43-141 (7) BP-2023-0879
26 LONGFELLOW DR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
43-141-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGI TERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2023-0879 PERMISSIONIS HEREBY GRANTED TO:
Project# 2023 BATH RENO Contractor: License:
Est. Cost: 40000
Const.Class: Exp.Date:
Use Group: Owner: THUR TON MICHAEL T &EMILY WOJCIK
Lot Size (sq.ft.)
Zoning: WSP Applicant: THUR TON MICHAEL T&EMILY WOJCIK
Applicant Address P one: Insurance:
26 LONGFELLOW DR
FLORENCE, MA 01062
ISSUED ON: 07/05/2023
TO PERFORM THE FOLLOWING WORK:
BATH RENO
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: • if y9 . ��
01a
Fees Paid: S260.00
212 Main Street,Phone(413)587-1240,Fax (413)587-1272
Office of the Building Commissi ner
FO
The Commonwealth of Massach,setts
5I° , Board of Building Regulations and .nett-,- FO
.1' /� Massachusetts State Building Code,_780 ►d='Tti ui�o� ICI E ITY
` '4tifi NG
Building Permit Application To Construct,Repair,Renovate Or :_,-, ,et•.• %evise Mar 2011
One-or Two-Family Dwelling °7060
7k°v8
'i Ttii,S on For Official the Only
Building Permit Number:"A 3- 3 77 Date Applied: _
4o-5 JZ- ,�� I 7-7-2023
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1,1 Pro dres/$:_illPi D r^ , , . .2 Assessors Map&Parcel Numbers
1.1 a Is this an apted street?yes kd'� - 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❑ Private El Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
a CT(0)2:_PRQPERTY OWNNHIP'
2c caner'of Record 1, 741/WV a c6
Name(Print) City,State,ZIP /
L.Det_5( i o•
tf
No.and Street Telephone siail Address
SECTION 3:DESCRIPTI OF PROPOSERK2(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied lif Repairs(s) 0 Alteration(s)bf Addition 0
Demolition Accessory Bldg. 0 Number of Units Other n Specify:
I,Fi'ief Description of Proposed WI': 64_Pi, " ram- d J . 4I' h�o A/
c x--v— �.o ^-- c —F -f-t ` , vf- -
ft
SECTION 4:ESTIMATED CONSTRUCTION COSTS r Pell, AL
Item Estimated Costs: Official Use Only
(Labor and Materials)
11.13uilding $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ O Total Project Cost' (Item 6)x multiplier x
3...Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire 40
Suppression)
$ Total All Fees:$ ••
Check No. Check
Cash Amount:
6.Total Project Cost: $ Cc 0 Paid in Full 0 a tstanding Balance Due:_
Pir City of Northampton
�i:te t�rl y stc..
"` Massachusetts w,' `r'`
'. DEPARTMENT OF BUILDING INSPECTIONS ` kJ t
-
:+`44 •' ,:� 212 Main Street •• Municipal Building �%� `a`
Northampton, MA 01060 'fr %
t
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 (if 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.
., , , '' ' s. xi. kaL)5
DocuSign Envelope ID:9FA043F0-C958-4E20-8FA9-89E7CBBD96D8 ,z, m. :
—
SH C'TiON S: CON ___ __. -. {
_ _ __�_� STRIIC I tON sERv#C F 5 ----4
1 5.1 Construction Supervisor Licence(CSL) -- 1
_ __ ._..__ 1 tturatnrrs Mite
\ame of t ,I t t r -._.'- Licsms'Number
r
-Lod(St. 1 cpc!wt t:1"ra 1
i No and Street
l7pe 1
t} I t nrestrrctcJ tlturldings up to ,. 000 cu. tl.)
— R KesItictcJ In I anvils IAccllln
t its loan State.tiP _...__ _ _
NI 61a,.4nn
RI,
Rolf rlrnO meting
_, _____.._— %S 1 wnxlu4, and 1r rnk
i SI- S 4.I I ttcl Burning Appliance — 1
_1 Insulation_ --�
telephone Email address ___D Demolition _________A
i 5.2 Registered Home Improvement Contractor(HH_') -
1
IOC(Amman,Name or Mc Registrant Name IIi{'Registration Number t sr-illation Date
No.and Street ____,__.__ __-__ _ __ ._ _ . ___.__ _ I
i.mail address
City/Town,State,ZIP
)cleptuane
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 attic building permit.
