18D-053-179 BP-2022-1325
80 DAMON RD#7206 COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
18D-053-179 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-2022-1325 PERMISSION IS HEREBY GRANTED TO:
Project# KITCH/BATH RENO Contractor: License:
Est. Cost: 10000 TODD PEASE 101384
Const.Class: Exp.Date: 01/27/2024
Use Group: Owner: MIRIAM BEREZIN, ILENE
Lot Size (sq.ft.)
Zoning: URC Applicant: PEASE HANDY MAN SERVICE
Applicant Address Phone: Insurance:
4 STILL WATER (413)216-1471 2001W6829
SOUTH DEERFIELD, MA 01373
ISSUED ON: 10/14/2022
TO PERFORM THE FOLLOWING WORK:
KITCH/BATH 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 VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
ji y •
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
FC E I VCC-——-
r______IR E--- --------
The Commonwealth of Massachusetts I OCT 1 !i 20k2 W FO
Board of Building Regulations and S ' dares
Massachusetts State Building Code,7 C C ALITY
US
OF be�N
Building Permit Application To Construct,Repair,Ren iPEc7�ytved ar 2011
o,A
One-or Two-Family Dwelling "" -so
This Section For Official Use Only
Building Permit Number: 6 P ZZ-)3 3-,5 ' Date Applied:
iIEU,,-541.s �� 10-Pi-2Ozz
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: extort^
mak 1.2 Assessors Map&Parcel Numbers
$o aretrv,N Rik UNt 7146
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(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❑ Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
tiP. 95e -eZ.n fDct w plan All4- Oilb G
Name�l (Print) City,State,ZIP
e norK el c•i- aA VI)-510-N-V` TjtAt heft zi4)LMt4.4'.rOr'
No.and Street Telephone Email Addre
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 11 Alteration(s) Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units _ Other 0 Specify:
Brief Description of Proposed Work': •ti 4 11. e'✓
1r4rvI /.., ox l P 1 - ."i4 (Dole t.'
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ gogp.G- 1. Building Permit Fee: $ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $
iGov'aG 0 Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ `GOG, cz, 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $Suppression) Total All Fees: $
Check No.2.S)1Check Amours : Lt(9 Cash Amount:
6.Total Project Cost: $ (Tao'- v ❑Paid in Full 0 Outstanding Balance Due: _
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) cs - (0(31.y 1 Ga y
License Number Ex iration ate
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
,/y/� J- U Unrestricted(Buildings up to 35,000 Cu.ft.)
cX/ Y ��7 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
0' �, RC Roofing Covering
V WS Window and Siding
SF Solid Fuel Burning Appliances
(�^ Q1t o - (v/) 6 T'4d Ptiot .,i 1.`AN I Insulation
Telephone Email address •1 D Demolition
5.2 Registered Home Improvement Contractor(HIC) `��,�, 3
QL�i 1 L HIC Registration Number Expira ion Date
ji
HIC Company Name or HIC Registrant Name
V suit �.,r"►-( RA Tawec )(�6) art"'No.and Street 1. c
SAh kt i-.Ca 4 a1'S71) /l3 - 011 v '6/)G Email dress
rk
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 Issua 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 0 er of the subject property,hereby authorize 1'IlM P C
to act on y behalf,in all matters relative to work authorized by this building permit application.
X a'Ieh e_ er A )0/4 c2 oac)-
Print er's Name(Electronic Signature) ate
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.
idvk gerpo .
Print Owner's or Authorize 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"
City of Northampton
o[NAMxro\
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'�''' Massachusetts ,./ . s,,f`
m: M i
fl� .4:!i(YL:s DEPARTMENT OF BUILDING INSPECTIONS �\
..ry, :. r 5.,
• 212 Main Street • Municipal Building J., a
1 Northampton, MA 01060 6sr ^0P
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: �(� G�h S
Location of Facility: V t ii3 I-v.43d e
The debris will be transported by: T Plei ft
Name of Hauler: T Q6 Sa
Signature of Applicant: a pill Date: I°//y/vICa&
f
The C'ontmontvealdt of alassachusetts
Department of Industrial Accidents
_:�► );) 1 Congress Street.Suite 100
�-'� Boston, MA 02114-2017
wtvty ntass.go►/dia
11 or kers'Compensation Insurance:5ffida%it: Buildersit'ontractorsJElectriciansi lunthers.
