07-008 (9) BP-2023-1016
460 NORTH FARMS RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
07-008-001 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-2023-1016 PERMISSION IS HEREBY GRANTED TO:
Project# CHIMNEY 2023 Contractor: License:
Est. Cost: 10000
Const.Class: Exp.Date:
Use Group: Owner: VOLLINGER GRACE F
Lot Size (sq.ft.)
Zoning: WP/WSP Applicant: VOLLINGER GRACE F
Applicant Address Phone: Insurance:
460 NORTH FARMS RD
FLORENCE, MA 01062
ISSUED ON: 08/01/2023
TO PERFORM THE FOLLOWING WORK:
DEMO CHIMNEY AND REPLACE WITH NEW
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:
II / N
Fees Paid: S65.00
212 Main Street,Phone(413)587-1240,Fax (413)587-1272
Office of the Building Commissi ner
The Commonwealth of Massachus v�'Or
I ?A� Board of BuildingRegulations and Stan.. 40,-,,,,,I, g
\�UP/. Massachusetts State Building Code, 780 C I' ti '�oti IUSE�I
r
Building Permit Application To Construct,Repair,Renovate Or I'' R ised ,r 2011
One-or Two-Family Dwelling ��o o
This Section For Official Use Only ,Ss
Building Permit Number: ,o-)-3 10(0 Date Applied:
404-> (ZSS I Z 6.1-ZbZ3
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1 1 Property Address: "l li60
Ivor s,-. 1.2 Assessors Map&Parcel Numbers
1.1 a 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:
Public 0 Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Recor ,
Gr&ce �iir�jer F-76re/let p (-4, 0(0(
Name(Print) I City,State,ZIP r 1
4(00 /--20( , Fans 15--c -452 j 6✓mi ;/i-lgcrcGc-i/ UlaCo-\
No.and Street Telephone Emai'IAddress
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify:
BriefDescription of Proposed Work': k ` n rf�
0, 4 6.f L o v s.e . IZ e ' - C L..:rn n. LI , L,,�; 1-�, e,ry I v
t 3r,ef5 c"on0 Ch,AI ^et b Ic�c!C rtr- 0 • I Fyirk c.. < e
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:
2.Electrical $ 0 Standard City/Town Application Fee
0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ 1
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees:$ io,�
Check No. IU"10 Check Amount: 6�f5 Cash Amount:
6.Total Project Cost: $ IQ1 Q 00 , y Paid in Full ❑Outstanding Balance Due:
Or -o b-eq ryQrt il1ani1 oto S/c/6IctoJci, cow
V
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License I'umber Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.R.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email 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 .0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
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 app ication is true and accurate to the best of my knowledge and understanding.
It
__ 7/3143
• gen s ame ectronic ignature)
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.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: 4
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 Numbe of half/baths
Type of heating system Numbe of decks/porches
Type of cooling system Enclose Open
3. "Total Project Square Footage"may be substituted for"Total Project ost"
‘11
.:-:.Z..„ The Commonwealth of Afassachusetts
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1
111.4.1IT . Department of Industrial Accidents
I Congress Street,Suite 100
0 —11 Boston. MA 02114-2017
www.ntass.govidia
‘),utters't'ompensation Insurance AMdas it:BuildersiContractors/Eketrielans/Plumbers.
11)BE t ILL])VI 1111 I Bt..PEKNI11112.46 Al'ItIORI1N.
Applicant Information Please Print Leffibh
Name ilitiamessoUrgtmizattort'Innividuali:
Address: .
City/State/Zip: Phone g:
— .
Art yas ma entpk*er?Cheek this a pprnprigte box: Type of project(required):
!E]I am a snuployes with employees(full tur part-trinet.' 7. 0 Ness construction
201.sm LI,,ole proprietor Pr purtnership and have no employees working fur mc m 8. 1 Remodeling
any capacity..[No 4 uricrs'comp.insurance regimen]
9,. El Dcmolitlon
..i.j I Ani a hormois act doing all Watt trosclf.fho workers' dalp..rimunrunct reguitmll'
am a lionsooixiau and will be hiring ountramors to conduct aft work nu my property I will
dirifilf.
