31A-311 (7) I BP-2023-0462
107 VERNON ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
31A-311-001 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-2023-0462 PERMISSION IS HEREBY GRANTED TO:
Project# PORCH 2023 Contractor: License:
Est.Cost: 25000 MATTHEW KOZUCH CS-106644
Const.Class: Exp.Date: 09/25/2024
Use Group: Owner: ROCKWELL LINDSAY
Lot Size (sq.ft.)
Zoning: URA Applicant: MILL RIVER DESIGN BUILD
Applicant Address Phone: Insurance:
6 HIGH ST 4133418893 WC2-315-624269-010
FLORENCE, MA 01062
ISSUED ON: 04/18/2023
TO PERFORM THE FOLLOWING WORK:
REBUILD 2ND FLOOR PORCH
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: I Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
Ili • Iir , .5.2 . 3- ,
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Fees Paid: $16150
212 Main Street,Phone(413)587-1240,Fax (413)587-1272
Office of the Building Commissi ner
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14 The Commonwealth of Massachusetts ; I APR 1
:0): Board of Building Regulations and Standards , R �O FOR
Massachusetts State Building Code,780 CMR L_ MUNICIPALITY
..,rT of in:r in ek1 •Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Dements 0t,, ,Ace,
One-or Two-Family Dwelling
This Section For Official Use Only
t,
Building Permit Number: - 1 3 -d/t2.- Date Applied:
1.6; : 0 i 1.5)611 Li i
Building (Print Print Name) I Signature leSECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
tDq- vtc-non. JJe_ / 31A 3t1 oeI
1.1 a Is this an accepted street?yes V no Map Number Parcel Number
1.3 Zoning Information: 1.4 PropertyDimensions: . Q /
ZoningDistrict Proposed Use Lot Area(sq ft) I Frontage(8))
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided I Required Provided
Ali 4/4 7WA //A
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zs ?
Public Private CI Checkif yes Municipal On site disposal system 0
SECTION 2: PROPERTY OWNERSHIP'
2.1 O�w i iNer'QfRecord• kvJ�' A / d (AA Ol06od
s�� �cc. � a V`
Name(Print) J City,State,ZIP ((''
IC�� -
V e.Ckt;/\, S � . �f13-32C-�}S-7 eMoelr,c.KicGod,cc"
No.dud Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building Owner-Occupied 0 Repairs(s) l( Alteration(s) ❑ Addition 0
Demolition El Accessory
Accessory Bldg. 0 Number of Units Other' 0 Specify:
(2‘
iL,
Brief Description of Proposed Work': ( `e bt 1V 2-," Q(ne r P o(' k. Insi n.U.l ►\�vvvi., rtti outs'
c.n �ryva t 'I,\ S Vi1,h,ei• 5 f&.[-e-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 2-C 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees: $ 16a.36
Suppression)
/ Check No.16)7 Check Amount: Cash Amount:
6.Total Project Cost: $ l I. Paid in Full ❑Outstanding Balance Due:
I
r �P_ License'Number Fxpi r'odDat
Name of CSL Holder
fn ISt ` List CSL Type(see below)
No.and Street-4 Type Description
f r e+c e J� n�i O'n 6 L Unrestricted(Buildings up to 35,000 cu.ft.)
b ` Restricted 18c2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
j c' a < SF Solid Fuel Burning Appliances
'1/ `t l 3 - i5 L Mgt 11 I ei ZS e `4 N ,I ,cC/\ I Insulation
Telephone Email address`s D Demolition
5.2 Registered Home Improvement Contractor(HIC) 1--14 tO1 Z
�,1M('.. HIC Registration Number Expiration to
HICmpany Name or HIC Registrant Name
•
,�►,11 C Net- ZC ral l, coal
No.and Street Email
• \
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 A \IND2 x'
to act on my behalf,in all matters relative to work authorized by this building permit application.
L A {kckufe,\ IA /t- 173
Print Owner's�e(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.
��. V .o1%)cV 4/1 71/4.
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 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
;ia--.-• _ Department of Industrial Accidents
Li 4• ' '�i 1 Congress Street,Suite 100
' 1:.,„. Boston, MA 02114-201"
"__ ,47
wwr .ntass.got/die
11urkers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED%%Till THE PEILSIII-1'IN(:AU-IHORJT1'.
Applicant Information ,(� Please Print Leitibh
Name 113usiress'Ortaniz3tion:lndn•iduall: I 11'I ��") �� b€5l r� i3_vt(1 ^--._^__
Address: (0 ;k►c\V\ S --
City/StateiZip: nof 'L Nce_ AM OIoCoZ Phone 4: 4(1) -341_( e" (_3
Are you an employer?Cheek the appropriate box:
Type of project(required):
1 a 1. m a employer with _ _ employees(full and-ot part-tme1_• i 7_ New construction
20 I am a sole prupnetur or partnership and have nu employees wotkumn for me in I `J S. 0 Remodeling
any capacity.(`u workers•comp.insurance requited.)
9. r Demolition
30 I am a hummeuss net duinc all work myself.[No seekers•curnp-m_surance reymtel-). }
1 10 J Building addition
4.0 1 am a ltomewvvnee and will he hiring ecniracturs to conduct all work on my property. I will
velure that all contractors either hate w'inkers compensation insurance or an sole 1 1 la Electrical repairs or additions
proprietor.with no employees.
l 12.0_.0 Plunthing repairs or additions
s
S 1 l tand 1 has am a ecnera contractor c hired the sub- t eunractun listed un the attached heet_
{� ! 13 11 Root-repairs
These sub-eurtraeturs have cznpiusccs and base workers'comp.insurance.: i
( 14.0Other
6.0 we are a corpocattun and its officers hate exercised their r'ghl of exemption pet NIC1L c. i
IS'_:11+1.and sic have no employees.[No workers•crimp.insurance tequired_[ {
1
'Any applicant that cheek,.but'I mot also till out the section below shoo inp their a orkers.compensation policy information_
'Homeowner.who submit this affidavit inehe:dine they are doing all work and then hire outside contractors must submit a new affidavit mndicatme such.
'Contracton that check this!NA must attached arm additional street slow trio the name of the sub-ezntractor>and>tate u helher or not those entities have
employees. If the sub-contractors have employees.diet mum provide their workers'comp.policy number.
I am an employer that is providing is orkers'compensation insurance far my employees. Below is the policy and job site
information. l�
Insurance Company Name: L 110 e Is-'--\ 6\v YJ t,\
•
Policy#or Sell-ins. Lie.-: \A/C231S—6 2y-26 ( D i I Expiration Date: 3 /Z 5 _
Job Site Address: i 0-4" V P C(\hid AU p City:Statc:Zip: 0 i D 6 O
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MMGL c. 152. ti25A is a criminal violation punishable by a line up to S1.500_00
antl'or 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 Investi_,ations of the DIA for insurance
coverage verification.
1 do hereby certify and r the pains and penalties of perjury that the information provided above is true and correct.
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Signature: �I �/wCJ"` Date:
Phoned: 14(3 3141 $3-43
Official use only. Do not write in this area,to be completed by city or town offtciaL
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
16.Other
Contact Person: Phone#:
City of Northampton
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i ff.; Massachusetts 7 ,._ -_i f1 DEPARTZ4ENT OF BUILDING INSPECTIONS 2 IP
212 Main Street • Municipal Building v •
'"� '�` Northampton, MA 01060 rfN ^0�
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: Val14..` iecichii.
J
The debris will be transported by:
Name of Hauler: Wil kisieC C5 ' idol
Signature of Applicant: ,A'
—, c r Date: 4 i 13
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