24D-284 (13) BP-2022-1143
186CRESCENT ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
24D-284-001 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-2022-1143 PERMISSION IS HEREBY GRANTE JP TO:
Project# ROOF Contractor: License:
Est. Cost: 3000 ERIC PAYNE 086442
Const.Class: Exp.Date:01/22/2023
Use Group: Owner: ANN GOODRICH, TARA
Lot Size (sq.ft.)
Zoning: URB Applicant: ERIC PAYNE
Applicant Address Phone: Insurance:
32 BURTS PIT RD (413)218-4276
NORTHAMPTON, MA 01060
ISSUED ON:09/13/2022
TO PERFORM THE FOLLOWING WORK:
NEW PORCH ROOF
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:
• y2 (Pi •L.
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
�J
Sep
The ommonwealth of Massachusetts
3 2 oard f Building Regulations and Standards FOR
SE
\ , FBU 202 assa husetts State Building Code, 780 CMR MUNICIPALITY
RTygv,itivri
t Ap lication To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
�N'MA 0=P NS / One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number:m� ,P— .).a. -//� Date Applied:
/il
ikvuv4Z5 __ !/Z (1- /3-2bzz.
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1� 1.2 Assessors Map& Parcel Numbers
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
1
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 CI Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 0
Check if yes CI
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Tq.v G,00�w� ', (46 fo CCt t5 C--GN^
Name(Print) City,State,ZIP
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 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: (/\e,W D r J GAr i—p p€
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 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 • $ Total All Fees: $ .
Suppression)
Check Nail Check Amount:
6.Total Project Cost: $ 2)b O 0 Paid in Full 0 Outstanding Balance Due:
Iiiiiiiiiir
City of Northampton
Y' Massachusetts 4 .4\ '''
t d iZ DEPARTMENT OF BUILDING INSPECTIONS
Qr 212 Main Street • Municipal Building sib,
�D
m. > a� Northampton, MA 01060 j'sj , . �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 specification 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. Homeowner's License Exemption Form(if applicable).
8. Note any Special Permit requirements (if applicable).
9. Energy Code-all new construction(Gut/Rehab)requires an HERS Rater Affidavit.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Sup rvisor License(CSL) '1 - C ty— C/ License Number E ir2atio Date
Name of CSL Holder
3 L ? ,tN S ` List CSL Type(see below)
No.and Stree '1 Type Description
N ��"1 W `C�� U R 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
/ Srolid Fuel Burning Appliances
4p / F
tA ,c Insulation
Telephone 1 E it address D Demolition
5.2 Register Home Improvement Contractor(HIC)
d ' `� HIC Registration Number Expiration Date
HIC Compan ame or HIC Registrant Name
No.and Street Email 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 Issuance of the building permit.
Signed Affidavit Attached? Yes 0 No ifk
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 c v , L m_ V\SIL._.---
to act on my behalf,in all matters relative to work authorized by this building permit application.
46,(J 1 z/z Z.
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 plication is true and accurate to the best of my knowledge and understandin
hitys �J(i, i !i -2-
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
2....*•.=._ _
Department of Industrial Accidents
.....1.,,,,:x I.= ..,.?
1 Congress Street,Suite 100
c_ 7. •.4;) Boston,MA 02114-2017
kc
WWW-mass.gov/dia
1 0)kers' (Unipensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
10 HE FILED WITH THE PERMITTING ALITIR/RITI-.
Applicant Information Please Print I.egiblv
Name(Business,Orlpulizationi Indivickut1): 19'N k e_.... 1,cs-i‘ .--‘9 --
..,---
Address: 3 2- 1)0 i
C ny/State(Zip: 1\1 • 1.1•0.,,-- Phone#: It')3 IA s 47--th
kre you as employer?Cheek die approprkate boa: Type of project(required):
LO I am a employer with employees MO arukor ptut-tirne i.• 7. 0 New construction
L'.211 am a wit prupriekar or partnership and have na employees*orking fur me in 8. 0 Remodeling
am ,...ipaetry,[NO workers'comp.manner required]
. DIn I am a fionsouwrier doing all work myself[No*oilers'comp insurance required.]' 9 Detrrolition
le 0 Building addition
-4.71 I am a homeowner and will he hiring ountracturs to conduct all w ork on my property.. I*J1
ensure that all contractors either have worker.'Ceeriperts3host insurance ur an.-sulc 1 1.0 Electrical repairs or additions
propnctors with no employees.
i.2.0 Plumbing repairs or additions
50 I km a general contractor and I hate hired the sub-contracturs listed on the:toadied sheet_
, I 3.0 Root repairs
Tbese tob-corarstiors have employees and hav e workers'comp.insurance.;
6.0 we are a corporation and its offiters have exercised their nen of elemplautt per 1114GL c. 14.0 Other
152.4}1(4),and vs e.have no employees.[No workers comp_insurane.e required.]
•tr,, applu_anl!hut,hecks bek 21 must also till out the section below mho*ing their workers'Co tripens.alit;polity infonna6un
lioneow ber.ss he submtt this attichr.it mdicating they are dome all ..,urk and then hue otonde contractors=Weil submit a new allitLi‘,IE maticaLu25 sts:11.
:Contractor%that check this bus.must attached an additional sheet mho%ins:the name of the sub-euntraeuirs and state whether ur nut those entities hase
,miployern, It'd*sub.contracturs 11.1'....7 Orlpil)!1.7C%.the:, ntusi pros de umr .... 14..,:rh ,..v-mr.is.,liu:,number_
--a----.....---
1 am an employer that is providing prorAer.s'compensation insurance for my employees. Below is the policy and jab sic
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Daw:
Job Site Address: City/StateiZip:
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$1,500.00
an&or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S230.00 a
day at.tainst the violator.A copy of this statement may be forwarded to the Office of Investigations of the DR for insurance
co'erage verification.
I do hereby certify under the pains and penalties of perjury that the Information provided abv re i.' tit e and correct.
4` Siviature: (....-°- ON6----------- Date:
Phone 4:
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Permitil.icense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Yawn Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
r1:'o
City of Northampton
Massachusetts 4,, .. 'e
1,1 '• Ii toi 1DEPARTMENT OF BUILDING INSPECTIONS . n,,
s 212 Main Street • Municipal Building vx, ��'
' Northampton, MA 01060 `r'Xy1 :�1"I''
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 Ie ( —
Y V
The debris will be transported by:
Name of Hauler: 1-1 ‘,C
Signature of Applicant: �/ Date: �, �L
City of Northampton
oiotiAm ' _ Ns ".H.,S�
4
' Massachusetts
mt
DEPARTMENT OF BUILDING INSPECTIONS
' 212 Main Street • Municipal Building y>. ,-e'b
m., ba Northampton, MA 01060 �"•--'""'c`ti®
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)