32A-202 (8) BP-2023-0213
59 PHILLIPS PL COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
32A-202-001 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-2023-0213 PERMISSION IS HEREBY GRANTED TO:
Project# ADD 2 BATHS 2023 Contractor: License:
Est. Cost: 39000 KRIS THOMSON CS084152
Const.Class: Exp.Date: 04/09/2023
Use Group: Owner: T. BERCUVITZ, DEBRA
Lot Size (sq.ft.)
Zoning: URC Applicant: KRIS THOMSON CARPENTRY
Applicant Address Phone: Insurance:
362 KENNEDY RD (413)695-6487
LEEDS, MA 01053
ISSUED ON: 02/27/2023
TO PERFORM THE FOLLOWING WORK:
ADD BATHROOM AND MUDROOM ON 1ST FLOOR, ADD BATH ON 2ND FLOOR, INTERIOR RENOVATIONS
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: l
G
Fees Paid: $254.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
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The Commonwealth of Massachusetts%?°40 ‘ C- �,
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Board of Building Regulations and Standardi FOR
Massachusetts State Building Code, 780 CMR y;/,ysp „MUN• ICIPALITY
Building Permit Application To Construct,Repair,Renovate Or>.3e " t.y f Revised Mar 2011
One-or Two-Family Dwelling ° rt'�
This Section For Official Use Only
Building Permit Number: 6 P— ?-3 47i.13 Date Applied:
' ,,2
as
Building Official(Print Name) Signature I Da
SECTION 1:SITE INFORMATION
1.159 4'HAddress:__s FL 1.2 3s s Map&Parcel Nu i
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
LA.l--
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:
Zone: _ Outside Flood Zone?
Public Private 0 Check if yeses Municipal CS On site disposal system 0
SECTION 2: PROPERTY OWNERSHIP'
2.1 (-:lie
er'of Record:
b r s �3.12 rcG, ,-.) Z -�,� M k}-i) o CZ.
Name ) City,State,ZIP
7/ tear"„c� _CI--, ti i 3 6 9 r /7`I 0U-ere .-;: Z e CAi-,Cc_f1.,,,J2_,>lo
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) ilk Alteration(s) '® Addition ❑
Demolition 0 Accessory Bldg. 0 Number of Units Z- Other 0 Specify:
Brief Description of Proposed Work': •
A S t-e. r` C 1(3s v.-E- c, v., (A-6 c,-'t `.-e r, -a.%-t_ r► . , /vi r.<re_r
a- d AA L ' 4. v, v 0-1.1n. 0 _ I /o,o r- (co y e.rt: ri c Cr-cf - r'J )
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ I (p 0 Old I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ $ 0 0 O ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 1 $ 0 0v 2. Other Fees: $
4. Mechanical (HVAC) $ —, List:
5. Mechanical (Fire $ o 0
Suppression) Total All Fees: $ 45°y�,
Check No. Check Amount:
6. Total Project Cost: $ 3 91 6 0 0 Paid in Full 0 Outstanding Balance Due:_l
F
City of Northampton
e Massachusetts -e:' •
•
DEPARTMENT OF BUILDING INSPECTIONS v$ ;'°
_ 212 Main Street • Municipal Building �y � ��
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)
Q C$4 � 415Z 4l j (2.
CS u 5 License Number Expiration Date
Name of CSL Holder
3 ! Z 14�v-k •
List CSL Type(see below)
b C� .
No.and Street Type Description
�// rJ. , 5 V U Unrestricted(Buildings up to 35,000 Cu.ft.)
City/Town,State,ZIP / R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
•q - k r 1 J1,1$ c)✓� SF Solid Fuel Burning Appliances
413 l� 1 rj f('t77 C.c,v y.eh l^✓ 4��{ (wrl�l I Insulation
Telephone Email address D Demolition
5.2 Registered Home Im rovement Contractor(HIC) 1 -7 1 s 4
4 e ' fky,s cram HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
SCt Q
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 WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize k. r s J /
to act on
my behalf,in all matters relative to work authorized by this building permit application.
ry e r-c., ,1-t. J&. - ` f?_ f I23,
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 appli ation is true and acc a the best of m knowledge and understanding.
rnS 6Yst (z ei_- 2- 3
Print Owner's or Authorized Agent's Name(Electronic ture) 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.govioca 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"
1.