moure that all contractors either has e workers'monsparsidion insurance or an:sole 10 ci Building addition
11.0 Electrical repairs or additions
prtspncton is ith no employers_
II la Plumbing repairs or oildirions
I Am a annual cows:whir and I bast hared the sub-contnicturs Listed on the attached sheer_
Thew.sub-euntructors have employees and have workers'mu 1 3C1Roof repairsnp,insurance,:
6.0 We un:il corporation and its officers have exercitiell their nen of exemption per ASOL c 14.00thet
1...2, .and liN c km,c nu arc luyees.(Ni'winters'comp.instaanee required]
'An2.uppli,xit 1:i:a,th:ck%box sr1 nausit also fill out the section below hbv4.mg then workers'oyoupensation pinny enfoannitsun
' lionieow nets A 1141 Adm-nt this affalasit nulscatirsu they arc doing all worl,and then hue outside i:iin tractor+must submit a new Articizor it indicating such
Cnnuactom that check dui box must atwheil an nil‘dinunal 5624::(aboi ing the name of the sub-risnrractors anti irate whether or not those clsittisN.ha .•
Inplo)l the sids-eunitaL(Lyr,11.1,,,:OM!V:,ex-.,LII.:) Inkt,1 pm'.idc thcir workers i.V.Ittr.pll is,:;.nutrtIvt ,
I am an employer that is providing workers'compensation insurance for my employees. Below is the polity unit/oh site
information.
Lilsuratit'e Company Name: _
Poli,:v ;-:or Self-ins. Lic.#: Expiration Dine:
dilillill11111111. 4(9 0 k)0 l'44k fcu1/4415 Rof. City/StateZip: nore,i(_e ytta o(c(c,
Attach a copy°Elbe 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 .h iolation punishable b) a tine up to 51.500.00
aintVor one-year imprisonment,its well as civil penalties in the for: of a STOP WORK ORDER and a tine of up to S250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of In%estigations of the DIA for insurance
coverage ,erification.
I do hereby certify on er the pains and penalties ofpetjuty that the information provided above k e and coma
aiii6g: - 7/31 (23
Phone=..
,
Official use only. Do not write in this area,to he completed by city or town official
City or Town: Permit/License 4
Issuing Authority(circle one):
I. Board of Health 2. Budding Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
_____
City of Northampton
Massachusetts
tsicv ?a DEPARTMENT OF BUILDING INSPECTIONS`*ri .-1. 212 Main Street • Municipal Building
K--� Northampton, M? 01060 '`Iy 3,.�\-\
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: Va I I L) ( -.e c G I t-N ,
The debris will be transported by:
Name of Hauler: ISaun\-t- {M\ckk 1r'1O(. )_54 r
Signature of Applicant: Date: i 1 .2S a-3
City of Northampton
,,.t1.,,
$ t Massachusetts .� ,�
4` ia� DEPARTMENT OF BUILDING INSPECTIONS $ ,�
�, 212 Main Street • Municipal Bui:ding ��i ��
Ye^ Northampton, MA 01060 'PS k -:''
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, (insert full legal name), born (insert
month, day, year), hereby depose and state the following:
1. 1 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 11,.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"home. ner"as defined at 780 CMR 110.R5.1.2:
Person(s) who owns a parcel of land on which he/she esides or intends to reside, on which
there is, or is intended to be, a one-or two-family dwe ' g, attached or detached structures
accessory to such use and/or farm structures. A person ho 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 supervisio license and, except to the extent that I
qualify for and will abide by the Massachusetts State Building ode's requirements for the supervision of
the project or work on my parcel, I am not engaged in cons ction supervision in connection with any
project or work involving construction, reconstruction, a teration, repair, removal or demolition
involving any activity regulated by any provision of the Mass, husetts State Building Code.
5. If I engage any other person or persons for hire in connection 'th the aforementioned project or work on
my parcel,I acknowledge that I am required to and will act as , • supervisor for said project or work.
Signed under the pains and penalties of perjury on this 3 o IL7' 20(11113
(signature) 11 _,_1,......„__
I
/
City of Northampton
Massachusetts %If 11
{ f < , DEPARTMENT OF BUILDING INSPECTIONS a r
212 Main Street • Municipal Building
Northampton, MA 01060 6yy' \V
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:
The debris will be transported by:
Name of Hauler:
e
Signature of Applicant: Date: _ •