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24A-054 (3)
BP-2023-0572 95 JACKSON ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 24A-054-001 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-2023-0572 PERMISSION IS HEREBY GRANTED TO: Project# REPAIR 2023 Contractor: License: Est. Cost: 2000 JAMES ROSS CS-074105 Const.Class: Exp.Date: 04/09/2024 POLACHEK DANIEL W&TRACEY G CO- Use Group: Owner: TRUSTEES Lot Size (sq.ft.) Zoning: URA Applicant: JDR BUILDERS Applicant Address Phone: Insurance: PO BOX 66 (413)374-7983 WC9024479 WHATELY, MA 01093 ISSUED ON: 05/04/2023 TO PERFORM THE FOLLOWING WORK: REPAIRS TO GARAGE 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: Itit • - gr 61T Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax, (413)587-1272 Office of the Building Commissihner lr BM t/0 eiVtAW// ,i / 0 / / qr / The Commonwealth of Massachu? e`..� �t7 Board of Building Regulations and Stan> FOR Massachusetts State Building Code, 780 CNIIi,"gs'OFcr'V' 'MUNICIPALITY US�,o�o 04 Building Permit Application To Construct,Repair, Renovate Or begnoftsh a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building P rmit Number:beer ,5V-,�3 "ti' Date Applied: �vea-)l Koss 077 5-3-2.6z3 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes ,9 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 0 Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: f/)d. get 7 tic t-r Awe/O./V4Che ( �©rftam/otdrl /V 6/b , Name(Print) .sty 09/tic/u/L,,barn't I L, City,State,ZIP KJAC/46aq 644 Pvtr trkM '1/3-58g-5V07 iac & d4 o/aClx.h,Corrl 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: Brief Description of Proposed Work': t�,11- C i tt.)1L of C-A-4A-4E ii 1 Ry CA-L SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ Z 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ClStandard City/Town Application Fee ❑Total Project Cost3 (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ Z 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Term--7,.> F% 5 License Numb r Expiration Date Name of CSL Holder Li- t List CSL Type(see below) No.and Street epe Description 50 - t�G�c�F7E�-�, ✓Y►/4• 0/'3 7j � 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 Lit 3 S'7 Y 79e-3 jl DJ c f 1 y i) - coo- I Burning Appliances Insulation Telephone Email address D Demolition 5.2 1cjegistered Home Improvement Contractor(HIC) -.c 3-1j--. y7 J 'Jt �ui '"'( ` HIC Registration Number Expiration to HiCo pany Name or HIC Registrant Name , D�o'y �e J J @J'pie i N'-f rs_a_1...-- No a nd Str -el S M Ac.iir ?-1 '. 7 3 Email address 4 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 TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize 3 h2 Bv'(N IILS to act on my behalf,,in all matters relative to work authorized by this building permit application. `Q,--:-Q .i .�- Met-AdO S 03 o'LOR3 Print O 's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By enterin y name below,I hereby attest under the pains and penalties of perjnry that all of the information containe ' this application is true and accurate to the best of my knowledge and understanding. D/L-- 5—3—2 D Print Ow '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 id have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important informatidn 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" I City of Northampton Massachusetts 'V - c' ' f 6 DEPARTMENT OF BUILDING INSPECTIONS r4 212 Main Street • Municipal Building v CD 'e0'' r Northampton, MA 01060 s%I! ‘'‘`� 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 4- ` re/\ C2-P`-` G r` - The debris will be transported by: Name of Hauler: 51) ��-- Signature of Applicant: Date: The Commonwealth of:1iasssttchttsetts • �,..„.'�-- Department of Industrial Accidents r �" ,_ I_ �� 1 Congress Street.Suite 100 R.. Boston. MA 02114-2017 .1.,;� .,. rwlan.masc.gor din 11 to kerns'(*un►pensalima Insurance:tffidas it:BuiWrrv'Cle r>Ktor iEfeetriciansrPlutnbers. 10 BE.1-114_I)'41111 t iii:PE:R\111 111G AMIIIORI111. Applicant lnformatinn Please Print Loki Id% Name lllusincsc'(hgantrationlndil,Id wit e: Y.D*12_- -a1) I `‘.4?--5, t& ` Address: 'hu i3.D x 4 City/State/'Zip: 1J\t`-kt13 MA p l 1 '3 phone#: 3 7 V- -7 '3 CS 3 Are yea sr employ rr?Clerk nee alrpnuprialc hoax: l��(required): �/ Tyr d 1.214 ant:a.ny±kn.r N al 63 enti loyeex(Tull and or p:irt-t mne 1.* 7. 0 New construction _s. 1 ant a sole proprietor or purmership and has ail.ntpluy is wt+rkirtp Cur nu:in S. agentodeling any capacity [No s inters'eLanp.insurance nquir.tL] 9. El Demolition 1.71 I ant a iulnnuutam.i doing all murk myself.IN airless'comp.m¢+urnttti cog.uar.zl.]' 10 0 Building addition t-❑1 am a lwnlr a.am,and a+ill the ham=cosi:ra.9tars to conduct all work on nry property_ 1 will e,Lwrc that all ootttracluas enlace has.:wod.crs .uenlhatsat.t.n insurance,or are sole 1 11.0 Electrical repairs or additions proprietors with rw onpluyt... 12.El Plumbing repairs or additions SO 1 ant a acru-ral cuniraLtor and 1!save kneel the sub-eontsactor.lrst.d to the attached sheet There soh-cuntraetor.fuse -tnpluye.y and has Isurkars'comp.insurance. I ❑Rtnlf repairs 14.f()the! Yn 6.0 We are a. twlratiou and zits officers havecxcrinsed then nigh of exenaltwln per'it(/1_c. .. 132,§1(41,sal we htas.no cropluyzv:a.No aurher..'cennp.insurance teyun.Jl.I *Any appli..xtt that dt.aks box al must also till out the section helots shoo ins:their anthem'canlpensation polies information. *ttornets%nets oho submit this atinckasit utalaeatmac they arc dame all wtark and then hire outside cL+atlractoes must submit a nets a11-0 it nrdicatmg such. ('untractorx that rhea$this boa must atsached an additional dam sharp imp the name of the a 7utrcLa[era.turs and state o tether or not those oristies has. employees. II the sub-contra:Am%laa.e argnlos ccs.they east pros:de Hacaa workers'.xaanp.pulley mamba. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance C'oi pans Name: c.4 J ec- s J I AS . C L `,- Policy#or Self-ins.Lie.#: V)C e10 7 y N 7 9 Expiration Date: 1 Z cl— 2 y Job Site Address: 9 S J j-c fc_S or,,, S 4' City/State/Zip: A/ jvw Attach a copy of the workers'tout penaatiaa policy declaration page(showing the policy number and expiration date). Failure to sarure coverage as 1opined wider MGL c. 152,425A is a criminal violation punishable by a line up to S1,500.00 and/or one-year imprisonment.as is d d I as cal.i l[penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A clap,. taf this statement [nay be forwarded to the Office of Investigations of the DIA for insurance ens cragee verification. I do hereby certifj.and r t e' ins `t1 penalties of perjure'that the information provided above is true and correct Signature: ( v J` ia:atc_ S - 2 3 Phone#: L/i 3 - 3-7 1- -7/> S 3 Official use only. Do not write in dais area,to be completed by city or town official ("its or Too o: I'ermit;l.icense rt Issuing Authority Icircle one): 1. Board of Health 2.Building Department 3.(`iti Joss Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: