24C-012 (2) B '-2023-0044
271 PROSPECT ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
24C-012-001 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-2023-0044 PERMISSION IS HEREBY GRAN ED TO:
Project# BATH RENO 2023 Contractor: License:
Est. Cost: 20000 LOUIS MONTGOMERY 013471
Const.Class: Exp.Date: 11/19/2023
Use Group: Owner: MESSECK TILEY LINDA &HARVE P
Lot Size (sq.ft.)
Zoning: URB Applicant: LOUIS MONTGOMERY
Applicant Address Phone: Insurance:
PO BOX 951 413-268-2028
WILLIAMSBURG, MA 01096
ISSUED ON: 01/19/2023
TO PERFORM THE FOLLOWING WORK:
BATH RENO
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 VI 1 LATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
V s CiAskikr,
Fees Paid: $130.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
\\
The Commonwealth of Massachusetts' :.;c 1
Board of Building Regulations and Standar y'9G, O
kti Massachusetts State Building Code, 780 CML�°12r, �c MiIC1P ITY
�^ e,p / U
Building Permit Application To Construct,Repair,Renovate OrD a evise, Mar 2011
One-or Two-Family Dwelling 0).
One-
This Section For Official Use Only N.
Building ermit Number: 802• ,X3" yLl Date Applied: Ni
trviki a.,„ I-1`l.ZUz3
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
2 7/ ,d s.o r4ec/J`s 7-
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?! Private 0 Zone: _ Outside Flood Zone? Municipalg On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
//4v/1 f AliZir,j7 GA 1(/ TOI ,40?,4 0/46 O
Name(Print) City,State,ZIP
27/ /OAospf,c 7'S T
No.and Street Telephone 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 0
Demolition 0 Accessory Bldg. 0 Number of Units / Other 0 Specify: ge,toot/c%-•q
Brief Description of Proposed Work2: /Z,,L, 4f/.tom R',,.si iSTiAA ze.riv/ZZUr+t
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ /3,000 to 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ �.r®p.06 0 Standard City/Town Application Fee
0 Total Project Cost (Item 6)x multiplier x
3.Plumbing $ I/i O- G O 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ j ,
Suppression) Total All Fees: $ t y�1/�,U
Check No. Check Amount: V,J
6.Total Project Cost: $ 2 G/ 000. 0 Paid in Full ❑Outstanding Balance Due:
r .0,i1,-
City of Northampton
Massachusetts 'tr
_ v DEPARTMENT OF BUILDING INSPECTIONS :- "fli ji
212 Main Street 4. Municipal Building Via`
Northampton, MA 01060 Pi a�1�
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 ConstructionnSupervisor License(CSL) 4947 y7/ // �j/3
ZCiCS�i7 d�NTCod/ �' License Number Expiratioirtih Date
Name of CSL Holder / 6//� List CSL Type(see below)
l/= �- /j d S
✓ 9 ' lid�
No.and Street Type Description
C� ./// ,q r�� e!ll G U Unrestricted(Buildings up to 35,000 cu. It.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
zG 6 Za Ze'" I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) b 3/ 27 ,23 /7_5'Y 11
c"f yyjy.�� f¢a �� rn� HIC Registry n Number Expiration Date
HIC Company Name or HIC Registrant Name
af Aei?ecait T i',Gy /2er
No.and St eet 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 3$(
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 eV 2 CTt.4/4' t z.r izs /eon.76d n.47
to act on my behalf,in all matters relative to work 's building permit plication.
XAlleX llebse c r !2, ,,Print Owner's N (El e ectronic Signature) ate
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.
10 vfs/l?rAr7-60 A / If/Zty & l!'.o-T.e ,�u. t.c //S/Z--
Print 0, it Authorized Agent's Name(E jic. -s nic 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.eov/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
0-0 Department of Industrial Accidents
1 Congress Street,Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERNII-rIESL;AITHORITV.
Annlicant Information Please Print 1.etiblt,
Name(Business,Organizattonilndtvidual):
Address:
CityiStateiZip: ,r Phone
,tre you an esunluver?Cheek the apiti,,priate but:
l'y id-project(required):
I.C3 I ant a traployer with eanr tfull arnior 7. 71 New construction
l sin a ivie puprwIo r rartnerthip and have no employees working fur erie 8. ii<1 Remodeling
am,capacity.[Nu workers'comp.latanniner required]
9. LI Demolition
;..j I am a hotnetov,Iter duing all work nayself ['ownrieri'camç..itnUninee required]
100 Building addition
4.C3 1 am a hurneowner arid will hie hiring emiraetura munhiet all work On ruy poverty. I will
emure then all..-ontracturS either have workers'...-iampeniatnet noaarance or are snle I 1 rj Electrical repairs or additions
proprietors with no emplu•yeec
I 2.0 Plumbing repairs or additions
lam a Menial euntractor anal I Isiwe hired the 1.ub-curitraeter%listed tbe attached Ace_
13 Roofrepairs
These Anb-euntractur%base anpluyees and e*criers'cLanp.uburan
14. Other
0.44 e are a ourptuallun and ut utfieers have exert:abed their rathl tut eaemptIon per?AU.c.
152,§1(4),and we have nu etiaplusem[No workera•tun*.inAuranee required]
*Any applieant that elle:1i%box=1 mint Ana fill out the Aection below Allowing their worker,' t. 11,.17.1 policy mformation_
Homeowner%who submit this atikfacit indicating they kne doing all work and then hire untaidc contractor,tram mitrnut a new affidavit indiLiume ALA:h.
untraetor%that chei..k thus boif.must attached an additional sheet show ing.the name of the sii.6-411nrxaelOr,and'Lae vt,6.^ther in not those,ithEte-A.
I If the sub-coritrac3:orN ha+4 criirlo:••ces. 1110.1,1 rti,N Ide their workers" mairthci
I am an employer that is providing workers•compensation insurance for my esstployee.s. Below is the policy and job site
in(ornrotion.
Insurance Company Name:
Policy#or Self-ins.Lic. #: Expiration Date:
lob Sae Address: City,StateiZip:
Attach a copy of the'workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage us required under MGL c. 152. §25A is a criminal violation punishable by a tine up to 81,500.00
andior 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
\ era riCaltiOn.
I do hereby c der the pains and penalties of-perjury that the information provided above is true and correct
Si:ntre: /* /) 6t) fro7"-ed‘-/O-e,/ Date: //
Phone 4:
Official use only. Do not write in this area,to be completed by city or town officiaL
( it) or Town: Penult/License#
Issuing Authority(circle one):
I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
b.Other
Contact Person: Phone 4:
City of Northampton
Massachusetts 4; C�rJ
DEPARTMENT OF BUILDING INSPECTIONS
W 212 Main Street • Municipal Building �r
Northampton, MA 01060 4
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: �a wry 4.'lC
Location of Facility: oT// S T ,V 7c)
The debris will be transported by:
Name of Hauler: rn /Z C7frzi e 7/2"70/1-12 '
Signature of Applicant: Date: '
City of Northampton
Massachusetts
11 = .
DEPARTMENT OF BUILDING INSPECTIONS 1°r
212 Main Street • Municipal Building
Northampton, MA 01060
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
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 day of , 20 .
(Signature)
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