17C-277 (4) BP-2023-0673
13 LILLY ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
17C-277-001 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-2023-0673 PERMISSION IS HEREBY GRANTED TO:
Project# REPAIR DECK 2023 Contractor: License:
JG CONNELL HOME
Est. Cost: 1230 IMPROVEMENT 080816
Const.Class: Exp.Date: 10/26/2023
Use Group: Owner: KRISTINE BOS, BLAKE W&
Lot Size (sq.ft.)
Zoning: URB Applicant: JG CONNELL HOME IMPROVEMENT
Applicant Address Phone: Insurance:
2 PETTICOAT LANE 413-695-4810 SOLE PROP
WILLIAMSBURG, MA 01096
ISSUED ON: 05/22/2023
TO PERFORM THE FOLLOWING WORK:
REPLACE ROTTED BOARDS IN FRONT ENTRYWAY
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:
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
,/ ' 1
,,c/ ,,
The Commonwealth of Mass'hus s y 2 *
W Board of Building Regulations afad Stud ds F Massachusetts State Building Code,`�8(I
ry /40 SEpLI I Y
Building Permit Application To Construct,Repair,Reno `tel0 ' 'sh a Revi ed Mar 2011
One-or Two-Family Dwelling �.Mq o�T,
This Section For Official Use Only
Building Permit Number: Bp-a,p'a.3 Ol07 3 Date Applied:
,c :1 i )• 97:),),/,
,_ _.5.:-A__y22
Building Official(Print Name) Signature Dat
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
!3L-+!ly 54.
1.la 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 Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood one?
Public III7 Private 0 Check if yes Municipal Jr! On site disposal system ❑
SECTION 2: PROPERTY OWNERHIP'
2.1 Ownerl of Record:
gla ice IQJ . P'/QrLace ij4A
Name(Print) City,State,ZIP
1.3 G.I1LV '7 775 31 r,iM
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building CI Owner-Occupied Q Repairs(s) % Alteration(s) 0 Addition ❑
Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify:
Brief Description of Proposed Work': A e yv,.PVC RDrrejie ite.atell, Ca gt C
d V 7-xlye crA.D-e4-hce 1,./.// ci, e, 4/ g e is/arse i 4,1:4`4. Ar e 14.0
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire ��
Suppression) $ Total All yleisi:Ajt, di
Check N eck Amount.
6.Total Project Cost: $ /)„ 120 0 Paid in Fu ❑Outstanding Balance Due:
City of Northampton
Massachusetts .c'
�;. DEPARTMENT OF BUILDING INSPECTIONS ?y
212 Main Street • Municipal Building 0�;., ,�
".j Northampton, MA 01060 1��
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS, ROOFS,RENOVATIONS,ROOF MOUNTED SOLAR,ETC.
1. 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.
V
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) GSFA L7'fre !Q/•4/2
't' G 1'je A C. el PI , (1/ License Number Expiration Date
Name of CSL older f;
7 List CSL Type(see below) /8r.2 ,r,
Pert/COO'44 1P10 171 y
No.and Street Type Description
t / U Unrestricted(Buildings up to 35.000 cu.ft.)
(111/11 I `t ni y () Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
Od, O 1 9 j Q� RC Roofing Covering
h WS Window and Siding
/ SF Solid Fuel Burning Appliances
4O 6 7.f 14 is cod{ f, &G."1 C c I Insulation
Telephone ..7 Email address D Demolition
5.2 Registered`` / Home Improvement,ssLL, Contractor(HIC) I L 9'Sa 15 v 7
�' Vf/a�yYi1 �T C4vlrt�(DD/L �if�i Ca t HIC Registration Number E rati n Date
HIC Company Name or Fir_Registrant Name
No.1t/ I//tl ors s]€Dazy MA, O (0 9‘ 36�+�/0 Email address
City/Town,State,ZIP Teleph.,,
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitte 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 .5 q[G I~) &-7 n.',
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMITT
I,as Owner of the subject property,hereby authorize .>Q3,0'7 G. Gatzte1/
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.
ghie 5/72/23
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.eov'oca Information on the Construction Supervisor Licensr can be found at www.mass.uov 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"
AP
:::. ..\ The Commonwealth of.$1assachusetts
' el Department of Industrial Arca' ents
I Congress Street,Suite 100
Boston, ,V1.4 02114-2017
••,-14 A
www.ntass.govidia
1%otters'Compensation Insurance Affidavit: BuildersiContractorsiElectricians/Plumbers.
