30B-001 (2) BP-2022-1355
132 WARNER ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
30B-001-001 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-2022-1355 PERMISSION IS HEREBY GRANT. D TO:
Project# ROOF Contractor: License:
Est. Cost: 2000
Const.Class: Exp.Date:
Use Group: Owner: GONSKI IRREVOCABLE TRUST
Lot Size (sq.ft.)
Zoning: URB Applicant: GONSKI IRREVOCABLE TRUST
Applicant Address Phone: Insurance:
132 WARNER ST
•
FLORENCE, MA 01062
ISSUED ON: 10/19/2022
TO PERFORM THE FOLLOWING WORK:
STRIP AND RE-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 VIO I ATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
r • S. ► ) •
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
411,
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: 8 p_ a .•1-355 Date Applied: _
Building Official(Print Name) Signature 'I D to
SECTION 1:SITE INFORMATION
a RINI 't 1.2 Assessso s Map& Parcel Numbe of
1.1 a 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 0 Private El _Zone: Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
M3bse Ql4 (reAs sKl FLO1 c e, rr7r9., o I o
Name(Print) City,State,ZIP
3a w Alt OM Sr. q,3-59y-y xi?3
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 ❑
Demolition 0 Accessory Bld . 0 Number of Units Other 0 Specify:
ftoor , R e 0.1c4C- 34p179Les
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:
0 Standard City/Town Application Fee
2.Electrical $ — 0 Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) Total All Fees: $
Check No. Check Amount:*4
a 006 0 Paid in Full 0 Outstanding Balance Due:_
p
City of Northampton
Massachusetts
0 1 DEPARTMENT OF BUILDING INSPECTIONS v°
212 Main Street • Municipal Building
Northampton, MA 01060 sib,
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 specifications 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. Home owner's License Exemption Form (if applicable).
8. Note any Special Permit requirements (if applicable).
9. Energy Code —all new construction(Gut/Rehab) requires a HERS Rater Affidavit
10. Please provide the appropriate fee in the form of a check made payable to: The City of
Northampton.
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)
HIC Registration Number Exp ation 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.§ 25 4(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure t s provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes 0 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 in this application is true and accurate to the best of my knowledge and understanding.
abseem (ro))SK 1 _' 10
Pr c Si e), Date 4
NOS:
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"
=72, The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
. 1/4ctr Boston,MA 02114-201 7
www.mass.gov/dia
1141/kers Compensation Insurance Affidavit:BuddersiContractorstElectriciansfPlumbers.
TO DE FILED WITH THE PERMITTL•iG AUTHORITV.
Applicant Information Plense Print Legibly
Name(BusibesslOrgantzation.
•
Address:
City/State/Zip: Phone#:
Are yea an employer',Cheek Obt appropriate but
Type of project(required):
1.0 I am a employer with erriployces tfull arat or part-time L* 7. 0 New construction
2.0 I am a sok proprietor or pantos/tip and have no employem working for Me 111 8. ci Remodeling
any capaxity.[No workers'comp.tristuaraxv• nitquireri]
9. D Demohtion
Avl i am a homeowner doing all work myself[No workers'comp_insurance required_J
10 0.Building addition
4.01 am a homeowner and voitl be hiring contractors to conduct all work on my property. I will
ensun:that all eontracturs either have workers'conwerisation insurance or are sole 110 Electrical repairs or additions
propocto.rs with no eniployecc.
12.0 Plumbing repairs or aiklitions
5.1:3 arta a gimeral contractor and I have hired the sub-eontructors listed on die anadied thect_
131:Roof repairs
These gb-COMM:WM have employees and e*triers'comp.insurance.,
14. er
6.0 We are a cog:rotation and its officers have exercised their right of exemption per MIGL c. 0 Oth
151,tlt41,and we have cio employeea.[No workers'comp.instaance required.'
'Any applicant that chunks box#1 most Also fill out the S•eir.lAnt 3auwinu their workers'compensation policy information.
liomeowners who submit this atiedasn indicating they are doing all work and then hire outside contractors mum submit a new affidavit indicating stich.
%Contractors that cheek this box must attached an additional sheet showing the name of the sub-ceattractors and suite whether or nut those entium ha.oe
employees.. lithe suh-coritracturs FLIVC eiriplo!..:1-71.they must provide their workers'comp.policy number
I am an employer that is providing worAers'contpensozion insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: 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. 152, §25A is a criminal violation punishable by a fine up to S1,500.00
andior 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 violator.A copy of this statement may be forwarded to the Office of Investii thins of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties ofperjatry that the information provided above'iN !rue and correct.
1111111k1"-IsliA )A.672.4,1>
()//i,ad use only. Do not write in this area,to be completed hi city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
'ontact Person: Phone#:
City of Northampton
4:047.4.1/4,
Ai:!-' t Massachusetts
R � *-M
�� �s DEPARTMENT OF BUILDING INSPECTIONS t
212 Main Street • Municipal Building—'• Northampton, MA 01060
DEBRTS3`i w
(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: �. 34 TN Pit)Al )2v(44 )//u.TJ1A.$)?rt21/ N) ,
The debris will be transported by:
Name of Hauler: ‘Lg1LEy grcyZ4,1•9 G
Signature of Applicant: ..34, ,C ,u Date: d 0_71 J4r,_)Dc,2 a
City of Northampton
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�jr DEPARTMENSPECTIONS x
I.#11 ,,, "Ja 212 Main Building _,, �tr
Northampton, MA 01060 `�.; `'^^-- 1'"
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)
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, �(� ‘\ C7O nsl (insert full legal name),born S �
(insert month,day,year),hereby depose and state the following:
I.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 / 9 day of deft. a ,20 AP.
•
(Signature) '-.4‘1"1124- -)1"141'
https://www.mass.gov/doc/homeowners-exemption-affidavit-sampledocx/download 10/18/22, 8:18 PM
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