I(I Ili. F!LLD 111 I II I lIE PF:RMI fl'ING At I DOR1Tl
Applicant Information y� Please Print IA—gilds
Name l Husincss Organization Individual): ( A se_ 7 tr►�� tt� SU i',jt
Address: / S+rt( (,erc t C (Z,/
City/State/Zip:Sctit11 4011_4•C�iIA M Phone#: (// z — -
Art yells nn ettapb)tr!Clerk the appropriate but:
d) Type of project(required):
I.Eram a en toyer with V employees atilt and'or part-tinsel.'
7. 0 New construction
2.01 am a sole proprietor or partnership and hate no eirtpluyci.s working for me in
8. tErtemudeling
a7ty rapacity.[Nu uurkcmti'curnp,insurance required.]
9.
30 I our a homeo ra%xwner doing all work myself.[No workers'comp.i ntr rcn{niirtzl_J ❑ Demolition
4.o 1 am a homeowner and will be hiring contractors to conduct all wok on my property. I will ! Building addition
ensure that all contractors either hate workers'eon i''minion insurance ire are sole I I.LJ Electrical repairs or additions
proprietors with nu employces-
12.0 Plumbing repairs or additions
50 1 am a generat contractor anti 1 hate hired the sub-contractors listed on the attached sheet.
These sub-contractors hate employees and has c u orkers'comp.insurance.; 110 Roof repairs
6.0 We ace a aurpuratrun and its officers has a exercised their nght of exemption per AKiL e. 14.0 Other
152,y 1141.and we have nu employees.[No stinkers'coup.insurance required.]
'Any applicant that cheeks boa.al must also fill out the section b:lust show ing their workers'compensation policy information.
Homeowners uhu submit this atlidasit indicating they are doing all stunk and then hire outside contractors mint subnut a new affidavit indicating
Contractors that check this but must attached an additional sheet showing the name of the sub-contractors and state w hither or not those entitle,lime
emnployees lithe sub-contractors haw employees.they must itie their workers'cutup.policy ixuoal,tr
I am an employer that is providing tvorhers'compensation insurance for nit employees. Below is the policy and job site
information.
Insurance Company Name: ci.(t'ts. Poi AN,,II 1,1 S
Policy#or Self ins. Lie.#: aOO( (,t)G.ea c) Expiration Date: 3/44 /01G01-3
Job Site Address: Bo ,k_. (hit City/StatelZip: jitz T11.y�n m�-
Attach a copy of the workers'compensation policy declaration page(showing the policy number and piratlon date).
Failure to secure coverage as required under MOL c. 152,*25A is a criminal violation punishable by a fine up to S1,500.00
and.ior one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a
day against the vtolator.A copy of this statement nay be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
1 do hereby certify muter the pains and penalties of perjury that the information provided above is true and correct.
Sienature: t HC� 1 �� Date. /'/i
Phone r: f/i3 -- c 2/0 ' 72/)
Official use only. Du not write in this area,to be completed by city or fawn official
('it% or Toss a: PermitiLicensc#
Issuing Authority (circle one):
I. Board of health 2. Building;Department 3.C'ityfll own Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
('intact Person: Phone#:
NOTICE , z E NOTICE
It I
TO =` = TO
r��err �r
EMPLOYEES 41/44 nit
► j EMPLOYEES
., ti
1.11°
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900- http://www.state.ma.us/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice
that I (we)have provided for payment to our injured employees under the above-mentioned chapter by
insuring with:
Farm Family Casualty Ins. Co.
NAME OF INSURANCE COMPANY
(11 P.O. Box 656,Albany, New York 12201-0656
ADDRESS OF INSURANCE COMPANY
2001W6829 03-26-202
POLICY NUMBER EFFECTIVE DATES
g TIMOTHY F VILES 55B N MAIN ST, S DEERFIELD MA, 01373-1059 413-665-8200
NAME OF INSURANCE AGENT ADDRESS PHONE#
TODD PEASE 4 STILLWATER RD, SOUTH DEERFIELD, MA 01373-9776
EMPLOYER ADDRESS
EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the ser-
vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are
hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER