38B-066 (15) BP-2023-0063
251 SOUTH ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
38B-066-001 CITY OF NORTHAMPTON
Permit: Exterior Res
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2023-0063 PERMISSION IS HEREBY GRANTED TO:
Project# WINDOWS 2023 Contractor: License:
Est. Cost: 2500
Const.Class: Exp.Date:
Use Group: Owner: S. MALINOWSKI, REBECCA
Lot Size (sq.ft.)
Zoning: URB Applicant: S. MALINOWSKI, REBECCA
Applicant Address Phone: Insurance:
251 SOUTH ST
NORTHAMPTON, MA 01060
ISSUED ON: 01/20/2023
TO PERFORM THE FOLLOWING WORK:
INSTALL 5 NEW REPLACEMENT WINDOWS
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:
(t9,1\p;L ,
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
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The Commonwealth of Massachusetts AN I '
s ° Ir, Board of Building Regulations andtandard FO
5 Massachusetts State BuildingCode,780 CMRn C '''PITY
� � A!',,.ri, U E
Building Permit Application To Construct,Repair,Renovate Or Deiiu> it, �cnoNv ised(1Llar 2011
One-or Two-Family Dwelling ,--_°fio
This Section For Official Use Only
Building Permit Number6/Z a 3 -03 Date Applied:
(I L] i O"s
Building Official(Print Name) Signature ' • —� te
SECTION 1: SITE INFORMATION
1.1 PropertyAddress: 1.2 Assessors Map& Parcel Numbers
..)-CI
o,4S{
1.1 a 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 ❑
Check if yes!:
SECTION 2: PROPERTY OWNERSHIP'
2.1 er'of Record I /� Z�
(/ G(,Ot IKp Ii ADN/SK 1 NOI ►o,A�I/1 I 'A OI 66
Name(Print) City,State,ZIP
7-1-1 S0,A44 c 6/6 633 al/ I2ec,iyn+AI:rowsk ' Qm4.'t car,
No.and Street Telephone (( Email Address J
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 Ad ition ❑
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Descri tion of P osed Work2:
/DISTA/4.1 9, NgA/ V/Mit- iftlival'Iri- /A/ wr /ivir (1,401 ,f
+ T i i" Idl W ifAF�/ - loa
u�/1 Ltd ` 6) i Z7
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:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing . $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
I
5.Mechanical (Fire $ Total All Fees: $ 0
Suppression)
S Check No. 1 O( Check Amount:
6:Total Project Cost: $ (/� 0 Paid in Full 0 Outstanding Balance Due:
City of Northampton
Massachusetts ��
'A 4 DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 3'}-)/-30
�>>
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 specification 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. Homeowner's License Exemption Form(if applicable).
8. Note any Special Permit requirements (if applicable).
9. Energy Code—all new construction(Gut/Rehab)requires an HERS Rater Affidavit.
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 mail address D Demolition
5.2 Registered Home Improvement tractor(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.
(Ze,yC/C-C/i• M� �Apwsk;
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.
R�Gt,G a �'r/?O wSk•� -I8-X3
Print Owner's or Authorized Agent's Name(Electronic 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 parch)
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 Accidents
: , ., 1 t). I Congress Street,Suite 100
Boston,MA 02114-2017
www.inass.gor/dia
1Vur kers'Compensation Insurance Affidavit:BuildersiContractorsiElectriciansTlumbers.
TO BE FILED'IS Ertl THE PERMITTING AUTIIORITI.
Annlicant Information Please Print Leeiblv
t.
' Name(BusinessiOrgantzationilndividual):
Address:
City/State/Zip: Phone #:
Are yea an employee Chet*tist appropriate has -1)pc of project(required):
t.C3 I 4111 a empLe!.LS With envioyees Mill andlor part-tinv ' 7. 0 New construction
In I 4111.a,oh:prupnetur or partnership and have nu eniployvvi working fur me to 8. 0 Remodeling
in!,,..tpsetty.[No workers comp.utsurnmet retittnedl
3K1 am a homeowner doing all it myself.[No workers'comp.insurance mature 9. 0 Demolitiond_r
100 Building addition
4.0 i ant a!turnouts-net and will be hiring wears...tors to ciniduct all work on my poverty. I sad!
ensure that all contractors either have workers'compensation insurance ix are x.)lc 11.0 Electrical repairs or additions
proprietors with no employee.
1.2.0 Plumbing repairs or xitilitions
1,0 I am a general contmetur and I lave hued the sub-onstmetors listed on die anathetl Meet.
These uk-euntractors bane ettpluyeen and he av *otters'comp.mumm 13.1:1Roof repairser.;
60 We are a corporation and its officers have exercived their right of exemption per W 14.C:10theriL e..
152.f 1(4),and,A.r ks..e.no anpluyees.[Nu nurkers'comp.imorane.e required.]
°Any applicant that chocks box;I most also till out the action below.showing their'Junkers'compensation policy information,
t liontes)Whers ecru submit this aridavit mdacturtse they art doing aft work and then hue outside contractors must submit a new&Mho.it indicating such.
k..-ontraetors that check tins box must attached an additional sheet slowing the name of the hub-contractors and date whether or not those',addles base
employees, lithe sob-contractor,.[woe ertyloy eett.they mum pros idt their A otter,',..x.tretp.pubes number.
I am an employer that is providing h'urArrs•compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: —
Policy#or Self-ins.Lie.4: Expiration Date:
Job Site Address: CityiState.,2ip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration 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 pinkies 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 kirwarded to the Office of Investigations of the DU for insurance
coverage verification.
1 do hereby certify under the pains and penalties ofpetjury-that the Information provided above is true and correct
Stentuf..: -3 Date:
Pia.mc : 01. ( i 71 g
62
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Ton: Permit license#
issuing Authority(circle one):
I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
' Contact Person: Phone 4:
City of Northampton
Massachusetts
i DEPARTMENT OF BUILDING INSPECTIONS �,
.-_
'� � > 212 Main Street • Municipal Building ��. Ob
. ., Northampton, MA 01060
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: 1Qr7 /M4 2 37 i A 1n1). T4) (42il'W
The debris will be transported by:
. Name of Hauler: J u14 A -4
Signature of Applicant: J1''✓) Date: I '1 P—�zi
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building ..,.
Northampton, MA 01060 'S'yjY
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, (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
qualifij 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 day of , 20 .
5 I•c-Ay 1944
(Signature)