24A-096 (2) BP-2022-1556
21 DICKINSON ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
24A-096-001 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-2022-1556 PERMISSION IS HEREBY GRANT. D TO:
Project# INSULATION Contractor: License:
Est. Cost: 1920 B&E INSULATION 087116
Const.Class: Exp.Date: 11/18/2023
Use Group: Owner: F LASH EMILY
Lot Size (sq.ft.)
Zoning: URA Applicant: B&E INSULATION
Applicant Address Phone: Insurance:
1179 STATE ST (413)435-9497 VWC1006025794
SPRINGFIELD, MA 01109
ISSUED ON:12/05/2022
TO PERFORM THE FOLLOWING WORK:
INSULATION/WEATHERIZATION
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:
�' C''/ • .
e. ' if a Y► Irj
'
Fees Paid: $75.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
r
RECEIVED ✓Ul„,i' )q31
The Commonwealth of Massachusetts
�r FOR
B yard of Building Regulations and Standards MUNICIPALITY
(;,is ,, 3 2022 M issachusetts State Building Code, 780 CMR
USE
Building Pe-mit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
L)�PT.OF BUILDING INSPECTIONS One-or Two-Family Dwelling
This Section For Official Use Only
Buildin Permit Number: b IN A r 'MO Date Applied:
/��v,J foss Date
11-30 7-07'7
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1. Pro rtyGns ddress: 1.2 Assessors Map& Parcel Numbers
1 jOr1 �r _
1.1 a Is this an accepted street?yes t/ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: 1
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1
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 CI Zone: _ Outside •Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2. Ovn r'of Record
r LA L IOC fI »gyp MA 0I0 .0
Name(P ' ) City,State,ZIP
A le)algolei 51 - 54M1C4-043E Cm ly, Las h@&mutt. Corn
No.and Street ephone V 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 Bldg. 0 Number of Un'ts Other 0 Specify: ��j�.,
Brief Description of Proposed Work2: 1117 5 A)1-4— IYl 14,1 .Jf7(7 6 f) dike,
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 Costa(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: Cash Amount:
6.Total Project Cost: $ ' Sao t 7(1 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) ^ n n q 711 1
I)1 '/23
NaK,Q,y1 n ut License Number Expiration ate
me of CSllder
m 1�� List CSL Type(see below)
'No.and Street 'f 7 Type Description
a
Unrestricted(Buildings up to 35,000 cu.fl.)
r * el Min o 'I a� R Restricted 1&2 Family Dwelling
City/Town,S ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
4 I 433 02O+( KNcm� e millooK.covp I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) ' `7 ( ix1iratiocDate
D , 3
`'[x,h h u HIC Registration Number
HI o pa Name or IC gistrant Na C
L_urn
.and Street , Email address
• r 0� Ma olioq l 3 [t3�20((
City/Town/'fate,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
contained' this application is true and accurate to the best of my knowledge and understanding.
eRA
Print Owner's or rized ge s Name(Electronic Signature) to
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"
i
Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building Regulations and Standards
1 !
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Co m.st ,sion isor
...,
CS-087116 -4, spires: 11 /18/2023
KENNY 11 NOpYEN ......
770 PLUMTREE RD
SPRINGFIELD:,- MA 01118 400
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Commissioner }a,i40 r. tY(.441(ita_,
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L.
RISE
ENGINEERING"
OWNER AUTHORIZATION FORM
I, Emily Lash
(Owner's Name)
owner of the property located at:
21 Dickinson Street
(Property Address)
Northampton, MA 01060
(Property Address)
hereby authorize
(Subcontractor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property. This form is only valid with a signed contract.
The permit will be secured by the subcontractor, at no additional cost.
Owner's Signature
/ � f i ) 2�
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335
www.RlSEengineering.com
The Commonwealth of Massachusetts
i:lj
a /, Department of Industrial Accidents
= ]= 1 Congress Street,Suite 100
7117 Boston,MA 02114-2017
y,_ www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lee bly
Name (Business/Organization/Individual):B&E Insulation
Address:1179 State Street
City/State/Zip:Springfield, MA 01109 Phone#:413-435-9497
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with_ employees(full and/or part-time).* 7. ❑New construction
2.0I am a sole proprietor or partnership and have no employees working for me in
8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition
10 ❑ Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Elp
Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6. We area corporation and its officers have exercised their right of exemption l4.pother
❑ rpop per MGL c.
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities'have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:AIM Mutual
Policy#or Self-ins.Lic.#:VWC 1006025794 /Expiration Date::0�5/2//2023
Job Site Address:d i r/164r 5Im Tl City/State/Zip: v/f`7haYY7 l M/l 010 4 0
Attach a copy of the workers'compensation policy declaration page(showing the policy number and ex 1 ration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1 500.00
and/or 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 der the pains a nd penalties of perjury that the information provided above is true and correct.
Signature: "�/'77c..! v Date: f I I
413-4 3-2 11 /
Phone#: 3 0 � ��
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
i
; .
City of Northampton
Massachusetts
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Af
DEPARTMENT OF BUILDING INSPECTIONS
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212 Main StrOtot • Municipal Building
,,,, Northampton, NA 010An
Property Address. „21 PLc,16 n .5'073 theimp-,1-In v7 4 0/010
Contractor
Name: 6 rk i no(1 , \_iii 1,1 Q () P C
Address: I 17q S.-i-7k1 , ..5-1--
City, State: 7 ric,0 dd M A 0 1 I 6 01
Phone: 4 1?) c-1 2,f. 3 2) — 6 if
Property Owner t
Name. (ri?i iv LA ,C'A i
Address: 21 /
City, State:
1, 16/7 l' tyle r\,./ (contractor)attest and affirm that the building I intend to
,-
insulate does t ha v ;in pen air(knob and tube)wiring in the spaces to be insulated and that I have
provided the propenyliwner with a copy of this affidavit.
Contractor signature ,,--
Date