18-035 (4) BP-2023-1232
66 EMILYLN COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
18-035-001 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-2023-1232 PERMISSION IS HEREBY GRANTED TO:
Project# BATH RENO 2023 Contractor: License:
Est. Cost: 8845 COREY PEASE 115950
Const.Class: Exp.Date: 09/07/2024
CHRISTIAN-JOHN VON ROSENBACH- TORBEKE
Use Group: Owner: & SHELBY MARIE VON ROSENBAC
Lot Size (sq.ft.)
Zoning: RI/RR Applicant: COREY PEASE
Applicant Address Phone: Insurance:
73 GLENDALE ST (413)218-5098
EASTHAMPTON, MA 01027
ISSUED ON: 09/11/2023
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: TIT
• 6 >2 .
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
1'04144j r etti-e/i Vic (ce
qi cZi/ 3
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
E I E MUNICIPALITY
a3� Massachusetts State Building Code, 780 CMR 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: ,Sp• 3- a a Z Date A plied:
41/)0(0,-, 8'26Z3
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 LA
Property Address:r / 1.2 Assessors Map&Parcel Numbers
(j 6 Ewirll/� Norkl,am fvv'\
1.1 a Is this an actrepted 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 9'/ Private❑ Zone: _ Outside Flood Zone? Municipal ion site disposal system 0
Check if yeskr
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
She )-\ vo.'N \"\. NI or let,o,+1B -N 1i�1� / O\O CoO
Name(Print) City,State,ZIP
o Er",VA L,� Li(S l (�8 `{ st"�L'(,rt�c, e- �` Lcyr
No.and Street 1 1L(
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. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work': IjAI-h 1^epy►x l~_ 1 J hA�i - D g.evi® . ,Ng it 1'Sao!f/
Pa i vt`t� S I Y�L / 13a-1-1-1 �t To: �2-7'� �lii wb•�. M wi i X8-T t VL 5'1�v�r✓.o
dr2Zs,411 +-aIt4— aH,L 3 11,1,K •
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ S 3 y 5 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee
tt8t5A coo 0 Total Project Cost3 (Item 6)x multiplier x
3. Plumbing $ 0 0 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Suppression) Total All FC,>/Check
s: $
Check No. AmoW:6 Cash Amount:
6. Total Project Cost: $ 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) ' 5150 9l7/ y
y
V3 O License Number Expiration Date
Name of CSL Holder
) List CSL Type(see below) 0
7�j G'>° �"�[ S
No.and Street Type Description
to
E G S f �4 p / � M /1 Q lO 2_7 Unrestricted(Buildings up el 35,000 Cu.ft.)
1- �'9 /'I R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
/� �''egt--91 SF Solid Fuel Burning Appliances
yI 3 Z Lo
lgrsocis, e_a5&6ma,l •CON1 I Insulation
Telephone // Email address D Demolition
5.2 Registered HomeJ Improvement Contractor(HIC)
Lore,/ [�QS HIC/Registration Number 70 /Exp-Expiration Date
H CompanyName or HIC R trant Name
GieifalP -
No.and Street Ema-ii address
F 454-1/la V ?1-0v1 Ot 0? 7
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 V 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 C(�r ` P Q S
to act on my behalf,in all matters relative to work authorized by this building permit application.
-Si/le-Vol1/s n .t✓•A\t-Da.CV\ (5<tt - `t I"1 13.E
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER1 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.
S(tee\b v o r c6Q Ac ,
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
Department of Industrial Accidents
1 Congress Street,Suite 101)
Boston, MA0211,1-2017
*1/4tn_l_
WWW.mass.govidia
Vuticer61'Compensation Insurance Affidavit:BuildersiContractortiElectricianstPlumhers.
to BE FILED WITH THE PlEltNtIll'ING AUTHORtl'I'.
Applicant Information Please Print 1.,eeibh
Name(13usines&Organizationandisidual): '
027
Address: 73 Gle..444le__ 5
City/State/Zip: Ea544-44"tplo.--z_ ajo-z., 7 Phone 4: 1) ) 3 Z1 85) 1-'
, .
Art you on emptily er?Clerk the appropriate box: Type of project(required):
Erj I am a entplo2,ex witherriployeen(full=dine part-tiniek• 7. 0 New construction
201 am a wie prupriettxr or partnership and have no empkryees working fur rise in 8. 0 Remodeling
any espartty [No workers'comp.insurance required)
30 I am a homeowner doing all work myself.(No worloas"comp.insurance required"' 9. El Demolition
IQ 0 Building addition
4.0 I am a homeowner and will bi:hiring i.xintramis to oundtut all work on my property. I will
ensure that all contractors either base vi.tprkevu'avaripatiagaiXt illattratleVi*an sole 1 .0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5C3 I am a general contractor arid I have hired the sub-contractors listed on the muddied sheet
I 31:3 Roof repairs
These sub-contractors haw employees and hit Iktrken:coml.insurance
14.0 Othei
nflwe are a corporiaiun and its Uffiorts hese exercised then nght of exemption per 11/4401 c.
1. .2..t•I i 41.and sre haw no unploye.es.[No workers'coinp.insurance required.]
*Ac. Applicant that checks but ril mint also till out the section below showing their workers'coinpcnsation poi iey 'utformation.
"itoir cow tiers who submit this artidasit indicating they are doing all work and then bee outside contractors must submit a new atTidas it indicating such.
:Curletom that cheek this box must attached an additional sheet showing the name of the.116.,:tantnu: --4 and state whether or nut thane entities have
einployees. lithe sub-contractors haw employees.they MUNI preside their Wuricias.,,L.mp.pula.:),number.
I am an employer that Ls providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
r / c
`Job Site Addrei; /00 WI-i I V i. A/ City/State/Zip: Akr fl,,aky,p 1-0i,1
Attach a copy of workers'comptimation policy decktratios page(showing the policy number and expirittion date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to S1,500.00
and/or one-year imprisonment,as \\,:11 as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy oi h is statement may be forwarded to the Office of Investigations of the DIA for insurance
co%erage verification.
I t hereby cerdf,ynder the pa- d penalties of perjury that the information provided above is:roc(11)(1 correct.
Si
> 1)=nature: ----
Date:
Phone#: 13 21 5'ofEr
Official use only. Di not write in this area.to he completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.Cityrfown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
f'untact Person: Phone#:
City of Northampton
oaYMA Mph p NS .. Si
Massachusetts wS' - `<<
VA
' A- :$: DEPARTIONT OF BUILDING INSPECTIONS
r f 212 Main Street • Municipal Building .>, Via"
Grp Northampton, MA 01060 ssyyY �1
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: Valley tiaI', Not-A-Vt,a MptOet 44 �I
The debris will be transported by:
Name of Hauler: ar Peal
Signature of Applicant: Date: V 7/Z3