17C-277 (3) BP-2022-1663
13 LILLY ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
17C-277-001 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-2022-1663 PERMISSION IS HEREBY GRANTED TO:
Project# bath reno 2022 Contractor: License:
Est. Cost: 30000 HANS DALHAUS
Const.Class: Exp.Date:
Use Group: Owner: KRISTINE BOS, BLAKE W&
Lot Size (sq.ft.)
Zoning: URB Applicant: DALHAUS CARPENTRY INC
Applicant Address Phone. Insurance:
11 CHERRY ST (413)977-6094
EASTHAMPTON, MA 01060
ISSUED ON: 12/29/2022
TO PERFORM THE FOL L O WING WORK:
RENO 2ND FLOOR BATH
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: (Ali
ri2
Fees Paid: $195.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
C 5L Ex9 i 12i=0 _-- ----:. --- i
The Commonwealth of Massachusetts; o F C 2 9 7(,22
W
Board of Building Regulations and Standads FOR
Massachusetts State Building Code, '/80 CM&. -.MUNICIPALITY
rr n=Rl;!I f i�`' IPIg?EG'IONS USE
Building Permit Application To Construct,Repair,Renovate Or'Demolish'hr.'`°RevisedMar 2011
One-or Two-Family Dwelling
This Sectionti For Official Use Only
Building Permit Number: aP— �--i" �G�'3' Date Applied:
410 72os� ///1L 12-2R•Zdzz
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
lb : \ o iunc Q--
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 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP1
1 Owner'of Record:
c UL. 15 oS 'AmNs....„ 0<0 b O
Name not City,State,ZIP
v) \_ � 18S 3►) I 61C 14 c.Le,boseAt\t . c ow\
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building Owner-Occupied Repairs(sN2 Alteration(sibi Addition 0
Demolition \O' Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Descriptionof Proposed Work?: '�,°,-_� S�coV�� J`cur 1r,Gk nv S Wo DNS ( ►,�VJ
-,j\n c+, v'Mi&e., vrc� ' A sk-a Ne,�.l -lt-�- c\o�' w I V1ea eM k- a V i ;,',5ice,q%
lnew qt,,,N:kA 1 p.,.,At <,.A , c--Si. C .k use-
SECTION `1
4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ .o, Oft,W 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ co a.), 4,-, 0 Standard City/Town Application Fee
0 Total Project Cost (Item 6)x multiplier x
3. Plumbing $ Saw • 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: }},,
Check No.)3 h fkheck Amoun . 1"1a
' Cash Amount:
6.Total Project Cost: $ SD 1 O''' • w 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Ibt 6a6 it 11
'
-t'�cv' W (1 \c(a� '� License Number Expira on Date
Name of CSL Hol er
11 C List CSL Type(see below) V
No.and Street
Type Description
c. _C\c V� �\vi J„v 1 L/1 ( , Cke,371 9 Unrestricted(Buildings up to 35,000 cu.ft.)
Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofmg Covering
WS Window and Siding
Ir,� - L i SF Solid Fuel Burning Appliances
41 11'1 GM Da\I W.NSC.e:I r 1 e9fra.l.tW, I Insulation
Telephone Emai address( t D Demolition
5.2 Registere Home Improvement Contractor(HIC) 'C(� �1 CI 1f i
OlA(1 )t l\t ? HIC Registration Number xp' tion to
C Company Name or HIC Registrant Name
No.and Street 3 j it \ E it addr s
City/Town, State,e,ZIP MI Vj 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 ssuance 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 Owner of the subject property,hereby authorize 'J ca\\\t (jist `"A�`
to act on my behalf,in all matters relative to work authorized by this building permit application.
' \o st $Q5 Ial'xtLa-a-
Print Owner's Name(Electronic Signature) ate
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest der the pains and penalties of perjury that all of the information
contained in this application is true and a t of my knowledge and understanding.
4-- s iafo e/ a
Print Owner s or Authorized Agen s ame(Electronic Signature) I 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
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Massachusetts �w
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DEPARTMENT OF BUILDING INSPECTIONS
mp �fc ,Ryµ, b`
212 Main Street • Municipal Building c",Northampton, MA 01060 srkn jt'
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: r (�` Rq'( ‘‘•,
The debris will be transported by:
Name of Hauler: \-1 GAY`, S r\) A\Nc,\J(..,
i'
Signature of Applicant: Date: a
IN
,.__.._. The Commonwealth of h. assachusetts
tt i Department of Industrial Accidents
txr Air—.
fi ' i i t 1 Congress Street,Sulk 100�
'is '' fe
►w ww.mass.gov./ddia
Workers'Compensation Insurance Affidavit: BuildersiContractorstEiectrwiansIPtutnhers.