Signed Affidavit Attached? ties..........0 No..-. ... ..C
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
_ OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
II,as Owner of the subject property,hereby authorize
1 to aa on my behalf,in all matters relative to work authorized by this building permit application
.
Print Ouner'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.
,;----oocuSigned by:
/I� I
k _--------- __ ...�.,_ �.�._..-.�.._..._ ...._..._._.
.I'.rig , ri' 3Authorized Agent's Name(Electronic Signature) Date
i NOTES:
1 I. An Owner who obtains a building permit to do hisiher own work,or an owner who hires an unreuistered contractor
i (not registered in the Home Improvement Contractor(HIC)Program),will gel have access to the arbitration i
i program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
I s w.mass.gov oca Information on the Construction Supervisor License can be found at wvtvr.massg.oy%dos 1
2. When substantial work is planned.provide the information below: 1
ITotal floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft) Habitable room count
t Number of fireplaces Number of bedrooms
Number of bathrooms _ Number of half/baths _
i Type of heating system Number of decks/porches
I I'.pe of cooling system Enclosed Open
1 3. `T e"Pro ect Square Footag may be substituted for"Total Project Cost'" 1
DocuSign Envelope ID:9FA043FO-C958-4E20-8FA9-89E7CBBD9BD8
CITY OF NORTHAIVII)TON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:___i _ -
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REAR YARD
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yki" tj.All'4,;,... , •
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SEY*It
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SIDE YARD
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4.''" ' •' '...44.4.*
,t 74, ,....,::" .-,1,., ' ' ''.7:—
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FRONTAGE _
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City of Northampton
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-*�'� C .�Massachusetts
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9 DEPARTMENT OF BUILDING INSPECTIONS -', 1
air ' 212 Main Street • Municipal Building
,� ..3 Northampton, MA 01060
lir
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: VicA.......)17P-e.__e_A,c__ 1 4 _
The debris will be transported by:
Pp } , ., L /—
Name of Hauler: r _ v l/� -e----t19.--..,
1
i
Signature of Applicant: Date: / / ../i�._-Z
Al.
k
The Commonwealth of.,tlassachusetts
wiineu .- Department of industrial Accidents
7.2.** l'1 !
" ; 1 Congress Street,Suite 100
Boston,MI 02114-2017
IrilIar
,-,- www..mass.gov/dia
— II orkers*Compensation Insurance Affidavit:BuildersiContractorsfElectricians/Plumbers.
Itl BE FILED% II II I DE Pf:101111ING AUTHORITY.
Applicant Information Please Print Leoihls
Name(Busines.surgiouzarionandividian:
Address: „..
City State. Zip Phone#:
Are y ou an VIM pit!,er?Cheek the appropriate ba
1‘,pre of project(required).
i.0 I sin a etripLoya watt t.131131tlyte%(full and,or part-timel.* 7. 0 New construction
20 tam a site proprietor ot partnership and have no employees working for me in 8. c3 Remodeling
any capscaty_INu workers'comp insurance rottaired.1
9. Ej Demolition
vef‹..,?,c27.0 I al:I ii..tassitsaer doing all work myself.rNo workers'corm insurartee
i o 0 Building addition
I am u homeowner and wit!be hiring contractors to Oanduct all work on my property, 1 will
ell5Litl:that all eontraeturs either have stAnkers compt-nsation insuraniv of are sole II.f.:1 Electrical repairs or add]tin
proprietors with no employees.
12.0 Plumbing repairs or additions
5r:j I am a general contractor and I has,e hired the sub-euntrmairts toted on the attached sheet
1 3.Ej
These sub-contractors hat eltiployces and has•e workers'comp.itisumme.: Roof repairs
I 4,rlOther,
6E]We am a corporation and its officers have exercised their right of CAATIViltAl per Mi..it....
