25C-186 (8) BP-2023-1276
22 HIGHLAND AVE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
25C-186-001 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-2023-1276 PERMISSION IS HEREBY GRANTED TO:
Project# 2023 FLOOD DAMAGE Contractor: License:
Est.Cost: 177450 TOSHI KASHIMA CS-060134
Const.Class: Exp.Date: 11/04/2024
Use Group: Owner: TRUSTEES CAPUTO VICTOR F&DENISE M
Lot Size (sq.ft.)
Zoning: URC Applicant: KASHIMA BUILDERS
Applicant Address Phone: Insurance:
15 UNION ST (413)522-1713 WC231s376057020
GREENFIELD, MA 01301
ISSUED ON: 09/18/2023
TO PERFORM THE FOLLOWING WORK:
FLOOD DAMAGE REPAIRS
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 X
Fees Paid: $1,153.00 (/
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
w
RECEIVED C a P 6(-)Alit- 8ady
SEP Th Commonwealth of Massachusetts
14._.. 1 4 23 oard f Building Regulations and Standards FOR
assa husetts State Building Code,780 CMR MUNICIPALITY
USE
NORTHA1'�l i�&r i i7 fSk cation To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
s�`h��'oso pp p
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Nu er: 'c ,3 — 4> Date Applied: q/S[Z3
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Proprt Address: 1.2 Assessors Map&Parcel Numbers
Z 4 104;%h101d a✓c
1.1 a Is this an accepted street?yes V 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:
Zone: _ Outside Flood Zone?
Public Private❑ Check if yes❑ Municipal ErOn site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2,1 Owner'of Record: /�'
Vic.404' Ccint4i) 22- Zq1 G-lia)' I*i l Ave /co¢-17Awjpiii
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building : Owner-Occupied Cl Repairs(s) V Alteration(s) Cl Addition Cl
Demolition B/Accessory Bldg. 0 Number of Units Z Other Cl Specify:
Brief De c iption of Proposed Work': ��o�jr W4-A Dc✓ fo int r l�nrt/.a
m5o(ed,ca1 l e-10
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ (4./ t s a 06
1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 3 g I 0 Standard City/Town Application Fee
0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
ti ►
Suppression) $ otal All F s $N 12•
heck No. heck Amount: Cash Amount:
6. Total Project st: $/7 o. Cl paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
b 5 SL Art Lice se Number Ex tion Da e
Name of CSL Holder t,I`
List CSL Type(see below)
No.and Street T e Description
Unrestricted(Buildings up to 35,000 cu.ft.)
Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonr
y
t RC Roofing Covering
C� `r `3 WS Window and Siding
�yl,' ((^^ SF Solid Fuel Burning Appliances
�ZZ ��7 �Cl �ry��'�J v� Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(H ) COI'V . 2-6'7 Oft 6
HIC Registration Number Expiration ate
HIC Company Name or H1C Regisalit Name l,�
ekk
No.and Street ba v-p ��"�. � bU: 1 ii) A6 cb
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 ... .... ❑ 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
o Sir •S��-��1C♦
to act on my behalf,in all mattersrelative to work authorized by this building permit application.cn. S�
$� L.ck.„*.hziSTr �Q /_/
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.
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.govioca 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
',-....7'— Department of Industrial Accidents
Z
=: - 1 Congress Street,Suite 100
= . . Boston,MA 02114-2017
c�*,.� ,�Y www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please PrintLegibly
Name (Business/Organization/Individual): C ?%J . C\exit r. ' -
Address: '3 tk S o.Nr�. S h.` ( i r tit. ((.� J
City/State/Zip: G(en je\6 M} et5Ol Phone#: H VI- 1117
Are you an employer?Check the appropriate box:
Type of project(required):
1. 1 am a employer with 1—1 employees(full andlor part-time).* 7. p New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling
any capacity.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. El Demolition
10 0 Building addition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.El Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ROOf repairs
These sub-contractors have employees and have workers'comp.insurance. /
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other C� \C ak1�1
152,§1(4),and we have no employees.[No workers'comp.insurance required.] \/tc.ke' a a
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Ca'V e.\e.c
Policy#or Self-ins.Lic.#: —1 P , u 6 - 0 GI 9519-4-?3 Expiration Date: G.`kR\a 4
Job Site Address: ,9D-' \ \}lg\. kit City/State/Zip: n tt 6t ,100
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well 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 of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certi under
(tt hepains and penalties of perjury that the information provided above is true and correct
d Signature: "m"' Date: l4 7-3
Phone#: 4\'3 - 71 4- - '3-7
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
v srr f� The City of Northampton
-y;.-- �Y i Building Department
te4-)....-� k: -.a {:l
,- ,., _ ,�,, 212 Main Street
ilkAtEo mai�`, Northampton, Massachusetts 01060
Phone (413) 587-1240
Fax (413) 587-1272
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVAT ION PROJECTS)
In accordance with the provisions of MGL c40, 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, s150A.
The debris will be disposed of in: V Q\`'e) .ACV c1`e
Location of Facility a3 Ems} a- n v,--t. / N o (� r`Otr NA-
The debris will be transported by:
Am�e.0 S 1 ru C
Name of Hauler kr1
Signature of Applicant: Date: 9 1 1 y Z