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12C-012 (12)
BP-2023-0337 97 MOUNTAIN ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 12C-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-2023-0337 PERMISSION IS HEREBY GRANTED TO: Project# CHIMNEY REPAIR 2023 Contractor: License: Est. Cost: 1475 JAMES FOLEY 065777 Const.Class: Exp.Date: 04/22/2025 Use Group: Owner: BIENKOWSKI PETER J Lot Size (sq.ft.) , Zoning: RI/WSP Applicant: JAMES FOLEY Applicant Address Phone: Insurance: 10 FOREST GLEN DR 413-563-0161 FLORENCE, MA 01602 ISSUED ON: 03/17/2023 TO PERFORM THE FOLLOWING WORK: CHIMNEY REPAIR 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: I , .52 55:613, • , • Fees Paid: S65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner DocuSign Envelope ID: 167674FC-1523-4871-A99E-5431D56AD343 L01ai 1 Lam . kt uCiy The Commonwealth of Massachusetts `�` �.',,. j Board of Building Regulations and Standards FOR .� .4 ,i,, Massachusetts State Building Code, 780 CMR MUNICIPALI3 "� USE / Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 1011 4f4 R One-or Two-Family Dwelling L /a' 6 fr 1 This:Section.For Official Use Only % n `ti or 3 Building Permit Number: A 3^ 63 7 Date Applied; '‘'') 1.M O/N( `/ ` rQ p� A Spy ' t1 • � 3• ) • aL3 M,10, rio i BuildingOOFlicial .Print.Name)' Signature T so SECTION 1.SITE INFORMATION :. 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers III &A a Luvtifincf Fiorf vt et I2-C. 1:'. I1 i,: DI 1.la Is this an accepted street?yesy no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: , (,��k $ 1 O 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 1.6 Water Supply:CA GI c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Public{a' Private❑ Check if yesi / Municipal❑ On sae disposal system I>e SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Pe 4C( s T.iei.Fa- k i Pa 'a ( O a,(4f r/ckeerce R77f of L Name(Print) City,State,ZIP Ili 3.67s—.28.YS lam- it",itousfl ©,/rel.e(.COlt''} No.and Street Telephone _^^ Email Address SECTION 3=DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction Cl Existing Building Q' Owner-Occupied 0 Repairs(s) lie Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units ( Other 0 Specify: Brief Description of Proposed Work': C4,(.i Yv. kt el1 fZe 0i i' SECTION 4 ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only (Labor and Materials) 1.Building $ 1 BuiklingPermit Fee:$ Indicate how fee is.determined 2.Electrical $ 0 Standard CityfFown Application Fee 0 Total Project Cost'(Item 6)x::multiplier x 3.Plumbing $ 2: Other Fees: $ 4.Mechanical (HVAC) $ Lisk i 5.Mechanical (Fire S Suppression) Total Ail Fees' Check No.: Check Amount: Cash:Amount: ._ 6.Total Project Cost: $ / Z _ • � 0 Paid in Full 0 Outstanding.Balance Due. DocuSign Envelope ID: 167674FC-1523-4871-A99E-5431D56AD343 SECTION 5: CONSTRUCTION SERVICES Si Construction Supervisor Licens (CSL) 06 +7 License Number Exp ratio ate Name of C older 10 G df G yal . List CSL Type(see below) r No.and Street Type .• Description V‘orl.eqe—e l '+e(ee5 11 Unrestricted(Buildings up to 35,000 cu,ft.) ' a R Restricted I8c2 Family Dwelling City/Town,State,ZIP M Masonry J RC Roofing Covering WS Window and Siding JP)S6 —D/6� Mast' W'- SF Solid Fuel Burning Appliances ./l(C I — Insulation Telephone Email address I) Demolition ' 5.2 Reg red Homemp vement Contractor(HIC) /966 � v r. HIC Registration NumberE i tion Date HIC Company Name or}U I cgtst t Narpe No.and Stre i G Email address City/Town,State,ZIP t/OG'y Telephone SECTION.6:WORKERS'COMPENSATION INSURANCE.AFFIDAVIT(M:G:L..c.III:4 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 lit:OWNER AUTHORIZATION TO BE COMPLETED WHEN- • OWNER'S AGENT:OR CONTRACTOR APPLIES.FOR BUILDING PERMIT . I,as Owner of the subject property,hereby authorize .JCt 1 ri P-C F61.f C CI to act on my behalf,in all matters relative to work authorized by this building