31A-297 (4) BP-2022-1498
94 VERNON SI COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lo
31A-297-001 CITY OF NORTHAMPTON
Permit: Alts Re ovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2022-1498 PERMISSION IS HEREBY GRANTED TO:
Project# SHOWER Contractor: License:
Est. Cost: 6000 ROBERT GOULD 90940
Const.Class: Exp.Date: 02/19/202302/19/2023
Use Group: Owner: A BUTLER STEPHEN&CHERYL
Lot Size (sq.ft.)
Zoning: URB Applicant: ROBERT GOULD
As s licant Add ess Phone: Insurance:
62 LYMAN S 413-531-1391 SOLE PROPRIETOR
GRANBY, M 01033
ISSUED ON 11/16/2022
TO PERF I'RM THE FOLLOWING WORK:
REPLACE 2ND FLOOR SHOWER
POST THIS ARD SO IT IS VISIBLE FROM THE STREET
Inspector of PI mbing 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 PER II T MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF IT' RULES AND REGULATIONS.
Signature:
'1`6144±1 , .)2 - TI)JIT
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
1 RECEiV L _ : i
1
NOV 1 5 2022
DEPT OF nUILDINC INSPECTIONS
NORTHAMPTON,MA°T h Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
i'll 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
Buildin Permit Number: 4J- I' Si 4 9 Date Applied:
EVIts) K 4,s 4 11-15-2022.
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
fe >J mob.- -5 - 3 LA- a0f ?
1.1a Is thin 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.f 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
6\ F1 ,_ 'A .
Name(Print) City.State,ZIP
91"1 ✓e si 413 s84.- (.1G.)
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) Iii- Alteration(s)'. Addition 0
Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify:
Brief Description of Proposed Work':^- ed, ''t L..e a¢•.4-Q
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use
(Labor and Materials) Only
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical ` $ �� 0 Standard City/Town Application Fee
0 Total Project Cost;(Item 6)x multiplier x
3.Plumbing `$/,0),------` 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5-Mechanical (Fire $
Suppression) Total All F��11
Check No.l?%U 1 Check Amount. Cash Amount:
6.Total Project Cost: $ CO.c", 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Con ruction Supervisor License(CSL) CS—OVWC7
k— C____ License Number F prat on Date
Name o L Holder
�e•--- List CSL Type(see below) 3
No.aqd S et Type Description
[C7 `�� U Unrestricted(Buildings up to 35,0t)O cu.ft.)
R Restricted l82 Family Dwelling
City/Town State.Z M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
y/3 sc3( I o n biGdv 2- t ► i E i t . .C-c7�, I Insulation
Telephone !!J % Email address D _ Demolition
5 Home Improvement Contractor(I3IC) J3 o
e�4 ...,--(—red - C..— C�t-D � I IIC Registration Number Expliration Date
HIC Company Name or HIC Registrant Name
No.and Street -- Email address
...q0./ ........_
City/Towa.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
r
i,as Owner of the subject property.hereby authorize f L-(1-0 Q)\
. to act on my behalf,in all matters relative to work authorized by this building permit application.
/I— /0- Sa.
Print Ow -s me(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.
l 0/D _____
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
Information on the Construction Supervisor License can be found at
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 o"bathroomsNumber of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Tota Project Square Footage"may be substituted for"Total Project Cost"
City of Northampton
`�1jrJ~
>� Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
�� � . 212 Main Street • Municipal Building
oar
Northampton, MA 01060
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: jQiia.
The debris will be transported by:
Name of Hauler:
Signature of Applicant: Date: // / ^O
The Commonwealth of Massachusetts
__'W Department of Industrial Accidents
"' 1 Congress Street,Smite 100
Boston, ,VA 02114-2017
' r ww.mass.gov�fdie
llurkers'Cosiptesoities Insurance:#ffidtavit:BuildersiContractersarketticiassiPlollibrri.
TO BE FILED W I ill I lIE PERMUTING AUTHORITY.
Applicant Information Please Print I-et ibly
r ;'(Business'(k antzatiun'Indiridinah• lC�l�G-d- ` ‘.... -/1-,:4. y
City State/Zip: (-7, _AtcA ��
Phone�- L S-' 1
I. 11
Are sr employee Caleti the q�i se
Type of project(required):
1.$ I a employer with ...-- tznployees(fall andrur part-timel.' 7. 9 New construction
I/ I m a sole prupnetvx or partncnhap and have no employees working for me an 8_ 0 Remodeling
,,,capacity.[Nu workers'comp.tivan:aratx remons.j [[--��
30I a lumaeawner doing all*ink myself.[No*otter'tuner insurance required.)' _ 7 Demolition
4.01 m mrrtwtrran a Inaer and will bar hiring work eandutt all tar mypoverty. I will I 0®Buildingaddition
.,.the that all contractors either have wtakerri'compensation insurance tar ate role I I Ekctric.al repairs or additions
.. netors with no employees.
12.0 Plumbing repairs or additions
5.Ci 1 m a general euntratior and I have hired the sub-contractors heated an the anadiet/shut BO RQ[►f repairs
se sub-cuntractors have employees and have workers"camp.insurance.:
6 area a a corporation and its officers base exercised their right o f ex arrptioa per NC r. 14, Other'
I.2.f 1i4it and we haw no employers.[No workers'comp.insurance minimal
*Any , team that th r:k.ai bast al!Hint also till out the seetuan hank show in then ti cirkers'compensation pulled information
t Ilionatta m-rs vaho submit this aft-Ann iathcatunt!they are drams all work and then hue outside contractors moist submit a new affidavit inalicating such.
tCori vac, _that check thru bat muse attached an additional sheet sho*em the name u-I the sub-contractors and state is bettrx or not those entities hase
employer, If the sub-contractors havc calptuyees.they must plus ide their workers'tramp.policy ntnnha:r-
I am an employer that is providing workers'compensation insurance for my employees. Below is the polity and job size
information.
Insurance Company Name:__
Policy#or Self-ins.Lie.#: _ Expiration Date:.V_._-___.__.__-._.___._---..__.
Job Site Address: City:'StateZip:__
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 SI.500-00
andllor 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 for insurance
cot crae verification.
I do hereb- > he pains and penalties of perjury that the information ps-enldadd above is true and correct
Sicn:tture: / I)aic/j — 1 0 ._aj—
Plum,: `/7 f.� — •-• C
— (.. G
Official use only. Des not rewrite in this area.to he completed by cur or town official
City or l ussn: PermitrLiceaste#J
Issuing Authority(eirck one):
I.Baiard of Health 2.Building;Department 3.('icy.Town Clerk -i.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone*::
City of Northampton
r"riry 5
ti)t
Massachusetts `� :_ '<<.
�',g DEPARTMENT OF BUILDING INSPECTIONS
. 212 Main Street • Municipal Building
Northampton, MA 01060 S'Nh 3''���C
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 e'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)