TO Ifl CILt►D WITH THE PERIVII!T1iVt:Ati"l"HO1t1T1`.
Applicant information Please Print Leiriblv
Name l ausitoeta hgtmcxati+t madly aluat r C.si S (Cs fV.-€Ok f
Address: I l . ,_
C ity/State/Zip:t .-` gym J ...,_... Phone##: 1.1 ( 1 i1 //
Are you aria employer?Cheek the approttr(ttttr twat Type of project(require t):
t.st, 1 bur:r employe/.with _.._ - ...•, empioyt.vio Oa snit xr poin,tiat et? 0 New construction
2.0 t sin 3 obit prilptx tax ur paatnetatup and)taut/VW employee%lourrkuve tvr cry:in ' 8 Retrlede:ling
any eapaeuty.[No workers'comp. insurance e requir ed.l
9. Demolition
313 I am a hvirortvrtra truing all Kura:myself,[No workers"eater.rtcstsv u. cvctt,ircal.l'
00 Building addition
4.0 t am a ktumtteuivnct aatd will he hiring itusetraaara ri:i:ogdur.9 all work on rny}►ttx}ai:rt}. t will
emote that ail courria:toes t.-ithct halve workers'caxtspv.rciaition tnsuranue et an WIC 1 1 Electrical repairs of addititm
proprietor%with no einplcryes'u.. tri
12. Plumbing,repairs or,n, shots
sC1 I tort a twill:'al euntracior ztaaf 1 haw c tun.cl the nub-cunts r0rs hated on the attached sheet..
sii
Thetie:wtr-contractor%have employee t334 a vvoniatrn"t 4 tap.noitnaner. l Reid tti�l lii
1a_ jOth
h. We are a corporation oral ids officer have men.toed then right of e,teemption pet Mt.,t.C. v__ __. __. _.
152.§i(4).arbl We have cart employe a.[No wurktm."comp inatitant:e eealtttU tt.]
"Any applicant that chozka box 4;1 mug ats.0 till out to section bieluw ahuwing their workers'compensation n p.iticy iatlurmatwtt_
t liuuuuwnerx who submit dma arrokiast tndiicat,ng.they are doing all roseit and Men hire outside co tractor%mm1 wbnut a new affidavit uatiaatiitg suiit
4Cunita.ttsr,that check dna bus:moos attacked an additional street%Auaring the nitre u3 the tas8 eureractura and aeaee whether i a not(how eaaistiax hay.
cutpl.av,zen. It;law wik ecitlinSat.ra ka'. cntpli.iy+'c,.the k'taus pro,,,ta.:iNctt wastiwn, ckmap pone.,mambo
1 all on employer that is providing s'orAers'compen.strtion insurance for my employees. Beloit is the polity and job site
information. r �
Insurance Company dame:`✓ _.
Policy It or elf--iris.Lit;.It: 6S5 1 U s S k 111&-\6-1^)F..xpiration Date: 6/11 It1-"-
Job Site Address:..._._ ____________________________ _ Cit /StateiZi I
Attach a copy of the workers'compensation polky declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under NIUL c. 152. $25A is a criminal't ictiatitm punishable by a fine up to$ ,5O(UX)
anchor one-year imprisonment,a well.is civil pexaatties in the form of a STOP WORK ORDER and a fine of up to 250.00 a
day against the violator.A copy o this statement may be forwarded to the OfTcc of Investigations of the DIA for i "titmice
coverage verification.
f do hereby certify er the pal . n is c perjury that the information providedabove/iss true and correct.
t
Sinaturt: Date. /)
Phony 4! -1'1 b 0 61 L
Official use only. Do not write in this area,to.be completed by city or town official.
t
t
('it or Town. PcrniitiLicenstr at
Issuing Authority(circle one):
1. Board of health 2.Building Department 3.cityfTown Clerk 4. Eteetrkal Inspector 5. Plumbing Inspector
ti. Other
t Contort Person: Phone#:
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City of Northampton _
' Massachusetts 4 ' c'��
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DEPARTMENT OF BUILDING INSPECTIONS pii k(;",
212 Main Street • Municipal Building �J''.,l .•••
Northampton, MA 01060rYip1^�
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, (insert full legal name), born _ 'nsert 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 projec 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 homeowne s'exemption,
does not involve the field erection of manufactured buildings constructed in accordance with 780 C R 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 whi.l there is, or
is intended to be, a one-or two-family dwelling, attached or detached structures accessor to such use
and/or farm structures. A person who constructs more than one home in a two-year perio. shall not be
considered a home owner.
4. I do not hold a valid Massachusetts construction supervision license and, except to the extent t 't I qualify for
and will abide by the Massachusetts State Building Code's requirements for the supervision of the ,roject or work
on my parcel, I am not engaged in construction supervision in connection with any project or ork 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)