152_§ipil,and WC have no employees.[No workers comp in.-Ana:lee required-1
'Any applicant that checks bus.PI muse atsu fill out the wetion below showing their wortiess'compensalion poliey information,
tionteciwnerm who suitnnit than affidak a eashcatitm they meaning all work and then hire outside contr-actors must submit a new affitlas it indicating 1.iek
k:untractort that cheek this bok thug mulched an additional abort show in g the name of the stibeecintracturs and state 0 holler or not those'mimes has:
employees tf the sLK-conlractcrt,havc employ res they most proide their workers‘omp poll,.....nuniber
I au an employer that is pro riding peariers*compensation insurance fur my employees. Below is the policy and 1 tds sire
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#:. Expiration Date:
ligliiiiiingresx t9e (..-Okli 6-7(es(.4i I)( Citv,State-7ip: qc:___ 4 ' I--•0166t)_—
Attach a copy of the vs orkers'cikpiperisation polity declaration page(showing the inilicyOumber and expirat on date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to SI.500.00
andOr one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a
day against the violator..A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage veriticinion.
1 do hereby certify wider thr pains and penalties of perjuo•that the infUrtnaliun provided lib!)Ve 11 true end correct_
Stguataket 1).11:'
l'hccc
o
Official use only. Do not trrite in this area to be completed by city or town official,
1 (it y or Ton n: Permit/License#
Issuing Authority (circle one):
I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
' 6.Other
( ontact Person: Phone#:
---
DocuSion Envelope ID:9FA043F0-C958-4E20-8FA9-89E7CBBD9BD8
The t ommonn enhlt of Massachusetts r;
- A Department of Industrial Accidents
. _la I Congress Street,Suite 100
t' '.- Boston, M.102114-2017
' ` where.nrass. o /dirt
V.urllerx•Co wine Inatlrauee Affidas it:Builders'( oittractor /Ekctriciant/Plumi►er*.
1ttNF'ilia will linn P'i.tt.Ntt1list. ‘l" 110111i1.
aadramunfornlatian 11lcasr Print I c ibls
Name l as Mniratirxr irrdisltttult �__.,.. ..lei, .'.I 4.. _ .. _...__ .
Address: ,___._.,.,_
City'Statc/Zip Phone q:
_.
Altos NI suretrt r r"i is i.tut appr o rr tate tat:�._ ..____.. Type of project(required):
1.0 I so i at9lrkwo t as* 4ltipkomex Ifni!and e t Nit tct:t:i• • 7. CI New construction
J
.:.v t I oh ii wk pn+ltrx'tis...I tonal rani,and lire r tot oast."o.,*e.tira no
il fur r in S. Q Remodeling
inn clrii:in No woke:, “bits tnautsnar retpartedi 9. Q Demolition
• 10 I - a ta.rrsa.weter„tong ale na.ti on wit (\ei aortas'comp inatatartoe erytwd J i
If
i(l Building addition
>•� (ihth a ttettt Canstear and ail$he haunteeaMtasG.rt to caen.tuet all nod,cn raypupetty. I it•
ensure that ail samtra un.other hate wsttkers'compentath n Insurance or me roll I i.Q Electrical repairs at addition
tv..txf' "%oh ta.•h•iriu\cC.. I 12 C]Plumbing repairs of addtt ant
SO 1 ant a!aural cintrwwr and I liras c hard the.oh Aurtra tun liiaicd on the attached dhna 130 Roof repairs7t't' w21+-canirac.tc.it has;.. tt xtiritiv, - an.l ha,s uiat.ft'comp tttwraxr.' L,J
I4.0 Other
i 6 E j N r my s t..rpora/it,ei and tt...46:eix klav anent tk.)th.:.,nyht et eaaatptnw per MCA-c ---.
I{:.$Itai.and,ic 111.111%.rso ss>Wi o ti.(No soli rt omit, matrrairceovum&1
.Awn',v.tw-aa.t dud tkttE,itt.%tt 1 miz,t.a'.,.,III).ud ilk K-e i1.L,ta-6'u show ens the*trotirair'c - weatxm soda"Intter►rnabaq
"VI/ "1%n w ha,.**ntrt trot aiIit :out..emu tht7 ar..i.or.ail..a ri.and then Ian outride trmlurt MUM rubrmt env*alfedinit tndnhets his h.
-t warn-tors thin,. eak tots is roust attxrs:•it an&lastt..tui she t th..w Irby eta taint of the Wt► t . tors and wtiee%furthe'r tut not those estates fuse
;-•,,..,,., .i a,'a.4..7',4Orra.:4 4 41.4.. LA's ct'iit.+....'.,1tnb,t-ui,t pioNs41t Ur,It '.•-,+e►:ers ..-:61, 1, '".