To HI:FILEI)A 1TH THE PiRlilITTING At TII()RITV.
Applicant Information Please Print Lesti hi+
Name iklubuuss,Or.gana-ttion,lnktilidunly
Address:
City/State/Zip: Phone#:
. . ,
.re yea am employer?Check the a pprepriate boil
Type of project(required):
' 1.0 I am a employer with crimloyem(full Imam pari-tinte t• 7. 0 New construction
2g(am a ule proprietor or partnership and have nu employees working fur me in S. a Remodeling
any capscity.[Ni*otters's:oitip.insunuace remnredi
De
3t3 lam a horricowner doing all work myself.(No*otters'corer,insurance renusted 9. 0 molition..]'
10 0 Building addition
1.C3 1 am a homeowner and will be hiring oillitractors to cornin,1 all w ork on my pmperty. I will
ensure that all contractors tither left e workers"corripen.ation rnsurance or are sole 11.0 Electrical repairs or additions
pruptietocn with no employem.
12.0 Plumbing repairs i.)r additions
.50 I am a general contractor and I have hired the nib-contractors Listed on the attached ahem..
I 3.0 Roof repairs
These mtb-contractors have employem and hAve workers'comp.msuraticesz
6E3 We are a corporation and it officers have mierciacil their nett of,rxrinpthon per NI(sL c. 14.0 Other
I 52.§I i 4),=LI we havt lk.)ticiployetl.[No*mien'comp.maimmee Tenni:till
l
Any applicattt that cheeka boa All mum Aka fill out the section below showing their wurter,'cornpensatiun pulicy utfortnatium,
t Homeowners who auhrint this atradat.it trulicating they art doing all work and then hire outside contractor-1 mint 5ubnmit a new alliatav it indicating sta.-h
*^Cuutractors titat.ilea thia bus.mini un.Ach.ni an sirditiunal ibet -bt.n..itm the name of the uti-coraracters and state whether OT riot thwic.nn.tn.-,
onployec, lithe,ub,eunirActors bas,e,itirrIv.:,,:i.:r,they niuNt pro,ikl,:tf.uir •••.ori.,:ri-.a inc' proJn::,,number
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: _
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: ' CityState:Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under NIGL c. 152_ §25A is a criminal violation punishable by a tine up to$1,500.00
atid:or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to 5250.00 a
day against the violator.A copy of this statement may be forw.it.:.cd to the Office of In°.._:,tigations of the DIA for insurance
kcrit'A2-2.'.icil.
do hereby ceTtif• der the pains and penalti of per' •that the infOrmation prtivideit all ,I..,,is true'and correct.
Signantre- _.----7
I)ate: t2/C KZ‘.._
Phone tt! 4C/_7---#7.5."--1 7 0
•
Official use only. Do not write in this area,to be completed by city or town official
City or Town: PermitiLicense#
Issuing Authority(circle one):
I. lki.trd of Health 2. Building Department 3.Cityirows Clerk 4.Electrical Inspector 5. Plumbing Inspector 1
6.Other
Contact Person: Phone#:
City of Northampton
•
Massachusetts
46
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 ,1+,
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: � 1/ 7 S A Livy
The debris will be transported by:
Name of Hauler: C 0//
Signature of Applicant: Date: ��
I
City of Northampton ____
Massachusetts � r
./ * 1
DEPARTMENT OF BUILDING INSPECTIONS rz'
'aw4* 212 Main Street • Municipal Building iZe.
--14•••--• Northampton, MA 01060 ';j;
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, (insert full legal name), born_ (insert
month, day, year), hereby depose and state the following:
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. 1 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 , 20_.
(Signature)