Fisher Signed Northampton Building Permit AppCity of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ● Municipal Building
Northampton, MA 01060
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR NEW
1 & 2 FAMILY DWELLING, ADDITIONS, POOLS, DECKS, ACCESSORY STRUCTURES,
FENCES, GROUND MOUNTED SOLAR, ETC.
l. Building Permit Application signed by legal owner and filled out by owner or authorized agent.
2. One set of plans and specifications of proposed work. (Digital and hard copy)
3. Site plan with location of proposed structure(s) and set backs.
4. Construction Debris Affidavit filled out and signed by applicant.
5. Worker's Compensation Insuran ce Affidavit filled out and signed by applicant.
6. Contractors must supply a copy of CS License, HIC Registration and proof of Liability Insurance.
7. Energy Conservation Compliance Certificate (new / replacement windows).
8. Home Owner's License Exemption Form filled out and signed by Homeowner (if applicable).
9. Note any Conservation and/or special permit requirements (if applicable). 10.
Driveway Permit (if applicable).
11. Proof of Water and Sewer entry fees paid (if applicable).
12. Trench Permit - public land by DPW / private land by Building Dept.
13. Stretch Energy Code - all new construction will require a HERS Rater Affidavit to be submitted with permit
application before issuance of permit.
14. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton.
The Commonwealth of Massachusetts
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Dwelling
FOR
MUNICIPALITY
USE
Revised Mar
2011
This Section For Official Use Only
Building Permit Number: _____________________Date Applied: ______________________________
Building Official (Print Name)Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address:
30 WARBURTON WAY NORTHAMPTON MA 01060
1.1a Is this an accepted street? yes no
1.2 Assessors Map and Parcel Numbers
Map Number Parcel Number
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area (sq ft)Frontage (ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
(M.G.L c. 40, §54) 1.6 Water Supply:
Public Private
1.7 Flood Zone Information:
Zone: ___Outside Flood Zone?
Check if yes
1.8 Sewage Disposal System:
Municipal On site disposal system
SECTION 2: PROPERTY OWNERSHIP
2.1 Owner1 of Record:
Diane Fisher-Katz
Name (Print)
Northampton MA 01060
City, State, ZIP
30 Warburton Way
No. and Street
(413) 320-9614
Telephone
dkatz1961@gmail.com
Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)2
New Construction Existing Building Owner-Occupied Repairs(s)Alteration(s)Addition
Demolition Accessory Bldg.Number of Units 16 Other Specify: Solar
Brief Description of Proposed Work :2 Installation of a 16 panel, roof mounted solar array. System Size: 6.72 kW DC
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials)Official Use Only
1.Building $ 16228 1. Building Permit Fee: $_______ Indicate how fee is determined:
Standard City/Town Application Fee
Total Project Cost3 (Item 6) x multiplier _______ x _______
2. Other Fees: $_________
List:___________________________________________________
_____________________________________________________
Total All Fees: $_______________
Check No. ______Check Amount: _______Cash Amount:______
Paid in Full Outstanding Balance Due:__________
2.Electrical $ 6955
3.Plumbing $
4.Mechanical (HVAC)$
5.Mechanical (Fire Suppression)$
6.Total Project Cost $ 23184
Expiration Date
413-584-8844
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
Patrick Rondeau
Name of CSL Holder
53 Fox Farms Rd., Florence, MA 01062
No. and Street
Florence, MA 01062
City/Town, State, ZIP
413-584-8844 Info@valleysolar.solar
Telephone Email address
CS-115680 4/9/2025
License Number Expiration Date
List CSL Type (see bellow)U
Type Description
U Unrestricted (Buildings up to 35,000 cu. ft.)
R Restricted 1 AND 2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
D Demolition
5.2 Registered Home Improvement Contractor (HIC)
Valley Solar LLC
HIC Company Name or HIC Registrant Name
116 Pleasant St, Suit 321
No. and Street
Easthampton, MA 01027 413-584-8844
City/Town,State, ZIP Telephone
186338
HIC Registration Number
info@valleysolar.solar
Email address
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 ...........
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 Valley Solar LLC
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: 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.
11/07/23
Print Authorized Agent’s Name (Electronic Signature)Owner’s or 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 have access to the arbitrationprogram or guaranty fund undernot
M.G.L. c. 142A. Other important information on the HIC Program can be found at Information on thewww.mass.gov/oca
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”
11/07/2023
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ● Municipal Building
Northampton, MA 01060
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: ______________________________________________________
Signa ture of Applicant: __________________________________Date: ___________
Valley Solar LLC
Valley Recycling, 234 Easthampton Rd, Northampton, MA 01060
11/09/2023
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers’ Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):______________________________________________________
Address:__________________________________________________________________________
City/State/Zip:_____________________________ Phone #:________________________________
*Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information.
†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:____________________________________________________________________________
Policy # or Self-ins. Lic. #:__________________________________________ Expiration Date:____________________
Job Site Address:City/State/Zip:______________________
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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone #:
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 #:_________________________________
Type of project (required):
7. New construction
8. Remodeling
9. Demolition
10 Building addition
11. Electrical repairs or additions
12. Plumbing repairs or additions
13. Roof repairs
14. Other____________________
1. I am a employer with _________employees (full and/or part-time).*
2. I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers’ comp. insurance required.]
3. I am a homeowner doing all work myself. [No workers’ comp. insurance required.]
†
4. 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
proprietors with no employees.
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers’ comp. insurance.‡
6. We are a corporation and its officers have exercised their right of exemption per MGL c.
152, §1(4), and we have no employees. [No workers’ comp. insurance required.]
Are you an employer? Check the appropriate box:
30 Warburton Way Northampton, MA 01060
11/09/2023