23D-174 (2) BP 2023-0008
30 BAKER HILL RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
23D-174-001 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-2023-0008 PERMISSION IS HEREBY GRANT D TO:
Project# 2023 RENO Contractor: License:
Est. Cost: 10000 MATTHEW KOZUCH CS-106644
Const.Class: Exp.Date: 09/25/2024
Use Group: Owner: MATTHEW KOZUCH
Lot Size (sq.ft.)
Zoning: URB Applicant: MILL RIVER DESIGN BUILD
Applicant Address Phone: Insurance:
6 HIGH ST 4133418893 WC2-315-624269-010
FLORENCE, MA 01062
ISSUED ON: 01/05/2023
TO PERFORM THE FOLLOWING WORK:
REMODEL 5'X8'BATHROOM
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: I ' I '
,a • _ 1 . 1 •L4
I ' I
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
i
g, ` - ` The Commonwealth of Massachusetts
c`-' I I Board of Building Regulations and Standards FOR
a ( Massachusetts State Building Code,780 CMR MUNICIPALITY
USE
,Building Hermit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
c One-or Two-Family Dwelling
--1
This Section For Official Use Only
Building Permit Number:
�'n3P Z025-00c Date Applied:
Ajel o..,4Z65 /2 i-5.201.3
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Pro a Address: 1.2 Assessors Map&Parcel Numbers
'� - 1�;11 R� D /l-t-oat
l.la Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
IZoning 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
WA' . AU/A' NA
1.6 Water� Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public It Private CI _ Outside Flood Zone? Municipal F�On site disposal system CI if yesB�
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
m 7.xLn F/orell.cL y444 0 io6 z
Name(Print) City,State,ZIP /
d eoj r [Till e\c) till 3412893 mI l Er JQJ' 2 .. Marl, «(
No.and Street Telephone Email Addrds
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition ❑
Demolition 0 Accessory Bldg. 0 Number of Units Other Er-Specify: Q a ('do/14 re/lei
Brief Description of Proposed Work2: (2,e medal „5--1 x 6-f Q q-bi f-co V
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 6 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 2. ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ Z. 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire /
$ Total All Fees:$ (.o5
Suppression) °v ov
Check No.07 Check Amount:Ob.:— Cash Amount:
6.Total Project Cost: $ 1 0 I`\ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
/Writ-/ t��- CS- Number Expiration Date
Name Hol� L� 1( r
-fi��/ List CSL Type(see below)
No.and Street Type Description
1en//� �/ym 1 D /O( - U Unrestricted(Buildings up to 35,000 cu.ft.)
(/� „/ ! R Restricted 1&2 Family Dwelling
Ci Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
o�f / SF Solid Fuel Burning Appliances
413' c34'! . d af3 ►�')r.��r'��V�r 6)djrria/!. I Insulation
Telephone Email address v 'C.0)2` D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I-74 20 7 01/ 0/202 3
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 ❑
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.
PADMLJ M02 ) /7/23
Print Owner's or Authorized Agent's Name(Electronic Sign ) 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
oatN� ro �S Si
•�'� � Massachusetts ��5 c,�`
(It )"
` .`I DEPARTMENT OF BUILDING INSPECTIONS a
' ' 212 Main Street • Municipal Building v� `��
Northampton, MA 01060 ssN1y 1,��'���
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: vik I�ec
The debris will be transported by:
Name of Hauler: MctA1-1- Wo2%cc-L
Signature of Applicant: Gi Date: 2-
/ S
I�'t` J 1' t °2
Extension of Information Page WC 00 00 01 A Item 4.
State of: MASSACHUSETTS
Classification of Operations Premium Basis Rate
Entries in this item,except as specifically provided elsewhere in this. Code Estimated Total An-nual Per$100 Of Estimated Annual
policy,do not modify any of the other provisions of this policy No Remuneration Remuneration Premium
0001-01 MILL RIVER DESIGN BUILD LLC
FEIN # 84-4134229
SIC CODE 1521
NAICS CODE 236118
6 HIGH ST
FLORENCE MA 01062
CARPENTRY - CONSTRUCTION OF 5403 IF ANY 7.77 $ 0.00
RESIDENTIAL DWELLINGS
EXCEEDING THREE STORIES IN
HEIGHT OR COMMERCIAL
BUILDINGS AND STRUCTURES
CARPENTRY - CONSTRUCTION OF 5645 $ 26,114 6.35 $ 1,658.00
RESIDENTIAL DWELLINGS NOT
EXCEEDING THREE STORIES IN
HEIGHT
TOTAL CLASS PREMIUM $ 1,658.00
STANDARD TOTAL $ 1,658 .00
EXPENSE CONSTANT 0900 $ 338.00
TERRORISM RISK INS ACT
2002 .03 9740 $ 8.00
MACHWC (SURCHARGE) 1.0418 0936 $ 69.00
FINAL TOTAL $ 2,073.00
POLICY TOTAL ESTIMATED COST $ 2,073.00
Experience Modification: RISK ID: 001175125
Policy No. WC2-31S-624269-012 Page No. 1
GPO 2923 WC 00 00 01 A
WC990605
WORKERS COMPENSATION AND EMPLOYERS LIABILITY
INSURANCE POLICY
POLICY INFORMATION PAGE ENDORSEMENT
THE FOLLOWING ITEMS(S) ARE CHANGED TO READ:
THE FOLLOWING CLASS CODE HAS CHANGED FROM:
STATE: MASSACHUSETTS RATING GROUP: 0001-01
CLASS CODE: 5645 (CARPENTRY - CONSTRUCTION OF RESIDENTIAL DWELLINGS)
ANNUAL PREMIUM BASIS: $48 , 924 . 00 PRO RATA FACTOR: 1 . 00
RATE: 6 . 35 ANNUAL CLASSIFICATION PREMIUM: $3, 107 . 00
TO:
STATE: MASSACHUSETTS RATING GROUP: 0001-01
CLASS CODE: 5645 (CARPENTRY - CONSTRUCTION OF RESIDENTIAL DWELLINGS)
ANNUAL PREMIUM BASIS : $26,114 . 00 PRO RATA FACTOR: 1 . 00
RATE: 6 . 35 ANNUAL CLASSIFICATION PREMIUM: $1 , 658 . 00
THE FOLLOWING FORM(S) HAS BEEN DELETED:
CNW 90 12 08-19 RESIDUAL MARKET SMALL EMPLOYER SURVEY
SNW 20 03 01-19 MA CONTACT AT A GLANCE
ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED.
The total premium and surcharges shown on this change endorsement represent the revised insurance costs for the
full policy term. Any additional or return premium payable as a result of this change is shown below. This is not a
bill. If necessary, a bill will be sent separately.
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
Policy Effective Date 05-16-2022 Policy No. WC2-31S-624269-012 Endorsement No. 001
Endorsement Effective Date 05/16/2022
Insured MILL RIVER DESIGN BUILD LLC RETURN PREMIUM: $ 1 ,517
Insurance Company LIBERTY MUTUAL FIRE INSURANCE COMPANY
Carrier Code 16586
DATE OF ISSUE 06-15-22 Countersigned By
20230105_110551 jpg
1/5/23, 11:08 AM
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