43-141 (8) BP-2023-0879
26 LONGFELLOW DR COMMONWEALTH OF M SSACHUSETTS
Map:Block:Lot:
43-141-001 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 PERMIT
Permit# BP-2023-0879 PERMISSION IS 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 Phone: 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: I !al
Ti
b . f • w • 1
•
Fees Paid: S260.00
212 Main Street,Phone(413)587-1240,Fax (413)587-1272
Office of the Building Commissi ner
RF
Ci
./U CFO
The Commonwealth of Massac i setts ` 'a
U
Board of Building Regulations and .ni.‘••�. FOIC :ALITY
Massachusetts State BuildingCode,.780 •kto'•7N'44/oN U:E
Building Permit Application To Construct,Repair, Renovate 0 -,i ley/se, Mar 2011
One-or Two-Family Dwelling AOjcksoc)'I+s
S on For Official the Only
Building Permit Number:"033- 77 Date Applied:
v,,_s /25 ,//& 7-5-2023
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1_ rt1Addres 1 W n^ ,2 Assessors Map& Parcel Numbers —
1.1a Is this an aL2pted street?yes � Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) r
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. Sewage Disposal System:
Public 0 Private 0 Zone: _ Outside Flood Zone? M nicipal 0 On site disposal system 0
Check if yes❑
' F. CT�OIY :_P`RQPERTY OWN R Q�
2.1 caner of Record. ��//�1// }}
Nem ,
Name(Print) City,State,ZIP
1 rts)4/4*.t. kes eks:)(-Gok-vt,
No.and Street Telephone Vail Address
SECTION 3:DESCRIPTI OF PROPOSERK2(check all that apply)
New Construction 0 Existing Buildin Owner-Occupied Repairs(s) D Alteration(s) Addition El
Demolition Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed W. 2: t,_ill ,„l ' <LJ • /1(1 /k�e '1
SECTION 4:ESTIMATED CONSTRUCTION COSTS 1— Pi f�C,L4LAL._
Estimated Costs:
Item Official Use Only
(Labor and Materials)
111Buildiniam. $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
33 l.umbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$ �at.0 Check No. Check t: Cash Amount:
(Fr-Total Project Cost: $ 0 Paid in Full ❑ tstandin Balance Due:
u g
City of Northampton
Massachusetts ? x_ ff
DEPARTMENT OF BUILDING INSPECTIONS b`
��. 212 Main Street • Municipal Building
Northampton, MA 01060 ',$)
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.
DocuSian Envelope ID:9FA043F0-C958-4E20-8FA9-89E7CBBD9BD8
_ SEC77Uti S: CONS T RU ___ ___ _ - i
15.1 Construction Supervisor License(CSI.) CTIO�i 5ER�'C F Sl_ _ i!
\ame oft st Ifolder _._._-___ t arn.c tamiv r
I.latllutn Date
i
1 i.t( tt. I.pc('.' tvlo..1 _
No and Street
Description
1
—t.'14Mn.titei_ .. I)p
I t`n_a7,-111 tul(Building�up to :51010 cu. tl,)
----
. - _ ._ ` R Re i�t�d Ifi2 Gannls Ih...r.lbn`
\1 Ma--air.
R(." Renofing(to mug_
ll S Windn.. and Sitting
SP Solid hid Burning ilpptiancc,Au W_ 1
-.__ i InkrlaUun
'1"ekphonc
Lmailaddress t) Demolition _
5.2 Registered Home Improvement Contractor(MC) 1 _
[BY t tttnpan.tiarrie or illy Registrant Name
._.- ____.._ ._._—. tilt'Registration Number I spit.ition lbw
O. Street _.._-- _ ._ ___
1:mail a klre.'.
City/Town.State.ZIP
Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AF'FIDA%IT(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.,,. .. ..Cl
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BIT LUNG PERMIT
I,as Owner of the subject property,hereby authorize_
to act ea my behalf,in all matters relative to work authorized by this building permit application f
i
1
Print Owner's Name(Electronic Signature)- i)ate
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.
