if applicable).
8. Note any Special Permit requirements (if applicable).
•
-9. Energy Cgde —ali nevp•construction (Gut/Rehab) requires a HERS Rate>i Affidavit .
10. Please,provide he appropriate fee�:jn the fgryn of a check nagde payabl9 o;� Thy City of
Northampton.
V
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
oogo'Ia O O
AleCe 7 License Number Ex ration ate
Name of CSL Holder Q
P.(7. Gox ��l � List CSL Type(see below) U._
No.and Street Type Description
/1_ ` _�CAN/
�.It , U Unrestricted(Buildings up to 35,000 cu. ft.)
/IA..�/ 1 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC hoofing Covering
a 3 Iq WS Window and Siding
SF Solid Fuel Burning Appliances
y07V^LOX [ Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
A.E, Re"oy ...L1 1a.36M • - ,37 3
g HIC Registration Number E at on Date
HIC Company Name or HIC Registrant Name
pi o. B svx as l h#oyvd crtV,I I c
No.and Street Email address
/la_ ()I Q5 (yip) 6SSt-L/Iq�.
City/Town, State,ZIP Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25. 6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure t• provide
this affidavit will result in the denial of the Issuuance of the building permit.
Signed Affidavit Attached? Yes 131/ 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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Vafl4 Ay'Y\ 1's\U4 S ;1 .� . Al : , on -
Print Qwner's ame Signature)(Electronic Si Date
t'n )
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 informatio
contained in this application is true and accurate to the best of my knowledge and understanding.
tiNsCJAI,C1513.-5P 0.0/a
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 ontractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitra on
program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can •- found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/ ps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or torch)
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"
Mr
I
---1 The Commonwealth of Massachusetts
__.
Department of industrial Accidents
. ,
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1 Congress Street,Suite 100
a i
Boston.MA 02114-201 7
www.mass.gov/dia
_,....-
1Voiters'Compensation Insurance A Bids v it:BuildersiCuntractorvElectricianv'Plumbers.
It)BC FILEI)V4 WI HIE PEL%1I 1-11.7sti AI I 11(3M 1 N.
Applicant Information Ple:ase Print Legiblx
Name i ausiness;Organizatietv Individual i'.. ifi.,E, Re,-Icki e_i I hs
Address: ( 0,, (3,,,,x ag I H el rrysi;II.r„,
CitylStattiZip:/17eL_ Oi 03 I Phone#: ifi) — 656 —
Are)au all 011041,c r.'( thel.IhL a ppruprivite Not:
1)pc uf project(required):
113,#?iii a eilipte a with enipio;,ecs I,lull andior purl-time i..• ' 7_ N Iv construction
2 am a sole propnetor or parhaciahm and lune no employees working for me in 8_ '.— k:modeling.
,
any tAlfraCiry. CNu*Ort.trl.comp.insurance required
9, 0 Demolition
30 I am a homeowner&ins all wort myself.[No workers'currgy irrturance required.r
100 Building addition
4.C3 Jim a hoinavancr and will he hiring airlift-Aims to conduct all wort on my propiatil.. 1
etbure that all contractors either haw 8,4niers'cOlnpntSZtilint insurance or ate sole 110 Electrical repairs or additions
proprietors v.ith no employees_
12.0 Plumbing repairs or additions
50 I am a m:rat contractor and 1 Isa..e hired the sub-contractors listed on the:Imitated dice_
13.E1Roof repairs
These sub-contractors hsa,:c emplu:,,LIN and!since workers'{331141.insurmce..; .
6.0 14.0 Other We are a corporation and its officers have exerc ised their right of exemption per?.4GL C.
152..144,1.1nd'A e li no implul.ecs. I No workers'cianp.insurance required.]
'Anv applicant that' cheeks boa 4 1 malt ak1.1(III out the..,,.'1.:7.1,`II 1',..11./*Abut,.ing their A oriur,',:ompt.m.ation policy information.
+t-LOMeoa nem who subitut this atrida%it man:auw thcy ne doing ail work and then hue outside eentractorA nimi submit 2 new atrhilIN ill insiieztting
Ct.)inblialtiri that Cheek Lin*Kn.rit.,-,1 attached an adttAtiunai Iheet Nbov.mg the name IA ilk:.5.11.&-ClintraiIIIMa and state whether or nut Cial,e 1,1trtheN,11.4ve
%.,.,p1.1,ve, ir the lub-eonirac-,,I,L. :cmplo...ers.the.,most pro%ide their is..Ilic number
. „... .. . . - .._ ,. . ..... ..„.
I am an employer that b providing trorAers'compensation imurance Or my employees. Below i.s the policy and job mte.
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: Citv.Statelip
Attach a copy oldie V6 1/rkers• compensation policy declaration page(shossing the polic, nuniber and expiration date).
Failure to secure coverage as required under MGL c. 152. §25A is a criminal violation punishable by a fine up to SI,500.00
anchor 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 against the violator. A copy of this statement may be forwarded to the OtTice of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
&vacate: .4 .,-. ...0*"." ••- - .., -"••" "--A...— Mae: "./.2,0/_, c. 2,2--.
Phone . .(Iii 3 ) 6.5 i3--— II id
_ .
Official use only. Do not write in this tired,to be completed by city or town official
City or Town: l'erinit;License#
Issuing Authority (circle uney.
I. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing(avec tii i
G.Other
Contact Person: Phone 4:
.„ . . .,...
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City of Northampton
YH 9.'` Siri Massachusetts �' r. %{
DEPARTMENT OF BUILDING INSPECTIONS `.Y � a
212 Main Street • Municipal Building
Northampton, MA 01060 .3sKW it?ti`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 qu 'tal Hcrcicrt.V .'1 L� i✓IGt,
The debris will be transported by:
Name of Hauler: AIckeYn Eve.is
Signature of Applicant: Date: ,‘/2•<2/2027_,
City of Northampton
Massachusetts
* DEPARTMENT OF BUILDING INSPECTIONS
` 212 Main Street • Municipal Building
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)
1 •11. manci:••=01:.:li • _
1 11 Li NONNEENE i '' 1
mimmommoomm im H I