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10B-031 (5)
BP- 022-1242 I EVERGREEN RD COM MONWEALTH OF MASSACHUSETTS Map:Block:Lot: 10B-031-001 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-2022-1242 PERMISSIONISHEREBYGRANTE TO: Project# Contractor: License: Est. Cost: Const.Class: Exp.Date: Use Group: Owner: LENNOX ANANDA M Lot Size (sq.ft.) Zoning: URA Applicant: LENNOX ANANDA M Applicant Address Phone: Insurance: 1 EVERGREEN RD LEEDS, MA 01053 ISSUED ON:09/30/2022 TO PERFORM THE FOLLOWING WORK: VYNIL SIDING 2ND FLOOR ONLY 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: I • 11 >2 - 311 Fees Paid: $60.00 • 212 Main Street, Phone(413) 587-1240,Fax:(413)587-1272 Office of the Building Commissioner C E'l I%-- i"--) r he Commonwealth of Massachusetts // 31 P 2 9 Bo d of Building Regulations and Standards FOR Ait r�a: {`' Q�Z M ssachusetts State Building Code, 780 CMR MUNIUSE TY W..° No Ty��k /N :4*It. ' mit pplication To Construct, Repair, Renovate Or Demolish a Revised Mar 011 ��~ °tv —_ ooso°Ns One- or Two-Family Dwelling _�'`— This Section For Official Use Only Building Permit Number: go^ •I Z 2_ Date Applied: f / q,2, . , '�, _- Building Official(Print Name) Signature SECTION 1: SITE INFORMATION 1.1 P rverty Address: �� L ns L 1.2 Assessors Map& Parcel Numbers 1.1a Is this an accepted street?yes 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: Publice Private 0 Zone: — Outside Flood Zone? Municipal 1:21/On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 O ner'of Rec d: —✓l..v.i•tY 6. /-2 ✓t 4, l e ed5 i Name(Print) City,State,ZIP No.an SStreet � elephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building`t_ Owner-Occupied ❑ Repairs(s) VL_I Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': V 411 5 , it :ks il , a,4 F iraoRad V SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 1. Building Permit Fee: $ Indicate how fee is deterthined: 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:• f� Check No. (,d01 Check Amount: �U" Cash Amount: 6. Total Project Cost: $ 1 0 Paid in Full 0 Outstanding Balance Due: O anC,O Lellna)( 0SfYtek,tig CzYY\ SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 ci.ft.) R Restricted 1&2 Family Dwelling City/Town, State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiratiot}Date HIC Company Name 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 ❑ 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. 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. yv,. ' ! Zq /2 Z Date 1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contactor (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 fokznd 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 1==== Department of Industrial Accidents • =' = 1 Congress Street,Suite 100 ;�; Boston,MA 02114-2017 :...a. sec V. `•, r' www.mass.govldia 11�„kern'Compensation Insurance Amdavit:Builders/Contractors/Electricians/Plumbers. TO RE♦ILLD WITH THE PERMITTING.AUTIIORIT . Applicant Information Please Print L ibis Name(Susiitiess'UrganezatiotuindivicluaI): _ x Address: City/State/Zip: Phone #: Are yes as employee Cheek are appropriate bet: Type of project(required): 1.0 I am a employer with__,_....,_employees(full andior part-time).* 7. Q New construction 20 I am a sok proprietor or partnership and have nu employers working for nit in K. 0 Remodeling capacity.[No workers'catt...insurance required.] irczy I am a homeowner doing all work myself.lNo workers.'eatery_insuraoe required_)` 9. ©Derttolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will I a Building additio,y emote that all ocwara tors tither have workers'compensation uisurancx ex ate sole l I.p Electrical repairs or additions prupnetors with no employees_ 12.0 Plumbing repairs or additions so I am a grnctd contractor and I have hind the sub•contracton listed on the attached sheet 13.0 Roof repairs These auheonirnctors have employees and have vvorkesri romp.insurance.: L,.l 6.0 We are a coapa tun and its officers have exercised their right of excerption per tiici e_ 14. Other r 15,2,§114),and we have no employees.[No workers'comp.insurance required] *Any applicant that checks box.1 mast also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hue outside Coniraetues rntrO submit a new a risks it indicating such. $C ontraetorta that check this boa must attached an additional sheet showing the name of the autrcuntraetarx and state whether in not those entities hese employees_ if the tub-contractors lose employee*,they must provide their worker*comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the polies and job site information. Insurance Company Name: Policy#or Self-ins.Lie. K:_ Expiration Date: Job Site Address: City/StatetZip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and cipi don date). Failure to secure coverage as required under MGL c. 152.§25A is a criminal violation punishable by a fine up $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form 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 ft. insurance coverage verification. do here • y under the pains a penalties e/perjart'that the information provided above a is trueand itmature: .� ' ' / / z Phone Z: Official use only. Do not write in thi+urea, to he completed by city or town official ('its or Toss n: PerntitlLicense q Issuing Authority(circle one): I. Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing I ector 6.Other Contact Person: Phone#: City of Northampton 0 TmL�t'1 S Massachusetts• x- s •.' y DEPARTMENT OF BUILDING INSPECTIONS ;_ 212 Main Street • Municipal Building J� - •" ." Northampton, MA 01060 PS 4 3PDN HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT I, �na-nak Lennox (insert full legal name), b. i sert month, day, year), hereby depose and state the following: 1. I am seeking a building permit pursuant to the homeowners' exemption to the permit re, irements of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a pro ect 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 homeo ers'exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 MR 110.R3. 3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110."5.1.2: Person(s)who owns a parcel of land on which he/she resides or intends to reside, on w 'ch there is, or is intended to be, a one-or two-family dwelling, attached or detached structures access.ry to such use and/or farm structures.A person who constructs more than one home in a two-year pe od shall not be considered a home owner. 4. I do not hold a valid Massachusetts construction supervision license and, except to the extent hat I qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision oft • project or work on my parcel, I am not engaged in construction supervision in connection with any project o work involving construction, reconstruction, alteration, repair, removal or demolition involving any activity egulated 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 proje 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 '2ti day of S` "` ,20?�r (Signature) tMp City of Northampton o cH9 >o `S .,G. s, F t, Massachusetts a�+s - w' : I( , fi, � ( p DEPARTMENT OF BUILDING INSPECTIONS S 4' I y „� 212 Main Street • Municipal Building Jtis �'a Northampton, MA 01060 on Arp � (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: Va-<< ' ac The debris will be transported by: Name of Hauler: Se\f pp Signature of Applicant: ON-i-Jsk- r`c Date: 1 / Z� ( 2Z g