DocuSigned by:
1,i'rig ,wr;ye 3Authorized Agent's Name(Electronic Signature) Date
NOTES: 4
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor I
I (not registered in the Home Improvement Contractor(MC)Program),will ffej have access to the arbitration !
I 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 w•ww.mass.gov,dps j
. When When substantial work is planned.provide the information below: I
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) I
I Gross living area(sq. ft.) Habitable room count- I
Number of fireplaces Number of bedrooms ________ I
\umber of bathrooms Number of halfJbaths
i vpe of heating system Number of decks/porches 4
1 T ype of cooling system Enclosed* Open .
1 3. "Total Project Square Footage"may be substituted for"Total Project Cost" {
DocuSian Envelope ID:9FA043F0-C958-4E20-8FA9-89E7CBBD9BD8
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR I OT DIMENSION:__
REAR YARD
Y;a
{
...,_
c 3v k. N tr iA
SIDE YAM) ,..._,. SIDE YARD
•
•
• 9
FRONTAGE
t
f
City of Northampton
` Massachusetts '{�.
f
' Af::
DEPARTMENT OF BUILDING INSPECTIONS
et \It
�' �: at
212 Main Street • Municipal Building
'"V. `,� � P 4 ` f.
Northampton, MA 01060 s' 7%jti`s'
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:
�1P-e_e__2,c__ 1 ,'Location of Facility: y �'l
, .,J .
The debris will be transported by:
. i L___'� i _ f Name of Hauler: � b � v
/
`� i
Signature of Applicant: Z
Date: , -(��
4,
4.
The Commonwealth of Massachusetts
Department of Industrial Accidents
....m„,. ,411•1•01
IMO III ,1 7%1, / Congress Street,Suite 100
s
\ MI ' ' -.,.
Boston, MA 02114-2017
• ••••-•-• WtIntass.goridia
LI4kers*Compensation Insurance Affidavit:Buiklers/ContractorsiElectriciansillumbers.
ID BE FILED WII II THE.PEDIktIFIINC ArtlIOR1 II.
Applicant Information . Please Print i-rf:i ith'
Name tilurlitsess;Organization individual 1: ,
Address:
City'Statogip: Phone if:
... , „..,
Ate y im an Vt1113141.k.er?Cheek the appropriate hoc Type of project(required),
LEI 1 am a cmploya with _ariployees i full Ma UT part-time 1.• - 7. 0 New construction
2171 lam a sole pinprick*or partnership and have no employees w odd= tor me in 8. 0 Remodeling
any capacity[No workers comp.mummer mionred]
9. El Demolition
'<I ji 1 tit a linineowner dotes all work tnyself.[No workers'comp insurance required)
lam a huillapknel and will be barns contractors to conduct all work on my property, l will i 0 0 Building addition
mute that all coiling-tors eillts..r haw workers'compensation insuranix or are sole : 11E3 Electrical repairs or Udditiktits
proprietors with no employees. - •
I 2.0 Plumbing repairs or additions
lainazaiemi contractor midi has hired the sols-euntructors Listed on the attached sheet_
l These sub-4.-ontracturs have employees and base workers'comp.insunnim 30 Roof repairs;
14,0 Other
6E3 We are a corporation and its officers have exixcised their tight of exemption per Skil...
152,§11 1 1.,and we lune no L'Ilsplu)ecs.[No winters'comp.insurance required]
*Any applicant that checks but el must also rill out the section helow situ)*ins their warloxs'compensation olie information_
*Bunsen%nen who mama this affidavit iiikheaung they are dome all work and then hire tut-side contractor,must submit a new affidavit indicating such.
tContractors that cheek this ball'tuba attached an additional sterns showing the name of the sub-zotitractix-s and stale whether or not those entitics have
an!iloyees. 11the sub-cimiractors have cruplivy res..they niust pro,idc their workers"comp.pol V:).number
i tun an employer that is providing Oi'Oriel compensation insurance for my employees. Below is the policy and jab site
information.
