43-079 (8) BP-' 022-1475
41 DUNPHY DR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
43-079-001 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-2022-1475 PERMISSION IS HEREBY GRANT I D TO:
Project# 2022 BASEMENT RENO Contractor: License:
Est. Cost: 16100
Const.Class: Exp.Date:
Use Group: Owner: KLEKOTKA KAREN J
Lot Size (sq.ft.)
Zoning: WSP Applicant: KLEKOTKA KAREN J
Applicant Address Phone: Insurance:
41 DUNPHY DR
FLORENCE, MA 01062
ISSUED ON: 11/15/2022
TO PERFORM THE FOLLOWING WORK:
FINISHING BASEMENT
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 ATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
V . .>.9 3-1
Fees Paid: $210.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
'At'---e ---. 1
��I r,
The Commonwealth of Massachuse s NOV 4 2 /EO
W
Board of Building Regulations and Staid CMassachusetts State Building Code, 78 CNl'ller ofw-v a�/cr°rllc UBuilding Permit Application To Construct,Repair,Renovate�l-�1 ffidhsli, E jsed2011
One-or Two-Family Dwelling °1 °p
This Section For Official Use Only
Building Permit Number: c—a1 ]..-- ) ' 7 Date Applied:
eeui...-/ 7Z.55 ////Z 1I-16-2oZ2
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 46 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes c/ 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 ❑ On site disposal system 0
Check ifsves❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O er'of Record: , r''" l
A 6-� is -o ( �'"�, f .tP / a
NammJee(Print) n City,State,e,ZIP ,
No.and Street T Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that appl))
New Construction ❑ Existing Buildin . Owner-Occupied„ -- Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other ❑ Specify:
Brief Description of Proposed Work': •
t 1 kir4rt�,, f alIlk.45 1 ..f
Ph ., 54 to r itif, O l docaelf )or(, %Alit"!t rke,iti,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
I
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ l0 € "7 a a 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee
t-foo
1 0 Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: f.,Suppression)
Check No. flak' Check Amount: CI tLI
6.Total Project Cost: $ ( (O i 16-5 0 Paid in Full ❑Outstand g 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 I&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 Expiration 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 .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
cont fined in th's lication is d acc ate o best of my knowledge and understanding. L�
A Li f� �� / 2 G Z 2--
Date
'
int Ow Authorized Agent's e e onic 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
*/* Massachusetts °px
/ rc
wi
4 ' 44 DEPARTMENT OF BUILDING INSPECTIONS
v .,
212 Main Street • Municipal Building 1��. 's
Northampton, MA 01060 {6Pr 01�
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:
/ r
Location of Facility: ( L
The debris will be transported by:
Name of Hauler: —
Signature of Applicant: Date: // i Z . 41_
., ,
, The 14) CoBnt onst to on nt:Afea Alth 02of III 2s o Jae 7husetts
Department of Industrial Accidents
ca
1 Congress Street,Suite 100
:, ,... www.mass.govidia
SVorkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO HE FILED WITH THE Pc.amirriNG AUTHORITY'.
An i)licarit I n fonts a t ion Please Print Legibly
Name(Husinesai'Ors,anizationAndividual):
Address:
City/State/Zip: Phone #:
.. . .. . . . . .. .. , . . ..
Are you on fittilitilber?Cheek die appropriate box! T,pc of project(required):
1.0 I am a erripkiyer with_ _ ernpluytvs(full arid'or p.ort•titnc).* 7. 0 New construction
2fl I am a sok proprietor or panneriship and have sio employees working for me ris g_ rj Remodeling
any capacity.[No workers'comp visor/env required"
9. ij Demolition
3.Mlam a homeowner doing all work myself,(No workers vorry,imurance requited"'
la 0 Building addition
4.0 lam a homeowner and will he tarin metors ks condisti all work on my property. I will
ensure that all Lsontracturs either hate &titers*compensation insurance or are sole 1 1.CI Electrical repairs or artilitions
pruproetori with no i-nipioyelN,
12 ]Plumbing repairs or additions
5C:j I am a general contractor and 1 have hired the sub-curitiractors listed ori the attattiod sheet.
131:: 3 Roof repairs
These sob-contractors levee.employees.and have workers'comp.insurance.:
1 4_(-lather
6.0 We are a otaptration and ns officers have exercised their right of exemption per 14GL c. .
152,§1(4 and we hose eio employees.[No workers'comp.insurance required"
*Any applitaint that checks INA 0 I mast also fill out the section below showing their winters'conmensiation polity irifoemation
t Homeowners who submit this affidatit indicating they are doing all wort and then hire outside contractors must submit a new affidavit indicating suck
1Contractors that check this box MUM attached an additional sheet showing the name rat the suh-contractots and suite whether or not those entities}Lae
employees If the sub-wntrAc Cori have employees,they oriel provide their workers" ltip.pulp:4,numbs:L.
I ant an employer that is providing workers'CONIpeffSilii011 insurance for my employees. Bela W i the polity eind job.site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: CitylStateiZipl
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage,as required under.MCIL c. 152,*25A is a criminal violation punishable by a fine up to$1,500.00
andior one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of tip to$250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA fear insurance
coverage verification. . .
.
filo hereby certi , tier the pain reds •naities of pelt, 1 e formation provided above is trite and correct
• 4 4
Signature:
/
1\Phone#:
0 i Date. //— •-22- 2-2--
. . ... , ...... ... . ..
f Official use only Do not write In this area.to be completed by city or town official 1 .:
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3,City/Town Clerk 4.Electrical Inspector 5.Plumbing I r .
,
,
6.Other
Contact Person: Phone. :
Cit •
y of Northampton
' Massachusetts
' iYY DEPARTMENT OF BUILDING INSPECTIONS St
g, 212 Main Street • Municipal Building d � �;
\c. ,tea Northampton, MA 01060 ". %'4'
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
.------- 0 I, re" ..'t. .1Kylf ke. l4- (insert full legal name), born iqg
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 require . is 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 acco 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 detache• 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 :xtent 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 connection with any
project or work involving construction, reconstruction, alteration, repair, removal o 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 projei t or work on
my parcel, I acknowledge that I am required to and will act as the supervisor for said project •r work.
Signed under he pains and penalties of perjury on thi day of K °&4 &20
g '...-a-,
(Sign turetOLA,/,,,,m .73,..t., 4/4&-—
1f f 77vitpy D2 GuaL(c our aase
cr Room 62
25 ft2
5' 4" x4' 9"
!gym
„9 ,9
co
0)
Room 63
647 ft2
„6 ,91
,,8 ,91
�tJ
Room 60
191 ft2 O
16' 8" x11' 5" 6)
l
N
d)