permit application. e—DocuSigned by: Peter J. Bienkowski 3/16/2023 Pni�,� %'* •goge(Electronic Signature) Date SECTION 7b:OWNER'+OR:AtjTHORIZED 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. Docu gn by: Peter 7. Bienkowski 3/16/2023 Q ggi@��gthorized 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. I42A.Other important information on the MC 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 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" ��dnuU CP& ftC6ki - DocuSign Envelope ID: 167674FC-1523-4871-A99E-5431D56AD343 The Commonwealth of Massachusetts ice{ Department of industrial Accidents 1 7 ,: I Congress Street,Suite 100 r Boston,MA 02114-2017 At' www ntass.gov/dia Workers'Compensation Insurance Affidavit:BuIdera/ContractorstElectricians/Plutnbern. TO RE FILED WITH'rilE PEttlif TI G At!THOR1'fl. Applicant information Please Print t_rt ibh Haute(Business Or inizatian'Individual).,.� Ci"5.4).-- • _.: . .• Address: . 1 46 w _ ._�... • City/State/Zip:._.._w: 't fG 2. • • . Phone#: • .t•.. . Ala yw WI employee Cheek the!Appropriate box: Type of project(repaired): 1-2ant winploynx w ith_,: .:_:.art+�i�r}rtF dull audio,pan-bate.• 7. ©New i otnstwction ` l atn**ate proprietor or partnership and have tat employee,wicking forme in El any capicity.[No workers'vamp.ins a:lie ra,itiuriaJ.E Remodeling 30 J am a hure r m&w Join$all wort myself.NO workers' raa comp.Maumee required"I' 9 Demolition 4.0 Jam a Iwnnarwncs and will be hiring rnxtacurs w candati all work on myI U Q Building addition tetg c ptnlrrty. E will rn3ute that all einler*k'O either hart wurkety'ecirnprasalam insurance or are sole I i.Q Electrical repairs or additions Pruptietiva with no employees. i 2.0 Plumbing repairs of additions t C3 J am a sorters!4:negro:tot and t lave hired the aeihdemriaetuta listed on the anal:he l she !ID Roof S t`patr3 `There sutreuntractiiia hate employed and hare wortera'comp.i eurofice.% 'f 9 6.Q We are a oorporainn and its officer*!Karr exemi led their sista of earmark,* Wit c•per W . I 152,Q tt4t,and we have no emyik vicei.[No winters'warp,insurance rti)tetreat.} /1* a 'Any applicant that i:Ai xki tux el mat ali'.i,liIJ nut the section hekiw stowing their warkera compensation Iodic}inf,xnwticwa_ 1'ttcntwownerc who sutxnit tier affidavit intheatins they are dome all work and then hire outside axitractura mean!auYmut a new affidavit inclit*tin t►udh. =t:ontrxters that cheek tens box mina atlachai ao ailed anal sheet stowing the name of the intreuntra lira and state whether or not dice eridiira hint irrnpkiyeea. attic saJswontractcas harp:err.loyter,they must Novick thee wofter+'a:it .policy riwaive l am an employer that is providing workers'compensation insurance for my emplo}ayes Below Is the policy and job site information. • Insurance Company Name: _.._...__.: . • Policy. or Self-ins.Lice 4: • • Expiration bate: � . .• lob Site Address: • . City/Statc^Lip: Attach a copy oftite workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL e. 152.*25A to a criminal violation punishable by a fine up to SI,300.00 and or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 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 the pains and penalties of perjary that the information provided above is true and correct. Signature: /I #st ? ► may^ Date: 1 J/6/Z 3 Phone ti: /� ,416.21%. Official use only. Do mot write in this area,to be completed by city or town official city or"town: permit/f.icease Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Tone Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - Contact Person: Phone a: City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: '9 7 /W d pe n71( S[ F/oPer? GI The debris will be transported by: j err? J JI < The debris will be received by: Vot /l/e'7 yC f'i Building permit number: Name of Permit Applicant JC1 N""ts fo/e y Date Signature of Permit Applicant