Insurance Company Name:
Policy if or Selr-ins.Lie.4: Expiration Date:
VIMMINOIfting 0 Loki 1-4(0 La Or City/State/Zip: (.01(e_IA ce,,Ai A-c)1(56,1---
Attach a copy of the norkers'cupipensation policy declaration page(showing the policy-number and espiratfon date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to SI.500D0
and/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 forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
1 do hereby certify under the pains and penult/vs of perjury that the intnrination provided above is true and correct
41.111Willibilli.11. I)ate:
Phone r.::
Official use only. Do not strife in this area.to be completed by city or town official.
(1it) or Town: Permit/License# ..
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.Cityriossn Clerk 4.Electrical Inspector 5. Plumbing Inspector
Other
Contact Person: Phone 4:
DocuSian Envelope ID:9FA043F0-C958-4E20-8FA9-89E7CBBD9BD8
-_ I hr- ( onintr►ll tt'e( rn of I hillaClruseris
i;: =,w/ fieintrintcill n/ industrial 4r•�•illen!s ,
t i I ('ongreN% .Street.Suite 10ft
"._• T;� flnslnn. .1f.4f121/d- 111
ntn'it'.mast Ro /skit
'11where'(`omn.n.arian lnsur,lnCe %tftd.1%it:RuIlder•( ctiilrarlur• I icctriciaf$JPlumbees.
tciIli 1IIt01111iI iItl i'11011111\t. %I I11t11i1i1,
Apirlwa It Inrurniatiuti Plea•r Print I.ereihlt
Name tattoarriat.l►:_ __ __. .._
Address: ._ . r_.. _-_� ! __..
t'111'St;eteZip Phone#:
1 in tar w ravplglrr;"t ►rri.ihr al.peoi/Hatt IW t• Type at pealed(r ).
t 01 trs a cuot.,s,a rtiiti .mpd.t..Ctr halt rod. ral%i,is.,• 7. 0 Nom construction
01 am a auk praprxntn c,liann.r.iatr and ha. eu,cngd.ea... ,ells; tar mt in II. O Rerncxkling
art;,t:-alv:)t\ Na rt.trters'tong* ttruraneC a +wat1.) y. Iatntt�ltiton
1�1 a tr,nwwacr c1.nn%all s.t,.r►urs..•It (NO w.Mlt.•ts't.np nwuntait rayri.rtal)'
Niii, t WS i i OttyVwtrct aa.l a al the tut.n I0 0 BUildlnit additionn
rk.VRI33ctt.rt(.t.rMlu.l ail wta4 oa mY t)n"ta*t7• (roll
MOO,:that atl..m:aa.t.+n tither tact'micec c.arltacnutlon tnauranat cm are i ok 11.0 Electrical repairs ur additions
i•rtt•taet.x.wrt4 sit,.ratrl.c�e., 12 0 Plumbing raapatnc or addition
1 s fl 1 a p am nctat attfara.tut and I Mt.heed the.ut+.usa atutr h,led on die im bed tend. 130 Roof it'It3irnl
1 be.,.tei•-tvnlra..i.nr hint-er.irtuti Cr.in.l h..t-.t twttre'cm" i,sir C.:
j 14.0Other __
h O u c s.r a..rrtaraar.sa OW Or onket�ht,4.:era. wt tl ten nese of au:swum per Rind_c, __
:. 1i4i,Mid'tita..na.aamtl.nc.a Vie stwten'camp.totnranormatoaal.l
-1n iris.-ant thsr ahz<ia t...c.1 nar,i slur Mao nt. ',cue*M,=i.eh.ins tarn workers'c imattrrt polity tlttatrtauati
' itt ttvvtn¢'r.■t to,..utrarut the%atli ti.n.nt.4aataos tt..) .,tc.itnow ail..•ri and tttcn hue t.vt.rak. eta ivn matte subeasi a ftta samba ii Iadtcatanr rice.
