24A-135 (3) BP-2023-1167
22 ROE AVE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
24A-135-001 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-2023-1167 PERMISSION IS HEREBY GRANTED TO:
Project# 2023 RENO Contractor: License:
Est. Cost: 23500 ROBERT J WALKER 034783
,Const.Class: Exp.Date: 10/18/2023
Use Group: Owner: DELAGE MARIE-JOSE
Lot Size (sq.ft.)
Zoning: URA Applicant: JUST WALKER
Applicant Address Phone: Insurance:
36 Service Center (413)584-1224 0
NORTHAMPTON, MA 01060
ISSUED ON: 08/28/2023
TO PERFORM THE FOLLOWING WORK:
FIRST FLOOR 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: � � TA
e; • • >2 -
Fees Paid: S153.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
eiN 1 Ack op whirl g
The Commonwealth of Massachusetts
Wt Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR MUNICIPALITY
USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: f. pJ�3 '' //0 7 Date Applied:
41,Ja5
.w 6-Zd 2o23
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION _
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
'Z.Z ig.o C (NA/£
1.1a 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) hi,A 1 In,Teuir-A d 1r'- P-SAAA.0OCA—
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 Zone?
Public l� Private❑ Municipals? On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Ma 12-►A 1-% r5 N..,0 try (-4-soc►wA PTO)--' ` MA otao 6
Name(Print) City,State,ZIP
22 E_ c_ rkv", SOT-. 0tO3 i1ags ne% o to 6,2-@ vi14►va11 4"4,n,
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) Addition 0
Demolition 0 Accessory Bldg. ❑ Number of Units Other 0 Specify:
Brief Description of Proposed Work': (e n, J ck+-P 1 % ((00 tz A 114.-c- ci OLy
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ i c i O GXl, 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee
t)U 00• 0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 7j . — 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All les^$
Check No. ( 1 Check Amount: 1 yJ Cash Amount:
6.Total Project Cost: $ 2-3, co(H % 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS ,0 4783 IJ i, 1 Z
ei-L—VG ,r\ License Number Expiration Date
Name of CSL Holder
3(a5e.v-V 1 Ce C _'AA �✓ List CSL Type(see below)
No.and Street Type Description
,�,�n O r � U Unrestricted(Buildings up to 35,000 cu.ft.)
✓" - R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
w e`m w G. SF Solid Fuel Burning Appliances
At3 sjg_ rjrc} CAS+Y I chkSS c)C.t S. its. I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
2-0%to sJi��Z4
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
S
No.and Street J �e 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 completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Iss ce of the building permit.
Signed Affidavit Attached? Yes No ❑
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 lan tr �ELr tJJ L--Kc(?
to act on my behalf,in all matters relative to work authorized by this building permit application.
At4.43 1 ci (sel z o Z'3
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.
ee
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.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,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"
"'� The Commonwealth of Massachusetts
jc Department of Industrial Accidents
a AB= 1 Congress Street,Suite 100
Boston, MA 02114-2017
4167 www mass.gov/die
11 utlecrs' ( i ii it ri.alion Insurance Affidavit: Builders/( contractors/Electricians/Plumbers.
I t 1 itt 1 II E:D WITH THE PERMI ll\(:AI I HORI hl.
li)liIa till Intiirnt:ittiui Please Print l.efibly
Name LHu.nu. .ut:an.c.inon lu<i.,weal):
Address:
City/State/Zip: Phone#:
Are ysn..tatp1syer'Check the apprsprtate box:
T)pe of project(required):
LE] am a employer ekfyar with enrployces'toll and of part•timcl.• 7. D ew construction
2 I am a sole pniprocttr or punncrship and has,:no empkryros working for me in S. Remodeling
am eap:Kay (NU workers'romp.insurance res urrail.]
9. ❑Demolition
t.a I am a hhimvvwnat doing all work myself.(!,u*Dries'comp.innuranee required)'
4.0 I am a homeowner and will hiring contractors.to conduct all wurk on my property. I will
10(3 Building addition
m
orison:that all contractor either tune worker'compensation inauranaz or an:sole i i.121 Electrical repairs or addition.
pr<iptn tar V.ith nu etlipluyees 12.0 Plumbing repairs or addition.
50 I am a general contractor and I have hired die sub-contractors listed on the attaches!sheet
These sub-contiacwr}woe employers and has workers'comp.invurarice. 130 Roof repairs
6.0 We are a oq*rratiun and its officers have cxtnciscd'liu right
of exemption per hkil. . I4.0Olher
t _
152,1!11 a 1.and w e have no employees.(No*otters'comp.insurance required.I
•Any applicant that chucks but al must alai till out the section below showing their workers'compensation policy information.
'Iknneuwnen who submit this aftitdaait tndicatmg they are doing all work and then hire outside contractors must anbmrt a new atT,dasit induating such
4.untraetur that cheek this box must attwied an additional sheet showing the name of the sub-contraet<rs and state V.hcther or not those entities have
eniptuyees If the soh contractors hued eirgiluycc...the} most pro%idc their worker'comp.peilicy number
s
I ant an employer that is providing worAers'compensation insurance for m1•employees Below is the policy and job site
in/ornnttion.
Insurance Company Name:
Policy tt or Self-iins.Lie.4: Expiration Date:
Job Site Address: City StatelZip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MMGL c. 152,§25A is a criminal violation punishable by a fine up to S1,500.00
and/or one-year imprisonment,as well as civil penalties in the form 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 Investigations of the DIA fur insurance
co%erage venticanon.
I do hereby certify under the pains and penalties ofperjnry that the information provided above iv true and correct.
Signature: L�.1v,1� Date: 5 ( ( '
Phone#: 4-V-4 53 S ' \1 ac A--
Official use oniy. Do not write in this area, to be completed by city or town official
('its or Town: Permit/License b
Issuing authority (circle one):
I. Board of Health 2. Building Department 3.('itsi iossn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
( ontact Person: Phone#:
City of Northampton
y • '� ~ Massachusetts k4Ss....
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building v6 Cam
Northampton, MA 01060 SMyy ��
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: ti c--\\.-E _ .e c , LAB mac)
The debris will be transported by:
Name of Hauler: Q�.vJ--t� , (Ae_
Signature of Applicant: 1. Date: V 17 VI ?.u2
MI
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