22D-108 (7) BP-2022-1264
25 AVIS CIR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
22D-108-Q01 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-2022-1264 PERMISSION IS HEREBY GRANTED TO:
Project# DECK REPARS Contractor: License:
Est. Cost: 10000
Const.Class: Exp.Date:
Use Group: Owner: LEONARD ANDREW J& SHERSTEN KILLIP
Lot Size (sq.ft.)
Zoning: WSP Applicant: LEONARD ANDREW J& SHERSTEN KILLIP
Applicant Address Phone: Insurance:
25 AVIS CIR
FLORENCE, MA01062
ISSUED ON:10/05/2022
TO PERFORM THE FOLLOWING WORK:
REPLACE DECKING,RAILINGS AND STAIRS
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 �
4 • JriT
Fees Paid: $65.00
212 Main Street,Phone(413) 587-1240,Fax:(413)587.1272
Office of the Building Commissioner
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR MUNICIPALITY
USE
Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: c P 3 a- 1 7,C.I Lf Date A plied:
I •
A/4_02Building Official(Print Name) I Signature
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1-� ,Vi Gll-G(e Ft xeince, Ma. .7-DS) 1 O$
1.la 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(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
g2$tL3o` 72
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 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP1
2.1 Owner'9f Record:
rew CSOltAlr)C F(e(Zw(Q AMA v10( A
Name(Print) City,State,ZIP AnIrto �AV) CI'c Cs- Z4-&rsq L�brttr)
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 Work': P4k44 j14 L�°LK�n j 62(Aile ilj j s -eciTS,C'- (Kim-,
5cr v* i'prw+1,t tl
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ `bJj,/.X2 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 Fees: $ 43 ' 1�
Check No.I6`I Check Amount:
6. Total Project Cost: $ iC?0oo.00 0 Paid in Full 0 Outstanding Balance Due:
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 cu.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) .�( Z
n Lh*-KS gawp e .0 Nt rtotrevne�t 45— v3 L3
HIC Registration Number E irat on Date
1tctYC Company Name or HIC gistrant Name
u7a wtiq (Actin v.A. * vain orrn5&&442(4(.cor1
LeYer o)1.14t QlOst'4 t')(3"74g- ,��gZ 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 .. . ❑ 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.
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• this application is true and accurate to the best of my knowledge and understanding.
Or-Q.kio Leol,I0A to/3 2Z.
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"
g
The Commonwealth of Massachusetts
I. =. lill I.111111.111111111 1 Department of Industrial Accidents
.� 1 Congress Street,Suite 100
r
4: :t== Boston, .$1.-10211 A-2017
1rC' WwW.mass.gov/dia
11 hikers' (*compensation Insurance.%fliidas it: Builders/Contractors)kctriciansiPlumbers.
to BE FILED 1%fllt .1 lit: PER1111111G At4110R1Tl.
Applicant Information Y� Please Print Les•ibly
Name(Business,OrgfanvationlIndtvidual):__ I r zv3 L..c:(Poi(
Address: "z 5 Avis Ci r k. 1
City/State/Zip: cI QCe'4(4 M, O I D 6 zr Phone#: L( 13` 7'Z 7-- p5
Are so.an employee'Cheek the piste bas: Ty pe of project(required):
1.0 1 am aesnelrry cr with _employees(full and or part-time)..'
7. 0 New construction
20 I sat a snk proprietor or partnership and hasc no cmpin;LLs noticing tut art in $. 0 Remodeling
any capacity.lNo workers'comp-insurance required.(
9. 0 Demolition
0 I am a homeowner doing all work myself_INo workers'comp.insurance nyuiredi"
10 Q Building addition
4.�1 am a hrmcowner and will be hiring a imacturs to conduct all Murk on my poverty. I will
ensure that all contractors ctors elitism.hat♦^workers"comp rts:dim imuranci or arc sole 11.0 Electrical repairs or additions
proprietors with no cnloyccs.
12.0 Phimbtng repairs or additions
5.0 I am a)moral contractor and I}Luc hosed the rub-contractors listed on the attached Acct. 13❑Roof repairs
These sub-contractors ha►c employee and base woken'comp.insurance.; �p
6.0 We are a corporation and its officers have%Ain-6scd their right of exemption per »L c 14.ri)oth�l ,(� eat _--
151 yo li 4'i.and we base no carnplurces.Iyo workers'comp.insurance rtquired.I
'An►applicant that clicks box+*I mast also fill out the scctiun below showing them workers.comp:roatxrr policy informaiwn.
Huniou sirs who submit this aflidaait indicating they are doing all work and then hue uursrdc contrnturs--mlYet eabatit a new affidav midi.it indicating su .
:Contractors that check this brit must attached an additional sheet showing the name of cite W b-ctntrarj wa and state whether or not those caddies.has
employees. Iftha sub-contractors hale crnployms.they must pnsidethen workers`cores}.pinto}numnhcr.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: _,— - --- —
Pokey#or Self-iris.Lie.#: Expiration Date:
Job Site Address: CityStat&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. 152.125A is a criminal violation punishable by a fine up to$1500.00
an for 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 Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under t e cats and penalties o f perjury that the in formation provide oho'e is true and correct
Signature: ^41 Date:
3 �.Z:
�U is _
Phone#: L' I S''7 Z- . -Q j c r l
Official use only. Do not write in this area. to he completed by city or town officktL
('its or Toss n: Permit/License#
Issuing.authority, (circle one):
1. Board of Ilealth 2. Building Department 3.('ity;Tosn Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other_
( intact Person: Phone*:
\)
City of Northampton
<`,17:144,.f� ��`s .w. Sir
,A4' Massachusetts '<<
* • G
w .S DEPARTMENT OF BUILDING INSPECTIONS ,
Y� � ///' 212 Main Street • Municipal Building yJd., a
�� Northampton, MA 01060 1:ry ;-^ '�'°
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: USA- L1et-S+e cuA ( cyAril
og
The debris will be transported by:
Name of Hauler: [-fttittAY(A./vhKS (t>,01{;e( O III
Signature of Applicant: AilI Date:
6'
City of Northampton
Massachusetts 1
IC
DEPARTMENT OF BUILDING INSPECTIONS
Svt �
212 Main Street • Municipal Building
Northampton, MA 01060 • •'�0
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT HI.be
AtA, (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 ' 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 •meowners'
exemption, does not involve the field erection of manufactured buildings constructed in ac • dance with
780 CMR 110.R3.
3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR '10.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 detach-• structures
accessory to such use and/or farm structures. A person who constructs more than o e 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 e, tent that I
qualify for and will abide by the Massachusetts State Building Code's requirements for the pervision of
the project or work on my parcel, I am not engaged in construction supervision in connec '•n 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 proje or work on
my parcel,I acknowledge that I am required to and will act as the supervisor for said project • work.
Signed under the ,'i s and alties of perjury on this 3 day of �c �2, , 20 2a.
1 1 'Lk.
(Signature)
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