17C-162 (3) BP-2023-0250
67 CHESTNUT ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
17C-162-001 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-2023-0250 PERMISSION IS HEREBY GRANTED TO:
Project# OFFICE RENO 2023 Contractor: License:
Est. Cost: 4800
Const.Class: Exp.Date:
Use Group: Owner: C BREWSTER TARA T&MATTHEW
Lot Size (sq.ft.)
Zoning: URB Applicant: C BREWSTER TARA T & MATTHEW
Applicant Address Phone: Insurance:
67 CHESTNUT ST
FLORENCE, MA 01062
ISSUED ON: 03/02/2023
TO PERFORM THE FOLLOWING WORK:
2ND FLOOR OFFICE 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 VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
61\140Ats-- 1,(1
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
RECEIV H I
! MAR - 1 2023
The Commonwealth of Massachusetts
jn ,r DING INSPECTIONS Board of Building Regulations and Standards FOR
-mr4,MA 01060 MUNICIPALITY
Massachusetts State Building Code, 780 CMR USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: 60.13 •-2 SO Date Applied:
CSPI4L Vbeg 2 9.1
Building Official(Print Name) Signature Dste
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
(ptr Goac-N ) h_oPf-tJC.E: �C—Ha2�OD
1.1a Is this an accepted street?yes >0 no Map Number Parcel Number
1.3 Zoning Information: gig 1,OE.a N1"Z� 1.4 Property Dimensions:(1
Zoning District Proposed Use Lot Ara(sq ft) Frontage(ft)
1.5 Building Setbacks(ft) CX 5-/,i\jv
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? Municipn,�On site disposal system 0
Check if ye `�"'
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Mm7 £z4 ws L- ,o c _ MA- 1 of e7
Name(Print) City,State,ZIP
iofi C a-ri.rvr ST Lf i - 20-10183 lu ee,LJ5 .A CC►rtc s7T iv(
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building' Owner-Occupied Repairs(s) 0 Alteration(s))4 Addition 0
Demolition 0 Accessory Bldg.❑ Number of Units Other 0 Specify:
Brief Description of Proposed Work': 2 N D FLop- oft C -gOONt Qf,�/p l n�� Tb /MOPp„G
I NSuL-1 -1 a,J,/CW-LE.F y fN D `0n O A-4 w M v-,,Do")S { mn,.,t
c a
e o u Tr, ,Q�uLg►S,V .,- 'nm Do o17---- CL-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ Li ST 0 1. Building Permit Fee:$ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ g 00 0 Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Ffitei
Check No. 17v Check Amount:
6.Total Project Cost: $ goo
0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) (\// Ps
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) kJ,Pc-
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 O 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.
1•APc2c j CEC j d. -- 3/I /2ot.3
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 pl ed,provide the information below:
Total floor area(sq.ft.) 5 b (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
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Massachusetts �4,,
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' DEPARTMENT OF BUILDING INSPECTIONS ? fi
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212 Main Street • Municipal Building yv�•.• �
' Northampton, MA 01060 4.'••••J .
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: V f -L. Y y Recker u ..)v c- iNcS � �iA-70r�, tThPc--
The debris will be transported by:
Name of Hauler: Z\ntIAL
Signature of Applicant: Date: / 1 /20 2_3
The Commonwealth of Massachusetts
l' {I Department of Industrial Accidents
t_—
iii riivo_= 1 Congress Street,Suite 100
s: ;'F�= Boston, MA 02114-2017
,,....-....1...:.,-, www mass.gov/din
Hollers'Compensation Insurance Affidavit:BuiklerssContractors/EkectriciansfPlumbers.
It)BE FILED Wl'TH THE Pk:RMITI'1N(:AUTHORITY.
Applicant Information Please Print Lecihli
Name(Buainessiorganazation'individual): l`-'\PtZ�i -1-f_..t.t E�4=v7S"\---cz 2--
Address: 'p.— C S-c--c-'jC Sc
City/State/Zip: FLOQ f°C MP's 6\Oho L Phone#: LA 13-320-\o k(e,3
Amy....employee Cheek die appropriate hot: Type of project(required):
I.Q tama.mttloyer with__ _...__.__employees(full anikor part-time I.* 7. 0 New construction
2.171 I am a sole proprietor or partnership and have nu employees working for me in K. EaRemodeling
any capacity_[No workers'comp.insurance required.)
9. Demolition
3 1 ant a homeowner doing all work myself.[No vomiters'comp.imuran& required.)'
4.a I am a Iwmuuwnt^r and will be hiring canter un to conduct all work on nay property. I will I 0 Building addition
erasure that all contractors either have Nvxrkery exantpentation insurance as are sole I I Electrical repairs or additions
proprietors with no employees. 12. Plumbing repairs or additions
SCI I am u general contractor and I hive hired the sub-contractors listed on the attached sheet_ 1 0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.0 We are a cttrporat on and its ut'facera have exercised their right of exemption per MU_c.
14_fl Other
152,$I(4),and we love no employees.[No workers'comp.insurance required.)
'Any applicant that checks boa a 1 must also fall out the section below allowing their workers'c:ompcnsatiun puticy information.
+Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must subnut a new afftdLtiv it indicating such.
1Cuntractors that check this box must attached an additional sheet show ing the name of the sub-contractors and state nhulher to not those entities have
employees. If the sub-cuntracturs have c-rrnialuecs.tliep must pro',ide their a,token':imp.policy ninnlxr.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job she
rpyi.vinformation.
Insurance Company .'dame:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/'State/Zip:
Attach a copy of the workers'compensation polky 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 S1,500.00
and%or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine 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
coverage verification.
I do hereby certify under pains and penalties of perjury that the information provided above is knee and correct
Signature: /(-/ • Dale . / t /Q023
Phone#: -k' - 320 -- \a‘CeS3
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cityrlov►'n Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
i • ' Massachusetts 1.f. 3- !r'
ai x
w t (` .a, DEPARTMENT OF BUILDING INSPECTIONS
w f' 212 Main Street • Municipal Building J Cb
\ +? Northampton, MA 01060 s*'.=• S
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, IAA Q k..ws r
a____ (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 requirem• is of the z.
Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a iroject 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 accorda, ce with
780 CMR 110.R3.
3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 11 O.R5.1.2:
Person(s) who owns a parcel of land on which he/she resides or intends to reside, o which
there is, or is intended to be, a one-or two-family dwelling, attached or detached s ctures
accessory to such use and/or farm structures.A person who constructs more than one ome 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 exte t that I /
qualify for and will abide by the Massachusetts State Building Code's requirements for the supe 'sion of
the project or work on my parcel, I am not engaged in construction supervision in connection ith any
project or work involving construction, reconstruction, alteration, repair, removal or d: olition
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 o work on
my parcel,I acknowledge that I am required to and will act as the supervisor for said project or Work.
Signed underins and penalties of perjury on this 'L'Cday of M C)k ,20 23
jt4t
(Sature)