1 urn on rmpiocrr that is proridinr worArrs'coinoensariun insurance for ors'emihn ees. Below it the nolict•and jab site
information.
in+.ctrarr.i.Comonny blame
Policy a or Self-ms.Lie ": Expiration Late.
t4a_ City'State'Zip:_f(Oil eg Ail 14"0 '-•
Attach a copy of the workers'c pcnsation tics declaration page(*bowie the lice number and es iratj/►n datct.
� p R R policy P
Failure to sceute cos crave as,required untkr\it it is 152, 25A to a criminal sAkslution punishable by a floc up to SI SIM.!(M)
and oir one-scar in-ti nsonment.as well as cis it pen,iltte,in the form of a STOP WORK ORDER and a fine of up to S250 Olt a
.ta. :it.hurt the s tailor A ropy at this statement may be(onsartkd to the Office of Inv stigationit of the WA for tnturance
l:!:ihrtleiliketiOift'«niter the pains and penaltirs of perjur•l that the infurmntianpreridelIuhove is true and curry(t
,ohs lliristr `a
____ laic
,3nr- ^.871564C3ii
...
U (Wheal use only. Do nut write in this area.to he completed hit its.or town u/frriut
11
0 City or loon: I_ erntitt'License aY V
4 Essuine'.Author°its (citric one): —
p I.Board of health 2.(Building Department 3.('it,/Toon Clerk 4.EIeetrical Inspector 5. lilunthine Inspector
1 6.(Ithc•r
Contact Person: ._. __��.,. Phone a:
li
DocuSign Envelope ID.9FA043F0-C958-4E20-8FA9-89E7CBBD9BD8 _ ;c ,
City of Northampton
•
-..� r?fit
Massachusetts
+< c P
DEFARTHENT OF Ha
TtbING INSDSCTTCNS
7I.' Main Stroo?
N r... t
Narthrmptob, lax 01o6o Auildinl t
�
NSTRCTION DEBRIS AFFIDA T
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
in accordance of the provisions of MGL c 40, 554, 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.
:9ur
f
The debris will be disposed of in:
VIC tLocation of Facility: L ,
The debris will be transported by:
Name of Hauler: ire r )t. L ..
- -,DoccuSigned by:
Signature of Applicant:o° "� `� Date
City of Northampton
Massachusetts ='
. DEPARTMENT OF BUILDING INSPECTIONS 14, '
212 Main Street • Municipal Building
Northampton, MA 01060
si.„ HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT °3 / r
I, 17/ ° r ) C.-ii �` (inse t full legal name), born insert month,
day, yFar),hereepose and stat�the following:
1. I am seeking a building permit pursuant to the homeowners' ex mption to the permit requirements of the
Massachusetts State Building Code, codified at 780 CMR 110.R5.1. .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 constru ted in accordance with 780 CMR 110.R3.
3. I qualify under the State Building Code's definition of"homeowner" s defined at 780 CMR 110.R5.1.2:
Person(s)who owns a parcel of land on which he/she resides r intends to reside, on which there is,or
is intended to be, a one-or two-family dwelling, attached or tached structures accessory to such use
and/or farm structures.A person who constructs more than o e home in a two-year period shall not be
considered a home owner.
4. I do not hold a valid Massachusetts construction supervision licen and, except to the extent that I qualify for
and will abide by the Massachusetts State Building Code's requirem is for the supervision of the project or work
on my parcel, I am not engaged in construction supervision in co nection with any project or work involving
construction, reconstruction, alteration, repair, removal or demoli on 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)
DocuSian Envelope ID:9FA043F0-C958-4E20-8FA9-89E7CBBD9BD8
,,o;v.v-,14 City o f
e.,.. ., Northam
� / t ,\ '4 Maa9ae Pton h Sr'''.ric
le
r"1 k hUsetts �" ._a�
f
0 DEPARTMENT OF RUILd2NG INSPECTIONS
• ,;.,, 212 Maxn Streat L7ZOg ,�
the M,inte,lnxl Aui!ding
ram, .r 44, .t
i0101"."*'HOP FOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
Emily wojcik
1, 7/3/20,,41
day, Year),here (insiert full legal name), born _ (insert month,
by 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 constn,cted 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.
I
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 thepains andpenalties ofe u on this 7J3/2day o
p rJ riJ y f ,20 .
DocuSlgnod by: I�,