•t oraracrin ttt.n ca..t.uus tan%must stunts:.!an adaltt.+t I spent ahna tit;tF..rutrx vt the aut.,,nitraiors lad.tact laticlher ut ma thaw.slate.Lase
,. It i.:u.4.-ir+ti.Jr;VTlt.a•.rul,,mpicvet ill.. n`,1.1`,1 t`.t,l I.,,l,i.::. '.•.,rt:.T, at,ntp ti��: ',.I'.'',.+
... t� __gyp
1 um an rmi)lat'rr that iA pros-idini irorLers'crtarptrnsap'un insurance for mr employees, Below i.►he halite and lob.lie
information_
Inc:s;tt;c lo"rrti UIIVNaive: _....
Polo. uc Srilrv-ins.Lin: 4: _ Expiration Date. ._.. __
City State /lp' (C.f,iei,,t c. _, A, /-''C:566t
Attach a cops of the workers'cr> pensation policy declaration page(showing the polies number and espiratf in date,.
Failure to secure tuscrave as required unt.k-s \ft,1 t 152,§25A is a criminal Violation punishable by a fine up to SI.501.0U
and cur tsne- ear ll-spnsunnlent.as 1rcif as cis it pt,n.tllies in the formula STOP WORK ORDI.R and a line of up to 5250 00 a
day alam.t the 1 te4alor. A copy`t,f this tale/m :t may be forwarded to the®hint of Inves;Itlaturos of the DIA roc tn.urance
it:)\crave.e[II l.:alK)n..
I:!:ken15410'eangti/i'under the pains and penalties of pe•riurr that the information provided above is true•end c'e:rrr;:•
530F7FA5715BtC3...
it
0 trial use only. Do not la-rite in this arras.ha be simple by citj or tur-n officio(
0
Ior Town: Permib'1_icense a
Issuing Authoriti (circle one): il{
I. Board of health 2. Buildint Drprrtlnent 3.Cit1'/Tona Clerk 4.E ketrkal Inspector 5.Plumbing,Inspector Ii
6.Other. �i
Contact Person: _ _ Phone tit: _W_
DocuSign Envelope ID:9FA043F0-C958-4E20-8FA9-89E7CBBD9BD8 .� ,,..p ;„,.-
City of Northampton
,c:` a ,f
Miss
achusetts +► ,
.M�/
.�� DEPARTMENT OF 9UI
5 212 Mn n Straye LDING I 11,4' i
"_. Nrarxh��� dun u•xpai Arai lcfic.7
fp t,, ►tA l3 1 0€
mR.
,2ONSTRueriON DEBRIS AFFIDAVIT
(FOR ALT,DEMOT.,TTTON AND RENovATioN,PT2C,),IJ,,Li k,)
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:
UCA—Location of Facility:
,
The debris will be transported by:
tw
Name of Hauler: _`5 iv C - .
DocuSfgned by
Signature of Applicant o Date:
-_-.530Frrtwtf5�a�e
4.
City of Northampton
tit{:tt�f,{�l. `4. .F�•,�
Massachusetts ��?'
*
N' w
DEPARTMENT OF BUILDING INSPECTIONS jg
lA
212 Main Street • Municipal Building
Northampton, MA 01060 , %jl`‘ '
Ilk HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT I/
C-( (insert full legal name), born _.511
nsert month,
day, year), here/depose and staWthe following:
1. I am seeking a building permit pursuant to the homeowners' e.emption 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"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 .etached 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 license 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 c. 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 wit the aforementioned project or work on my
parcel, I acknowledge that I am required to and will act as the supe ,'sor 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
1
,,,�rt,V: 714c, City of
/, Northampton
r �, x
P' e. f MassaChugetts
��yyrr f.
r� +- i.k DEPARTMENT OF DUI r
212 Main Strwyt • l
dINC INSPECTIONS
--te r.... • Z
...'iha.n k°antc,lawl Putltfln4 .4x. .l
eP HOMEOWNERS'EXEMPTION EL IC;Ili ILI II AI-I mi);t VIT
Emily Wojcik
1, 7/3/20,V
e, __ - (Insert full legal name), born _,__ (insert month,
day, year),hereby depose and state the following:
1. I ant 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 In, 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.
1
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 ofperjury on this 7/3/P2 o
�;�' p rJ nJ y f .20w.
OocuS gned by: