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31A-005 (2) BP-2023-1716 11 MASSASOIT ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 31A-005-001 CITY OF NORTHAMPTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2023-1716 PERMISSION IS HEREBY GRANTED TO: Project# ROOF 2023 Contractor: License: Est. Cost: 6500 DEAN COUTURE 072541 Const.Class: Exp.Date: 12/07/2023 Use Group: Owner: LLC. 11 MASSASOIT, Lot Size (sq.ft.) Zoning: URB Applicant: DEAN COUTURE Applicant Address Phone: Insurance: PO BOX 95 (413)575-4941 HUNTINGTON, MA 01050 ISSUED ON: 12/06/2023 TO PERFORM THE FOLLOWING WORK: STRIP AND REROOF 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: P9Ttft,_ Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner t• E DEC 5 ' The Commonwealth of Massachusetts 023 Board of Building Regulations and StandardsoF�u� FOR Massachusetts State Building Code, 780 CMR ORTNAn,nTON iv /oNs Building Permit Application To Construct,Repair,Renovate Or Demolish a Revis 011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: (I( )3"/71 'f' Date Applied: 4frt i/' ' /Z- ZOZ3 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property.Addre S 1.2 Assessors Map&Parcel Numbers I t W 1.1a Is this an accepted street?yes )4' 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❑ Private❑ Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: / �erc 5o1n5�or Alei -�1i 7tn-. mA- Ol060 Name(Print) City,State,ZIP 9 An CtOQ so f 51- Ain;i4uxv O. 41 S-2 9,474% K.13 061216 a 4 i d 1. crr►- No.and Street Telephone Email Adiss SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) ]lr Alteration(s)NO Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Wor 2• / f t�►,as 4..._ +1 auk I '�` r� t \.,s+,4,a cvv 2 t , fp Oka O2 haJ+ A�� t� � s SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ to SVo 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost3(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees: $ Suppression) Check No. 1,›1 Neck Amount: D Cash Amount: 6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 0.72 C2-17 -23 ,afteN CBS License Number Expiration Date Name of CSL Holder 7-1 t List CSL Type(see below) No.andkg - V Street VIZ Type Description ,�j,� U Unrestricted(Buildings up to 35,000 Cu.ft.) SD"�•`a ) �� Ur R Restricted l&2 Family Dwelling City/Town,State, M Masonry RC Roofing Covering WS Window and Siding I (� SF Solid Fuel Burning Appliances 4!)--4q4� cAeav,cJufc. e'm tz,vicj' fur d I Insulation Telephone ethail address �a.l•fc�.t D Demolition 5.2nn--Regi__stered�Improvement Contractor(HIC) aiLa" WJI" HIC Registration Number Expiration Date HIC Compapy Name of HIC egist^r Name 1 Nand t 1 01��� 4,3-c- s'11414, Email address 1� `hM 1 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 ..........'p 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 j,p p,.,. Co A IA _ . to act on my behalf,in all matters relative to work authorized by this building permit application. IGv1 S1t 5 PL/512 Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I ereby attest under the pains and penalties of perjury that all of the information con ,fined in this app' tion' e and accurate to the best of my knowledge and understanding. ► , , 4512 `3 Print Owner's or Au rued 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" CITY OF NORTHAMPTON SETBACK PLAN MAP: LOT: LOT SIZE: REAR LOT DIMENSION: REAR YARD SIDE YARD SIDE YARD FRONT SETBACK FRONTAGE City of Northampton p tHAM 1 ?� .'� S�S SAC,, t '[ , Massachusetts tea`' y- << { f DEPARTMENT OF BUILDING INSPECTIONS S M i• ir * 4 212 Main Street ilk Municipal Building y' . a� , Northampton, MA 01060 `:Fil'Y N'`' 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: r+" uvlo i N► l�— The debris will be transported by: Name of Hauler: it4R.cv.A CD-tjw--e--- Signature of Applicant: a4,,,, Date: 02/ /2 3 The Commonwealth of Massachusetts k e Department of Industrial Accidents ;a/r1 t 1 Congress Street,Suite 100 "~-ai "" Boston,MA 02114-2017 Workers'Compensation Insurance Affidavit:BuildersiContractors/EitetriciansiPlumbers. TO BE:FILED WITH' DE PERMITTING At(THORJT'k'. Applicant Information Please Print Legibly Name(Husines&Organtrationfladividual): t, w,>_, Address: "7 7 s2 so (A.t2. 2t City/State/Zip: %vottek otAfriwt 4 u c Plume - 1`3- 5 7 S - 44 4 Aft y..artatytlover:I tis,k the aptitotrriateb0it: Z 3,pe of project(required): 1.01 am a employs with.._________..enaplo s:es peril and-ve part-tinge • 7. O New COnitrtiction 2►w)1 am a sole proprietor or poe1nerthrp and have no employees working for me in S_ 0 Remodeling any capacity.[No workers'comp.insuran x r ywred.j 9. 3� a 1 am a homeowner doing all work myself.[No workers°comp_insurance required.]' ❑Demolition 4.01 am a homeownerand will he hiring contractorsco to conduct all work on my pitmen,. 1 will I 0©Building addition ensure that all coaotra1Urs either have MWtker]cumpensati(n insurance or are sole 11.0 Electrical repairs or additions proprietor.with no employees. 12.0 Plumbing repairs or additions 50 I ant a,teaerat 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.; ha We are a corporation and its officers have exercised their right of exemption per NIGL e. 14. Other 132.§t(41.and we have no employees.[No workers'comp.insurance rcyuiretil `?ens applicant that checks box 41 must also fill out the section lacluw sbo w ing then workers compensation puticti urtoi nation. t Homerrwners who submit this affidavit indicating they are doing all work and then hoe outside contractors most submit a new affidavit indicating such. 'Contractors that check this box must attaelsed an additional sheet showing the name of the subcontractors antl state whether or not those entities have employee-,. If the sub-cuntractdus hose employees.they must pots ide their workers comp.policy'ntanber I um an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Na MC Policy#or Self-ins. Lie.#: Expiration Date: Job Site Address: CitytState 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 S1,500.00 andror 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 cover-4.... verification. I do hereby c-er Iv under the pa- s an penalties of perjury that the information provided abovei.a true und correct. ....,, Signature: .fti Batt. C Z/S/2 3 Phony= ,� , S 40-4 Official use only. Do not tsv'rte in this urru.to Ire completed by city or town of/i tat City or Town: PermitfLicense# Issuing Authority, (circle one): 1.Board of Health 2.Budding Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other ( uuta+;t Person: Phone#: