24A-044 (6) BP-2023-0007
167 JACKSON ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
24A-044-001 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-2023-0007 PERMISSION IS HEREBY GRANTED TO:
Project# 2022 167 JACKSON RENO Contractor: License:
Est. Cost: 23000
Const.Class: Exp.Date:
Use Group: Owner: MCMULLAN WIENER, ELIZA C.& BRENDAN T
Lot Size (sq.ft.)
Zoning: URB Applicant: MCMULLAN WIENER, ELIZA C.& BRENDAN T
Applicant Address Phone: Insurance:
159 JACKSON ST 860-382-2726
NORTHAMPTON, MA 01060
ISSUED ON: 01/05/2023
TO PERFORM THE FOLLOWING WORK:
RENO BATHROOM &HALL
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:
el
2
• a •
Fees Paid: $149.50
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
C`
c
a The Commonwealth of Massachusetts
L� ,� Board of Building Regulations and Standards
FOR
rt _ Massachusetts State Building Code, 780 CMR MUNICIPALITY
.< = uilding Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
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�p One-or Two-Family Dwelling
F This Section For Official Use Only
Dtiyilding Pe t Number: Zp -OHO Date Applied:
Eths-) /Z,S lL I'4.2025
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
�KP c 1. Property Address: 1.2 Assessors Map&Parcel Numbers
'ace I "'a 6CSC /12 5i NJ o-rt fo-rl 010(9 0 ZL/ 4 -Q L -bD /
IJ5`� 1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
C 1 R6 2.72- acres
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 OWNERSHIP'
2.1 Owner'of Record:
6-teitilia NlcUudto kok E,�iza lA`►Ul.,e c NiactioNet-aet, NAB 0 I O(a d
Name(Print) City,State,Z
I (g '61 c1 -6-el 5-t. ?�60 3482 g26 b-'ertdar-I wtc "ta.i l.Caxic
No.and Street Telephone Email Addleich
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied L Repairs(s) fi Alteration(s) di Addition 0
Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify:
Brief Description of Pro osed Work2:fergea Br 6t b,, QliI �l .`171�
alb. 9 t _11A,'or a `f eftcVe..t-to-a_
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 3)00 0 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ 10 G��1 0 Standard City/Town Application Fee 5e
❑Total Project Cost3(Item 6)x multiplier2-3.00) x 6,.
3.Plumbing $ 10l 00 0 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total 1 Fees: $ ILief•S-D
Cho g" Check Amount:420230I o1143y 7
6. Total Project Cost: $')3 0 00 0 Paid in Full 0 Outstanding Balance Due:
City of Northampton
��t rrr,rr
Massachusetts
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DEPARTMENT OF BUILDING INSPECTIONS U
111 • 212 Main Street • Municipal Buildingtea
M^*i Northampton, MA 01060
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS,ROOFS,RENOVATIONS,ROOF MOUNTED SOLAR,ETC.
1. Building Permit Application signed by legal owner and filled out
by owner or authorized agent.
2. One set of plans and specifications of proposed work(Digital and hard copy).
3. Construction Debris Affidavit filled out and signed by applicant.
4. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance.
6. Energy Conservation Compliance Certificate (new /replacement windows).
7. Home owner's License Exemption Form (if applicable).
8. Note any Special Permit requirements (if applicable).
9. Energy Code—all new construction(Gut/Rehab) requires a HERS Rater Affidavit
10. Please provide the appropriate fee in the form of a check made payable to: The City of
Northampton.
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 1&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 Expira.ion 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 No 0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHFN
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 1 e and understanding.
f tik 01 /G fo7-3
Print Owner's or Authorized Agent's Name(Electronic e 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.eov 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"
The Commonwealth of Massachusetts
Department of Industrial.-fecidents
1 Congress Street,Suite 100
Boston, MA 02114-201 7
www.mass.gov/dia
witers*Compensation Insurance AMdas it:Builders/Contractors/EketriciansfPlumbers.
TO 131..FILED WITH THE PERMUITING ti MORI n.
Applicant Information Please Print Lew:ibis
Name 0111:1111i:SS _.1111Lattint Ind:\IJUaIex ut.sxit.
Address:__1101 _113-0-1L
C.ityi State/Zip: at Iv Mf1f1tM4 0LOPhonc#: O 367
Are yew ata ramie:ter?Cheek the apprriprIate hot
Type of project(required):
am a employer with alibi.vex(full andor parttime • 7. []New construction
413I a suit proprietor or partnership and have nu employees*Inlay fur me in c, [] Remodeling
ari:k capaelry,iNu workers'comp.insurance idiscinall
9 , Dctuolilidh
lifiOnn a homeowner doing all work myself[No workers'comp,insurance rtxpuredi
10 ElIluikling addition
4151 am a flu Mat 44.MI and will be hymn*war:mins iuinduct all work on my property. I will
enstitn:that aLlcentrui.-toru either!lace Worktm"corrawaisation msurance or a ili I I Electrical repairs or additions
proprietms with no employed
Plumbing repairs or additions
tiI Am a gram.]contractor and 1 has e bred the sutimmturactors listed on the anacied sheet.
These3. 1 sub-eintinviur%Ira..e employees and har e workers'eortip.ununin Root repairscej
°Other
6.C3 We are a corporation and as officers nave exercised their right of eterliptsixt per MCA.c.
132. I 4 l,and we ItVot nu cnivit.r.•,,er5..[NO workers:'comp_insurance required.I
applicant that 1 merit a6d fill out the vettarn bdutc ovans their workers cur:ye-manors puiie iinfortnatatmr.
itaTili-W4rsers who .111141t,it indicating they are Jinnir all work and thim hue outside eurdracters must submit a nen'3Cfki...tc it indicating suelt
:("ancractors Lit.11 lust attached an additional sheet bowintt the name of the sub-contructor,,and darc whether or not those ent ha'*e
employees. If the ha% rh..”: rE Rh:thcr
„ .
1 am an employer that is providing worhers'compensation insurance for my employers. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under NIGE c. 152. §25A is a criminal violation punishable by a tine up to SI,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine 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
ec.,erase verification.
I do hereby.certifit der 'Its an allies of perjury that the information proVidtql 11h0 re ix true anti correct.
Signature: Dale: 0 VOI-1170
Phone#: 666 3 2 72Ca.
Official use only. Do not write in this area,to be completed by city or town official
(It,. or Town: Per
Issuing Authorit!, (circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS � ^
212 Main Street • Municipal Building
-^! Northampton, MA 01060 z�,. /%i'
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: (Y1A1Ade -.R.004 (coj ?P- 5+
The debris will be transported by:
Name of Hauler: P/O-CLC/4 A-CAkv1/41
Signature of Applicant: Date: O1/0472073
City of Northampton
•
Massachusetts
14
F =x DEPARTMENT OF BUILDING INSPECTIONS s '
212 Main Street • Municipal Building
Northampton, MA 01060 V‘
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
LAI,fi tit (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 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 0 day of Ta.n uai`l , 20 2..3.
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