38A-074 (6) BP-2023-0867
155 GROVE ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
38A-074-001 CITY OF NORTHAMPTON
Permit: Exterior Res
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2023-0867 PERMISSION'IS HEREBY GRANTED TO:
Project# ROOF 2023 Contractor: License:
Est. Cost: 6000
Const.Class: Exp.Date:
Use Group: Owner: FOSTE CANNON APRIL L& KAREN
Lot Size (sq.ft.)
Zoning: URB Applicant: FOSTE CANNON APRIL L&KAREN
Applicant Address Phone: insurance:
155 GROVE ST
NORTHAMPTON, MA 01060
ISSUED ON: 07/03/2023
TO PERFORM THE FOLLOWING WORK:
STRIP AND RE-ROOF
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: •
Xt
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax (413)587-1272
Office of the Building Commis& ner
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r The Co monwealth of Massac' sett
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rBoard of Building Regulations ar 4 Sta •ards �i .3
�� !NIC 'ALITY
1. ;7 Massachusetts State Building Coc-, .• •..
•v 4, ^, o,� E
i Building Permit Application To Construct, Repair, Reno 9 ,c-molislha Revised Mar 2011
One- or Two-Family Dwelling opt, 'lsp
j This Section For Official Use Only 4,
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I Buildino Permit Number: &P' , —Z 7 Date pplie :
1
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Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers,
(SS C,(oVc S4-• S 8 A 07 �f
1.la Is this an accepted street?yea/ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
I Zoning District Proposed Use Lot Area(sq Frontage(II)
r
1.5 Building Setbacks(ft)
bFront Yard Side Yards Rear Yard
r--
i Required Provided Required Provided Required Provided
Zv ✓ i- lS
f�
1.6 Water Supply: (M.G.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: __ Outside Flood Zone
Public Private❑ i Check if yes ^j Municipal On site disposal system 0
SECTION 2: PROPERTY OWNERSHIP' C,61hy10 yl ek t SS 6) ...-V
2.1 Ow/r'of Record: /' non — A /6 r A 36%e' ►tv M
� et CGL� I V �n ^ A J
Name(Print) City.State.ZIP "
1 cc &r1v L S'1/4-. (f l3 -S 37- R760
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building- Owner-Occupied Repairs(s) 0 Alteration(s) Addition 0
Demolition Accessory Bldg. ❑ Number of Units 1 Other 0 Specify:_
Brief Description of Proposed Work': t --_—_
Afic-to
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ /_ 606 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ 'v` ClStandard City/Town Application Fee
0 Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $_
4. Mechanical (HVAC) $ List:_
5. Mechanical (Fire $
Suppression) Total All Fees: $ I�
Check No. Check Amo . Iv Cash Amount:
6. Total Project Cost: $ (a r 0 'V 0 0 Paid in Full 0 Outstanding Balance Due:
City of Northampton
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b �`'r Massachusetts
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4 DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street s Municipal Building rt( y"
Northampton, MA 01060 fps
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR NEW
1 & 2 FAMILY DWELLING, ADDITIONS, POOLS, DECKS, ACCESSORY STRUCTURES,
FENCES, GROUND 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. Site plan with location of proposed structure(s) and set backs.
4 Construction Debris Affidavit filled out and signed by applicant.
5. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
6. Contractors must supply a copy of CS License, HIC Registration and proof of Liability Insurance.
7. Energy Conservation Compliance Certificate (new / replacement windows).
8. Home Owner's License Exemption Form filled out and signed by Homeowner (if applicable).
9. Note any Conservation and/or special permit requirements (it applicable). 10.
Driveway Permit (if applicable).
11. Proof of Water and Sewer entry fees paid (if applicable).
12. Trench Permit - public land by DPW/ private land by Building Dept.
13. Stretch Energy Code - all new construction will require a HERS Rater Affidavit to be submitted with permit
application before issuance of permit.
14. 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 D. •
Name of CSL Holder
List CSL Type(see below)
No.and Street Type j P scription
U Unrestricted :uildings up to 35,000 cu. It.)
R Restricte. &2 Family Dwelling
City/Town,State,ZIP M Maso'
RC '•. ing Covering
WS I indow and Siding
SF 'olid Fuel Burning Appliances
Insulation
Telephone Email address P Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC egistration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP elephone
SECTION 6: WORKERS'COMPENSA ON INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6))
Workers Compensation Insurance affidavit m be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the I uance of the building permit.
Signed Affidavit Attached? Yes ..... .... ❑ No .0
SECTION 7a:0 ER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGE OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject prope ,hereby authorize • •
to act on my behalf,in all matt- s relative to work authorized by this building p mit application.
Print Owner's Name(Elect onic 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.
Afr 7 -
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 owrer 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,finisl-ed 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"
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: U LOT: ° `V
LOT SIZE: `�
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton
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y Massachusetts ° °•.°,�c
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DEPARTMENT OF BUILDING INSPECTIONS
,., 212 Main Street • Municipal Building , `1
Northampton, MA 01060 Z4. ;I
HOMEOWNERS'EXEMPTION ELIGIBI►ITYAFFIDAVIT
1, hr(' l I `A IA Vk d ' (i sert full legal name), born (insert month,
day, year), heiy depose and state the following: 0
1. I am seeking a building permit pursuant to the homeowners' •xemption to the permit requirements of the
. Massachusetts State Building Code, codified at 780 CMR 110.R5. .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 seeki g the aforementioned homeowners'exemption,
does not involve the field erection of manufactured buildings cons cted in accordance with 780 CMR 110.R3.
