17A-188 (11) •
BP-2023-0655
21 KIMBALL ST COMMONWEALTH OF M SSACHUSETTS
Map:Block:Lot:
17A-188-001 CITY OF NORTHA PTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGI TERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARA TY FUND (MGL c.142A)
BUILDING P RMIT
Permit# BP-2023-0655 PERMISSIO IS HEREBY GRANTED TO:
Project# KITCH RENO 2023 Contractor: License:
Est. Cost: 16000 DOUGLAS GOODN W 082188
Const.Class: Exp.Date: 10/16/2023
Use Group: Owner: H BELL ROSS J&ERICA
Lot Size (sq.ft.)
Zoning: URB Applicant: GOODNOW CONSTRUCTION INC
Applicant Address Phone: Insurance:
45 WESTVIEW TER (413)548-4561 WCC-500-5026062
EASTHAMPTON, MA 01027
ISSUED ON: 05/22/2023
TO PERFORM THE FOLLOWING WORK:
RENO KITCHEN CABINETS
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:
f ' 2.1 - / •
Fees Paid: $104.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Buildine Commissioner
The Commonwealth of Massachusetts': MAY !'7 2023
t/ Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 C _ -MUNICIPALITY
c IIDING INSPC IONS USE
Building Permit Application To Construct,Repair, Renov�at n bl�§BC' °'O i-ReviseciMar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: 81° of 3"t/ T' Date Applied:
Building ..) N,
Official(Print Name) Signature 1 ' e gn
SECTION 1:SITE INFORMATION
1.1 Pro erty Address: 1.2 Assessors Map& Parcel Numbers
.1 Mba 11 Sr.
1.1 a Is this an accepted street?yes '_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
i
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 ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: r/.f.e^ ' 1 U/ 0 6)
I�os3 6e
Name(Print) City,State,ZIP
.D-1 kMl a1( 574, y/3 al0-Lsos 6 6t1/71 e 9Mo I. (A4v,
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) drAddition ❑
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: 10,41 o o/d if-H-ti(a.e. LOB,r. -7`n s-44"
/vim Co1,.st-'S - A!( Pif -{-LJr r 5 5fi1 11\ Cc Mt-- ,Sp o77
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ Aolo I) ov) 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ a ) 0 Standard City/Town Application Fee
1 0 0 Total Project Costa(Item 6)x multiplier/b 0 0 V x b�'
3.Plumbing $ ) o e0 2. Other Fees: $ i
4.Mechanical (HVAC) $ ,,/J Pc List:
5.Mechanical (Fire
Suppression) $ /VA_ Total All Fees: $ 101.I-2`o o v
,Check No.2 Check Amount: 1 O''.- Cash Amount:
6.Total Project Cost: $ II>. 0 6 0 0 Paid in Full ❑!Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) D (.21 r /o//'/3
GJJ d t w License Number Expiration! Date
Name of C§L Holder
List CSL Type(see below) U
f S W 5tu luti✓
No.and Street Type Description
'k. S, j- 0-/K-11 ,# 0 l Unrestricted(Buildings up to 35,000 cu.ft.)
City/Town,State,ZIP /N v` R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
I SF Solid Fuel Burning Appliances
Li/3 - 5 g—'(5-() 1 )os1,.ow e 4.4 .(,eM I Insulation
Telephone Email iddress D Demolition
5.2 Registered Home Improvement Contractor(HIC)
,,//��o odd L• CO". C« . 'sir 3 y
[jRegistration
�9 n HIC Registry on Number Expiration Date
HIC Company Name or HIC Registrant Name 1
K S lives-rbicw 7-�- (� d 'w e m
No.and Street Efnail 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 AUTHORIZAT ON TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACT PLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work au orized by this building permit application.
c25 S 13eA ( 7,va3
Print Owner's Name(Electronic Signature) Date
SECTION 76: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.
pc:.s s A-c( 5/fi/a--.
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 eot 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 rdom 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"maybe substituted for"Total Project Cost"
City of Northampton
1r t:° Massachusetts ff./ �'cf
S 11 DEPARTMENT OF BUILDING INSPECTIONS 7` ,yn '
212 Main Street • Municipal Building '.
Northampton, MA 01060 rsN ���`,
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: 01k
The debris will be transported by:
Name of Hauler: poi G�� ►�
Signature of Applicant: Date: L-1/(//)--5
The Commonwealth of Massachusetts
1 Department of Industrial Accidents
„+ 1 Congress Street,Suite 100
`- "{'� "" Boston, MA 02114-2017
y1- .. a www mass.gov/dia
r� ry
Nutkers' ( unlpensation Insurance Affidavit:Builders/Contractors;Elect ricians'Plumbers.
TO BE FILED N I III Ink 1'F:K%tfl'LING At 77IOR1 1 1.
Applicant Information I Please Print Ixi ibls
Name(Business/•"Chganiration✓'lndivutua1): 6�d " S �(.
Address: `i s- wg t a-' 7-(,
City/State/Zip: .-0`-5 t7 0-44,f O' Phone :: 4l3`-S7e-4'Y(
Are yea�r etttnpiayer?Check the appropriate box:
t�J�(/ Type of project(required):
1. tam a employer with.___.i__....._._.er�'y (full and car pan-tirnet 7. 0 New construction
20 1 am a sole proprietor or panncnhip and hare no employers working for me in 8. laltErnodeling
any capacity.(No workers'comp.insurance squired.)
30 I am a homeowner doing all work myself.(No wotkerz`comp_insurance required_ .
9. ❑Demolition
40 lam a hum€s+wner and will be hiring contractors to conduct ail work on my property. I will I O Building addition
ensure that all contractors either have worker'compensation insurrnev or are role 1 I.O Electrical repairs or additions
proprietors with no employees_
12.0 Plumbing repairs or additions
50 I am a general contractor and I have hired the sub-contractors listed on the attacked sheet_
These subcontractors have employees and have workers'comp.insurance.: 13{J Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per Mt L c. 14. Outer
152.*Hai.and u c lace no easpioyeea.[No workers'comp.insurance required"
*Any applicant that chucks iw.s al must also fill out the section below showing thou workers'compensation pulse}information.
t Homeowners who submit this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating suck
!Contraeton t that check this tux must attached a::additional sheet showing the name of the sail-contractors and state whether or not thou canapes have
employee, If the mull-contractors la:aec ct:mlk,+.rc,.thcy most pat idc their worker,'.vamp pufrcy nurnh er.
l am an employer that is providing workers'compensation insurance Or my employees. Belot is the policy and job site
information.
Insurance Company Name: / _
Policy#or Self-ins.L ic.#: ' -Pr)1✓r9,4 9 6 a- )-2 I Expiration Date: (1/1°r-3
Job Site Address:?I / ' 6 57ci City/StateiZip: ��r of d
Attach a copy of the workers'compensation policy declaration page(shouting the policy dumber and expiration date).
Failure to secure coverage as required under MOL c. 152. §25A is a criminal Violation punishable by a fine up toi1,500.00
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 the pains and penalties of perjury that the information provided above is true and correct.
Signature: �" 't Date: r/ � 2//�
Phone y,/3— - C-1/5--6
Official use only. Do not write in this area,to be completed by cite'or town offcial
City or Tow n: Permit/License#
Issuing authority(circle one):
I.Board of health 2.Building Department 3.City/Town Clerk 4.Eketrical Inspector 5. Plumbing Inspector
G.Other
Contact Person: Phone#:
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