39A-056 (2) BP-2023-1540
64 LYMAN RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
39A-056-001 CITY OF NORTHAMPTON
Permit: Demo
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2023-1540 PERMISSION IS HEREBY GRANTED TO:
Project# INTERIOR DEMO 2023 Contractor: License:
Est. Cost: 20000 JOHN SACKREY 079384
Const.Class: Exp.Date: 10/14/2024
RICHARDS HELEN M&JEAN M HALL& S
Use Group: Owner: MCCARTHY&W E MCCARTHY JR
Lot Size (sq.ft.)
Zoning: URB Applicant: SACKREY CONSTRUCTION
Applicant Address Phone: Insurance:
83 SOUTH MAIN ST (413)563-6639 0 WMZ-800-800-5793
SUNDERLAND, MA 01375
ISSUED ON:11/01/2023
TO PERFORM THE FOLLOWING WORK:
INTERIOR DEMO AND REMOVE REAR PORCH ROOF
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 i
• '2
'/ •
at � � •
Fees Paid: S130.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
The Commonwealth of Massachusetts `FC
Board of Building Regulations and Stan rds FOR
Massachusetts State Building Code, 78 C
Nov ALITY
1' . S
Building Permit Application To Construct,Repair, nov a Or Demol'ts0 a Revi Mar 011
One-or Two-Family Dwelli n''Ar <90
This Section For Official Use On tid'9r aU'44,e
1'T'r i 1
Buildin Permit Number: 30' c)-3-1.5.-4/0 Date Applied: oti, tiso
ev$..)7255 2 ill-I-zaz3
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
!o y hkA-0 R)
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public ll. Private❑ Municipal ISKOn site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Ry itt39 RA-00.- yLy 44-(<P6U ANalne ) City,State,ZIP
toy lAivAlvt4 RD- IiLTAkAlitifrALI 413-8844"(7i$ rA cN I.-. L.fiNa..16 (rkit I t,- L
No.and Street-0 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) 0 Addition 0
Demolition fl' Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2:
l wAk-C 'Co D o I...T(740it Demo u To-4 o F ?LA STIR A-40 L ATat 14
fi kiSTI ACr kItuo(r3J 1 tot 41r4'Lr A•1`-t,0 1-.1 l/h4 1, KOZNAS 4-P447 1t4 A--rn (—
A-No i3fKg malt,-7 . A LSo, KkHolIII SSA-LL, Pout( Rz ZY oPF 12.11AIZ of (-+-4N3 -
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ .2 C . 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 1 D O o 0 Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No.5 7 citheck Amount: I Y.Iash Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
•
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) [ S- Ol 9 38`1 l ti, 2y 1 zy
D}4 to N - 5 Ar 42.A. 1 License Number Expiration Date
Name of CSL Holder
�,o List CSL Type(see below) lJ
6 3 S - k 1-4 6 ( ,No.and Street Type Description
,� _ - ^ 1 A A /t O I31 U Unrestricted(Buildings up to 35,000 cu.ft.)
W�.4� ►7�-i1, V� /3R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
'/ I Cluck SF Solid Fuel Burning Appliances
ti 13.7f 4 0 31 SA-4 (o ck-AL-(./I.. I Insulation
Telephone mail address D Demolition
5.2 Registered Home Im rovement Contractor(HIC) I (40,y ,o t ( 3ti -24
`.\0 iJ (k ' 6 , HIC Registration Number xpira on Date
HIC Company Name or H1C Registrant Name
£ 3 4- N4. SrC.
No.and Street Email address
St i4ic.(.4A9-4-0, t4 t - d 131 S' I ' 3'(d G. `I
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 19 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 .]D 4-1.1i W • C
" to act on my behalf,in all matters relative to work authorized by this building permit application.'
b�1�...../y�� j,,��� ,0131 Jai
Print Owner's Name prone Signnature 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
contain this application is true and accurate to the best of my knowledge and understanding.