3. 1 qualifij under the State Building Code's definition of"homeowne "as defined at 780 CMR 110.R5.1.2:
Person(s) who owns a parcel of land on which he/she resid z. 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 lice se and, except to the extent that I qualifij for
and will abide by the Massachusetts State Building Code's require •nts for the supervision of the project or work
on my parcel, I am not engaged in construction supervision in ..nnection with any project or work involving
construction, reconstruction, alteration, repair, removal or demo,ition 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 a''th the aforementioned project or work on my
parcel, I acknowledge that I am required to and will act as the supe isor for said project or work.
Signed under the pains and penalties of perjury on this day of _ , l 20--- 3
61.,/,____6i
•
(Signature)
•
The Contntonrcealth of Massai useits
4i,- - — r'i• Deportment of Industrial.4cl'dents
I Congress Street,Suite 1 0
Boston, MA 02114-201,-
. ,
trn,w.mass.goridio
1$Otkers' ('ompensation Insurance Affidas it: Buildersi('ii ractorsiElectricians:Plumbers.
to BEI-11AI)NVI"I'Il 111E1 PERN11 t l'iNt;. terlIORITY.
Applicant Information Please Print I..ev.ibls
Name itiusincs,s,olgulliZaililil lath ktuai i, ,l—
Address:
City/State/Zip: Phone #:
Are nil an entritny rr?Cheri tbr appr•priate box: -r!,pe of project(required).
3.0 i Attri d ernp toy et voth employee%(fall=dr.,'part-niner• 7. 3 New construction
20 l ain a&kite propnetis or prannership and have Slid employers workrns fur the in 8. CI Remodeling
any capacity•[Nu saori.ers'c•xtrp.insurance regional.)
9. 0 Dernolitioli
eili blit1104!Ve flti doing all kskirt niyielt rNo workers'comp inwinuscr required r
1 o 0 Building addition
4 a i Ain a horiso.%/K-T and*Ill he hirinir Qontraours to conattei ali%talc on iny property. I will
CMIltIC that all COntrat:it,n,either lia,„K'Ac.,rierN"1..oinpertsanosi oiNanuiwe..4 are-..ol.: I 1.,:i Lie:lib:al repairs or atiditior.,
prapneion with no employees
12 0 Plumbing repairs or adtillItitti
..C:1 I arn a general contnietor and I have hms1 the Nub-contractors listed on the ituatired maces
l 31:13 Roof repairs
t'llew.0.4,-coiti74iram-,,.tiro,-einployee and have workers'ctanp.insurance
14.0 Other
otj We am:a‘.,,,,isporatJoii and its officers has exsaviNed then nylst of'exemption per MtLrE.c. -
I 52..§l t4t.,and tve h.%,c nu onploers,(Na,wuriker,'a:nm'.insurance required.i
— —
*Nit:,iipplikarti that threit.%bwi Pi MUM 4Iii‘u till out the st etton belov.shins Inr their woriktss'wive-crimson policy Inforinutron
' Homeowner,who Nubrnit this alforbir it indseating they are(hang all work and then here Ma.104.41.!,tyntractors mu sfr submit a new alftd 4%Ik Indivating such
',Contraputurs that cheek this hoe MUM attached an additional skeet Nhov.ing the 1121V11:of the Nub-c,..ntractors and state ts healer CV noi those,:nt:Ii.t,ha.,
ctiviOyCl"'V If this:MA,ionlc.sCrAWI',.ha,..c 1:n4,1o:ices.,flb.:',, ;num pavr,ale i'mcir , olkers',v,Inp puh.....ra,ank...1
-- ------ ----t—.-1-', —
I am an employer that is providing worhers'compensation insurance far my employees.. Below is the policv and job site
infarmation.
Insurance Company Name:
—
Policy#or Self-Ins. Lie.#: Expiration Date:
Job Site Address: "ity,Siate.:Zip._
Attach a copy of the workers'compensation policy declaration page(showi ig the policy number and expiration date).
Failure to secure coverage as required under M(iL.c. 152. §25A is a criminal v" !alum punishable by a fine up to$1.51X),(X)
anchor one-year imprisonment.as well as civil penalties 111 the form of a STOP (:)ltk ORDER and a fine of up to S250.00 a
day against the violator.A copy of this statement nut) be forwarded to the Offi of Ins estigations of the DIA for insurance
coverage verification.
I do hereby rer ',,k.under the pains »allies of perjury that the information pro;tided above is true and correct.
inature: D'i, 7 -- -2-7
P one v:
ti
Official use only. Do not write in this area,to be completed by city or town official ,
("ity or Town: Permit/license it . .
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Eleclrkal Inverter 5. Plumbing Inspector
h.Other
Contact Person: Phone :
City of Northampton
Massachusetts .
t4L7/...-r.
DEPARTMENT OF BUILDING INSPECTIONS ,'
212 Main Street • Municipal Building y>'
Northampton, MA 01060 ''s-1'4 ryJ y `
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: g u. 5+ rt C.-IG Up
The debris will be transported by:
.6
Name of Hauler:
Cl S-i-e c
1
Signature of Applicant: Date: 2 ,_3 17