1
- The Commonwealth of Massachusetts
, 7 _
Department of Industrial Accidents
(
I Congress Street,Suite 100
Boston,MA 0 2114-2017
moitmass.gov/dia
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Workers'Compensation Insurance.Affida%it: Builders iintractursiEleetricianv Plumbers.
TORE F it.E0%all't Ili_ PERNiiiIIN , \I 1 How ill.
Applicant Information Please Print Legiblv
Name I Business:Orgatuzation,Indrildual 0: l4,r I S " tfia_ 5d:::57)%:)
Address:" 2- r- .Q., \A ri.)2,d_ t, (12 .
citystatezip: Legeds __A4c, o I ag 3 Phone#: 4( . 4,7 -5 • ‘4.87
Are yen an eistplovert Cheek the appropriate boa: Type or project(required):
Lasts a employer*oil esavItr!Ceh l.full=dor partaimet.• 7. 0 New construction
inn lain a sole proprietor ur partninstim and have no emptoycvs work* for true in K. eRemodeling
..."‘any capacity.[Nu workers'comp.insurance required]
9. El Demolition
30 I am a linineownia doing all wink myselfo[N workers'comp,it-aura:nee ivituired.1'
100 Building addition
I am a bahineownior and will bie tunny cvntracturi lw taieduct all work on my property, I will
enaure that all contractors either hoe workers'aaniwnisation intrurani.v or are aule I I CI Electrical repairs or additions
prupriet,ofs with nu einployes ,
12.0 Plumbing repairs or AtlidlliOnS
10 I am a general euntra:tor and I have hued the gib-contrackirs hated on the ainaled sheet
3.
These sub-contractors have employees and have workers'corm.inaurari I 0 Roof repairsce.:
14.00ther
6.0 We are a corporation and its officera have exercised their tight of exemption per hltil.c. ,
1...:!.. $li 1.1.and lie hiVe tiO erriplOyees,INC)*Orkert comp.insurance required.] 1
'Aa appLicait inar.Liiks box ci must also fill out the section below show in g their woes:Las compensation policy infermation.
'Hinneow nen who submit this affidavit indicating they are doing all work and then hire out.odo contractor,mom salami a new affidav it milimoung such.
:Contractors that cheek this bid mug attached an additional sheet showing the name of ilk:sub-eontrackers and gate whether ur not those entities have
emplovecs. If the alb-col-Arai:NAN have employees.they mug provide their workers'canip.policy number
1 wry sat employer that is providing workers"compensation insurance for my employees. Below is the polies.and job site
information_
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City State:Zip._
Attach a copy of the workers'compensation policy declaration page(shim ing the policy number and e‘piration date).
Failure to secure coverage as required under MGI„c. 152, §25A is a criminal violation punishable by a fine up to S1,500.00
anclior one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a
day against the violator.A copy of tin, ,zatement may be forA,Inicd to the Office of Investigations of the DIA for insurance
coverap.: ,,ertlication.
I do hereby r ' .under th pains an pc alties of perjury that the infOrmation provided above is true and correct.
,
Sinature: Date: /72— ./a 7
/
Phone , 4 1 '3 . (13 6 • (c.4- 7
ow,ial use only. Do not write in this area.to he completed l city or town official
City or Town: 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
E'ontact Person: Phone#:
r
City of Northampton
Massachusetts s, • relit
DEPARTMENT OF BUILDING INSPECTIONS -
212 Main Street • Municipal Building
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:
The debris will be transported by:
Name of Hauler: 13 ) vut,,DS t E'
Signature of Applicant: \ Date: \ 24 2�
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City of Northampton
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Massachusetts 40, `"4fte
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{o- DEPARTMENT OF BUILDING INSPECTIONS rai
212 Main Street • Municipal Building 1.,. rt
Northampton, MA 01060 r "` ,
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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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