101 11 ) z 3
Print O er' uth ' e Agent's Name(Electronic Sign ture) Date
OTES:
1. An Owner who obtains a building permit to do hi er own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contra or(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 Construe on 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"
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton
!4. sjCf
r• Massachusetts 4?'
DEPARTMENT OF BUILDING INSPECTIONS �`•
212 Main Street • Municipal Building
r�- P 4 Jdf•. pD
Northampton, MA 01060 st% `..
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-Lt./Cul Pk L
The debris will be transported by:
Name of Hauler: Wrgs<fu/l4 1/4A-1-5 r-D i -h Li rIGck_J
Signature of Applicant: Date: 10 3 t Z�
t
The Contntonweulth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
;:41 Boston, MA 02114-2017
1Vww mass.gor/dia
11.urkers'('unlpensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
II)BE FiLED%%11'11 THE i'tat111Tf11i(:AtITHOR1T1'.
Annlicant Information Please Print Leeibly
Name(Busincss'Organrzatiom Individual►: 6 {cG t . 60
Address: 3 S - 1Nt.t4.14J (-
City/State/Zip: 5ut , l .cZ(.410.4.0 Phone#: N 13-SL.3-6 4 3 9
Are'sr as employer?Check the appropriate boa:
Type of project(required):
1. 1 am a employer w ith W_employees(full aodd'oe part-time I' 'J. CI New construction
2.Q 1 am a sole proprietor or partnership and have no employees working for me in X. Q Remodeling
any capacity.(No workers'comp.inauranix requiresi.)
3r�1 a a hucown doing all t myself.[No workers'comp.insurance required]' 9. El Demolition
m m et uck
4.0 lam a homeowner and will be hiring eoraracturs to conduct all work on my property. I will I 0 o Building addition
ensure that all contractors either have workers'oompeasation insurance or arc sole 11.0 Electrical repairs or additions
proprietors with no employees_ 12.0 Plumbing repairs or additions
SO I am a tn-ncral contractor and I have hired the sub-contractors listed on the attached sleet. 13❑Roof repairs These sob-contractors have employees and have workers'comp.insurance.; ('� p
6.0 are a corporation and its officers have exercised their ugh!of exemption per?ail_c. I t--+O�ei
152.§1(41.and we have no employees.[No wuhm'comp.insurance required]
'Any applicant that chocks bus nI must also fill out the section below showing their ourkers'compensation policy information.
Ik n cownen who submit this affidavit iuheating they are doing all wink and then hire outside contractors must submit a new al fldas it indicating such.
:Cunn:etors that check this box must attached an additional sheet showing the nine of the sub-contractors and state whether or nut those entities have
employ ecs If the sub-contractors have employees.they must pro,.ide their workers'comp.policy number.
1 ant an employer that is providin,('workers'compensation insurance for my employees. Below is the policy and job site
in/wrnation.
Insurance Company Name: 1 ZA1, £d C 51 1 3
Policy x or Self-ins.Lic.#: 00 s 7 et 3 Expiration Date:_ Z-/ Z! Zy
Job Site Address: (O' It.t jP4 4RD City/State:Zip: I ,.. 1C.Lbfjiii
Attach a copy of the workers compensation policy declaration page(showing the policy number and elcpi t�ate).
Failure to secure coverage as required under MGL c. 152,125A 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 fine 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 for insurance
coverage veriticati
I do hereby certif u er the l 'ns and . ies of perjury that the information provided ided above is true and correct.
Stature: Date: I 2-3
Phone#. ll
Official use only. Do not write in this area.1r1 be completed by city or fawn official
('its'or Town: Permit/License#
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.CiRrfown('lerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
Massachusetts �4{�'•.
\ w
DEPARTMENT OF BUILDING INSPECTIONS y
212 Main Street • Municipal Building Vp`.,,
Northampton, MA 01060 fsYjY-�j\\0
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
1, (insert full legal name), born _ (insert month,
day,year),hereby depose and state the following:
1. I am 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. 1 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 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.
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 the pains and penalties of perjury on this day of ,20_.
(Signature)