38B-026 BP-► 022-1106
117 SOUTH STUNIT A COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
38B-026-001 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-2022-1106 PERMISSIONIS HEREBY GRANTE# TO:
Project# 2022 RENO KITCHEN&BATH Contractor: License:
STEPHEN D ROSS GENERAL
Est. Cost: 63700 CONTRACTOR 079160079 60
Const.Class: Exp.Date:04/28/202304/282023
Use Group: Owner: W. ROY,ANN
Lot Size (sq.ft.)
Zoning: URC Applicant: STEPHEN D ROSS GENERAL CONT' TOR
Applicant Address Phone:, Insurance:
36 SERVICE CENTER RD (413)584-1224 WMZ-800-8006546-202 A
NORTHAMPTON, MA 01060
ISSUED ON:09/07/2022
TO PERFORM THE FOLLOWING WORK:
RENO KITCHEN&BATH
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:
44
9
� ,
Fees Paid: $416.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
4jOLLF-r, KAP S
p-n-9 U
CV `,,1 2
�? - - The Commonwealth of Massachusetts
' * t Board of Building Regulations and Standards FOR
2 c L „= Massachusetts State Building Code, 780 CMR MUNICIPALITY
_ USE
��I w Build.ng Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
cn One- or Two-Family Dwelling
a
This Section For Official Use Only
t
Building Permit Number:isP2o12.-" I/O( Date Applied:
1•
r ► vu lJ . °`
Building Official(Print Name) I Signature ate
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1(7 Sowfh► S/r- -1- u.0i1' 4 2?6—026-- 00 /
1.la Is this an accepted street?yes iV-no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
thee_
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft) 4/'4 ' Al ..4.e-6#1.--U/•r A--
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 ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
/9Kol Re-y 44 n..7 «. ./!94' °/oGo
Name(Print) City,State,ZIP
/ /7 Sour c/r-•#-A LAM", A / k/3--2-7f-((4D
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2 (check all that apply)
New Construction 0 Existing Building li Owner-Occupied Repairs(s) 0 Alteration(s) -B -Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units_ Other 0 Specify: j
Brief Description of Proposed Work': ( IL/ 12,1 e ► ' p.04 Qc11& K� .tom(c A'''.0
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ S'f/0 0 '14 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $
Je r w 0 Standard City/Town Application Fee
/ 0 Total Project Cost' (Item 6)x multiplier x
3. Plumbing $ 61 r0(f, 2. Other Fees: $
4. Mechanical (HVAC) $ - C./ - List:
5. Mechanical (Fire $ -Suppression) Total All Fees: $ C(o =" Co
`v Check No. II70 Check Amount: (//d-'Cash Amount:
6. Total Project Cost: $ 0 7/d 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
a
5.1 Construction Supervisor License(CSL) es 7 9/G d 4I .028
L.Welhen V. Roy r$ License Number Expiration Date
Name of CSL Holder v
34 (3ervi Ce.Cen�xY 7foad List CSL Type(see below)
No.and Street Type Description ,
WO Knh2n2/An/ me. 0/b G 6 U Unrestricted(Buildings up to 35,000 cu.ft.)
R , Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC _ Roofing Covering
WS Window and Siding
y/.5'J56y/a ((�� t�eirasj ZL/Gt�j(,1d•CGN7 SF Solid Fuel Burning Appliances
V� r 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 150 4I7 v5. ,/
1,e c5 h„Alpo `'/en.,.f confrador HIC Registration Number Expiration Date
HIC Cofnpany Name or,-BC Regi ame
...74,�P�'Ure_G(� ./7• " ka J cOdeh0 0Vilk J•corm,.
No.and Street Emait address
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 Issu a of the building permit.
Signed Affidavit Attached? Yes 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 S' �"/ '-''., � v���c`
to act on my behalf,in all matters relative to work authorized by this building permit application.
A4 A ° C/c V?.
Print Owner's Name(Elektronic Signature) Date
SECTION 7b:OWNER'OR A : e RIZED 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.
/0Z
nt er's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. 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 1
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
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Massachusetts x"?' <<
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°�'' �� DEPARTMENT OF BUILDING INSPECTIONS D
".* 212 Main Street • Municipal Building J`1,M1 a�
Northampton, MA 01060 ss"'•»•aro
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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: asp.,7
�..c�C i ✓�
The debris will be transported by:
Name of Hauler: (o /,44-( C �—
��y
Signature of Applicant: Date:
The Commonwealth of Massachusetts
T '- :-41� /. Department of Industrial Accidents
=;ef�i�- t, I Congress Street,Suite 100
= 1q Boston, MA 02114-2017
',as www.mass.gov/din
1l arkers'Compensation Insurance Affidavit:Builders['ontractors Electricians,Plumbers.
TO BE FILED WI III THE PERM!IIIM;At•l'HORJTl'.
Annlicant Information Please Print Legibly
Name(Hustness'( anizvtion'Individuall: ��s'v 1}2-Yi-7 ____
Address: 3 6_ c v- G..._ (vt.1- --
City/State/Zip: Ø24b.. /fi!/1 f/OGG Phone #: 4/(5 — r y /ZZ-y
Are yea ao employee?C'hack the appropriate bus:
Type of project(required):
1E1 1 a employer with , employees(full anrt'or part time)-• 7. '�W construction
am a aok proprietor or partnership and ha%e no employees working fur me in
S_ �, Remucieting
any capacity [Nu worker,Lump.insurance required.)
9. ❑ Demolition
3E3 I ant a hurncwwm r doing all work myself.[No workers'comp.rnwrnue requarcd]'
I00 Building addition
4.E3 I am a humans net and will be hiring contra:tors to conduct all work on my property- I will
ensure that all contractors either hate w(Vrker'corrcensation insurance Of are sole I L°Electrical repairs or additions
proprietors w tth nu empluycey. 12.0 Plumbing repairs or additions
SC3 1 am a vomit contractor and I ha.e hired the yob-contractor listed on the situated sheet 13E3RoofrepatrlG
These gib-contractors lust employees and lase workers'ctanp.insurance.:
6.0 we are u corporalion and its officers have exercised thee r. hi of exenmptruai per Mt,L e. 14.in Other
152.§I(4).and we Kaye no employees.[No winters'ecmp-insurance f-quiaed.l
•
*An)applicant that chocks but a I mitat also till out the section below showing their workers'componatian policy information
'Homeowner who submit this affidavit indicating they an doing all work and then hrre outside contractors must srthnut a new affidavit rmdiuting such.
:Contractors that check din but must attached an additional sheet showing the name of the sob-caniracturs and state whether tv nut there entities have
employers If the sub-contractors have employees.they must preside their women mp'or policy number-
1 am an employer that is providing workers'compensation insurance jor my employees. Below is the policy and job site
information.
Insurance Company Name:_ _
Policy#or Self ins. Lie. ': Expiration Date:
Job Site Address: City/State:'Zip:______
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. 151 §25A Is a criminal violation punishable by a tine up to S1,500.00
andlor one-year imprisonment,as well as civil penalties in the form ofa 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 under the pains and penalties of perjury that the information provided a correct.re 's true and
Signature: Date: I. 4, 2 2--
Phone 4: Le/3 CrIt' /2z 7
Official use only. Do not write in this area,to be completed by city or town officiaL
C'it♦ or Town: Permit/license#
issuing Authority(circle one):
I. Board of Health 2.Building Department 3.('ityiTowa Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#: