30C-052 (13) BP-2023-0573
105 CLEMENT ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
30C-052-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREG STERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUA NTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2023-0573 PERMISSION IS HEREBY GRANTED TO:
Project# ADD SHOWER 2023 Contractor: License:
Est. Cost: 9000
Const.Class: Exp.Date:
Use Group: Owner: SCH DIG CYNTHIA S&BONNIE COOPER
Lot Size (sq.ft.)
Zoning: SR Applicant: SCH DIG CYNTHIA S&BONNIE S COOPER
Applicant Address Phone: Insurance:
105 CLEMENT ST
FLORENCE, MA 01062
ISSUED ON: 05/03/2023
TO PERFORM THE FOLLOWING WORK:
ADD SHOWER
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 VIQLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
1 . , I )2 . cs-147),
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fa : (413)587-1272
Office of the Building Commissioner
4lgy , .7
3 2n
The Commonwealth of Massach efts 0Fpz /
W Board of Building Regulations and Standard"'D, H t�itorN FOR
Massachusetts State Building Code, 780 CMR��'row iNSpF CIALITY
Mq o/ bO,vs USE ,
Building Permit Application To Construct,Repair, Renovate Or Demolish a -Revised Mar 2011
One-or Two-Family Dwelling
LL�� This Section For Official Use Only
Building Pe it Number:� /� )1j 573 Date Aplied: _
i& 6✓��� J% 77 5.3-20Z3
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1:1 Property Address: 1.2 Assessors Map&Parcel Numbers
(o 5 C/e LAt Si"-. F/a reptc-e
1.1 a Is this an accepted street?yes 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 L. 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 ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ipwner'of Rec
C to s e_d
�N FidN2 vAGe._ /lit ii--- d l 0 C Z
Name(Print) City State,ZIP
C5C-Iloke-cin41- Q.-
No.and Street Telephone mail Address
SECTION 3:DESCRIPTION OF PROPOSED WORIe(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) ❑ Addition ❑
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed W ,4 GwQ Mir)/ ` a
e mu % 4t PALI
SECTION 4:ESTIMATED CONSTRUCTI6N COSTS
Item Estimated Costs: fficial Use Only
(Labor and Materials)
Min $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
AIM $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ pa
Suppression) Total All Fees: $ .
exFJ Check No. 7a5 Chedc Amount:
6.Total Projeretrt: $ q' O(7(� DI Paid in Full ❑Outstanding Balance Due:
pr .V1-1G
City of Northampton
,40
Massachusetts
' s *ems
. DEPARTMENT OF BUILDING INSPECTIONSz 212 Main Street • Municipal Building
Northampton, MA 01060 T Y Q'
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS,ROOFS,RENOVATIONS,ROOF MOUNTED SOLAR,ETC.
I. 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)
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. Ii.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC j Roofing Covering
WS I Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
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 0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,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.
//41 Coe � S-3 -a3
*+tint O er 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), +ill 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"
a.
i,.. ... The Commonwealth of Massachusetts
.. au,.
Department of Industrial Accidents
1 Congress Street,Suite 100
14 .... .
Boston, MA 02114-2017
toottntass.goridia
11 inters t'ompensation Insurance Affida%it:Builders/ContractorsfElectricians/Plunthers.
1(1 ilk.FILEI) 11-11 IIIi.PERAIIIIING AUTHORIFV.
Annlicatit Information Please Print Legiblv
Name illusincss;Organtzation:lislividual0:
Address:
City/State/Zip: Phone ::-
Ate YOE in employer?Check the apprnprtat r hit :
T)pe of project(required):
lam a employer with empk,yee%(fail-aid or part-time0 7. 0 Nev.construction
2,0 lam a z4lepruprietut pc parmashrp and base no etriptol.res worktm for me in 8. 0 Remodeling
an L.-apiary [No stutters"comp.maw-mix textured]
9_ El Demolition
.1:::j I ama&now*ner doing all wort inyielf.[No worloo:'comp_anus-am:0 mquirell"
i 0 C] Building addition
4. v I am a horneossnex and*ill be hum*iraetura iv conchal all weak on nt!,property. I rk til
,m.sure that all contraouts either flare vi,orrkers'vonipoisation ireslatanix or an:wle I I a Electrical repairs or addition:,
pruprueborra in ab 00 employeu_
i ID Plumbing repaim or addition,
SO I ant a eateral contractor and 1 bai.e hared the sub-euntraelots hated tan the attached sheet
1 3.C3 Rout soh-Lunt employees and lime worke rs'comp.utattranee.'. f
These :actors have oy 14.1:10t11M
6.0 We urn a corpomnon and its on-Kw:have,exeretsed then mtlit of exemption Nr lkitiL c,
1142,§1141.and A e ha..1:no employees.[No vairkera'comp.insurance ramped...1
'Any appbc4nt tut..h...elt....i box n I mmt ab.0 till out the iceoon below at11)4 Inv their xorktr,`evrapensah,n Nlazy nit-Ay:ma-xi
tioirtem*ners IA bll SUbMri LIM allitkv.11 nithcatiog they are doing all wurk and than hue tmtmde eiminbctee4 mum imilnut a new a1iitia..111 dial!eating such
:Contractor%that cheek this bas must attached an adchtiunal sheet am*ing the name of the sub-enntractors and state‘shether m not those enhtlea.hme
onpluyeea. If the aub-eunii,aetos,.1.u....:•ortplu.,et ,tht!.must pn.wide their uurkets`eonap.policy,number
I ant an employer that&providing ovorAers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company blame: _
Policy#or Self-ins.Lic. #: Expiration Date:
Job Site Address: City'staxezip:
Attach a copy of the workers'compensation policy 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 SI.500.10
iindior 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 ins estigattons of the MA for insurance
coverage verification
I do hereby medic ander the pains and penalties of perjury that the information provided above is true and correct.
Si —4 __5 ature: (2 f,tea..... ...S.W6Ca___ (-'-r... Date: 3- -
Phone=-.
Official use only. Do not is in this area,to he completed kv city or town official
City or Tow n: PermitiLicense#
Issuing Authorit!, icircle one):
1. Board of Health 2.Building Department 3.Cityfrov;n Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone*:
. _.. .. .. _
/
City of Northampton
.'" Massachusetts
S.
DEPARTMENT OF BUILDING INSPECTIONS��1,:1411 212 Main Street • Municipal Building ,``,
Northampton, MA 01060 sF;� *‘'
y ri
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: ilea 1 ic 7 QG.y c l 1 c�
s The debris will be transported by:
Name of Hauler: S e--) ')
T
Signature of Applicant: JC---- 0,-Pcl .,<-3Date: 5-3-�3
1
City of Northampton
t d� JjC
'� `�` Massachusetts q' " ?�
DEPARTMENT OF BUILDING INSPECTIONS Vx
,,,,,(t
212 Main Street • Municipal Building -Ct.
Northampton, MA 01060 . 1,ttt
OW
/' HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, ` VI !A 5�t't at' pL c 1 (insert full legal name), born_(insert
month, day, year), hereby depose and state the?llowing:
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 '117 , 20'3
d 4,caL_ -
(Sign re)