17D-040 (19) BP-2023-1796
8 HIGH ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
17D-040-001 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-2023-1796 PERMISSION IS HEREBY GRANTED TO:
Project# 2023 ROOF Contractor: License:
Est.Cost: 1800
Const.Class: Exp.Date:
KOZUCH TAMMI M&MATTHEW&A JARRETT&
Use Group: Owner: R WOODRING
Lot Size (sq.ft.)
KOZUCH TAMMI M&MATTHEW &A JARRETT&
Zoning: URB Applicant: R WOODRING
Applicant Address Phone: Insurance:
6 HIGH ST
FLORENCE, MA 01062
ISSUED ON: 01/02/2024
TO PERFORM THE FOLLOWING WORK:
REMOVE ASPHALT ROOF &REPLACE WITH METAL 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: /
if?
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
The Commonwealth of Massachusetts
IV Board of Building Regulations and Standards FOR
, ' Massachusetts State Building Code, 780 CMR MUNICIPALITY
USE
i 05 13,tiilding Permit Application To Construct,Repair, Renovate Or Demolish a Revised Mar 2011
I rN�v 1,_` i One-or Two-Family Dwelling
�' This Section For Official Use Only
Buildinelemal Number: -20Th- 1 Date Applied:
,_ ..`.:' ._-__--.1.---.7.--_:.:_jj 2
y! ,
, , ,...
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1.la Is this an accepted street?yes )( no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
--Ui?,- (3 ReS,defYh1 o `1d,j 1 b,ono 100
Zoning District Proposed Use (G ram) Lot Area(sq ft) Frontage(ft)
1 1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
10 aLi IA $ 9 010
1.6 Water Supply: (M.G.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone:Public fa Private 0 --- Outside Flood Zone? Municipal® On site disposal system 0
Check if yesUr _
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Flo-op Co 0 p 414:AVet, Zf'c "Flvre,o.c.k, M A 0 1Ol02
Name(Print) City,State,ZIP
'2> N N:h Si- _ 1413-3`t l-25 22_ f ut n`p eel n l P eoP le,Goo?
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction 0 Existing Building JR. Owner-Occupied Cf. Repairs(s) R Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg.gt Number of Units Other 0 Specify:
Brief Descriptionl of Proposed Work':-„-, p2v,C,ovt" c)l.� aspineA-1- shin U repIac ._
WFlh exedtbA (1C..1 1
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building $ 1 El p o I. Building Permit Fee:$ Indicate how fee is determined:
J 0 Standard City/Town Application Fee
2. Electrical $ 0 Total Project Cost3(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
S. Mechanical (Fire
Suppression) $ Total All Fees: $ 4P°° �} 02
Check No� u t_Check Amount: C1'1'0 —
6. Total Project Cost: $ I 1 $OID I 0 Paid in Full 0 Outstanding Balance Due:
City of Northampton
Massachusetts .. .
i4. DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS, ROOFS,RENOVATIONS,ROOF MOUNTED SOLAR, ETC.
I. 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. Construction Debris Affidavit filled out and signed by applicant.
4. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance.
b. Energy Conservation Compliance Certificate (new/ replacement windows).
7, Home owner's License Exemption Form(if applicable).
8. Note any Special Permit requirements(if applicable).
9. Energy Code - all new construction (Gut/Rehab) requires a HERS Rater Affidavit
10. Please provide the appropriate fee in the form of a check made payable to: The City of
Northampton.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below).
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. ft.)
Restricted 1&.2 Family:Dwelling
City/Town.State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SE Solid Fuel Burning Appliances
Insulation
Telephone Email address Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street
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 0 No 0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
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:OWNERt 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.
RyNk Viecolf 1(11
Print Owner's or Authorized Agent's Name(Electr nic Signature) Date
NOTES:
I. 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. I 42A. Other important information on the HIC Program can be found at
www.inass.govAx:ii Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned, provide the intbrmation 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"
.‘r\
The C'onsmonwealth of Massachusetts
"--\ ----:t4' i;t• Department of industrial Accidents
'-.....'.. .,, ..,...:-..,‘t.',. 1 Congress Street, Suite 100
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.......,...-4 t, Boston. AtA 02114-2017
wwW,mass.gov/dia
' ‘S vikers' Compensation '.nsiirlince Affidavit:BuilderliC4atractors4:kctriciana(Plumbers.
11)BE FIEED W11 il 111E.PERMITTING AUTIlt)R11 .
APPik ant Information Please Print Legibl%
Name 1 Hustacss thyatuzatnot traits ith:411: _..., -BC) --Q.k.) KfthAs1-1 t_SCc
Address:
City/Stale/Zip: Ftw-vv... MA- 01 c,2_ Phone #: 't II -3t-i I z_s"2 a_
Ara,sso as eleogris. eel e lreet dre oppevereisde Ma:
Type of project(required):
t.0 1 An 4 SI:00y a*gin crr544,yetN t NI and or Nat sun*1* 7. 0 New castaastslas:ticatt
:01 res a ode peoprietur co posintnlarp anti havc no cIttrissr_s LW;smoking for roc tra 8. 0 Remodeling
any eaporily psi°*otters's-samp tna manioc na.futres1)
1,3-1 a 9. 0 Demolition ra a lictenvosaner doing 4.11 Ale'.tnysclf.iSso ssorkorss`f:t.m r ra v i.., taotnce t4tortai l'
i 0 0 Building addition
4 0 1 ant 6 hcarncov,uct anal sstil bc hot":s‘ostractors to ccost.iutt ail*oat,on tny
4216111*that all Lotto:a:tura caber hose sslot.cr. t4ltIM11,31.ti,m'mon-once co arc sa4c i 113 Electro.v.al repairs or additions
props-actor,.*oh no anployees
12.n Plumbing repairs or additions
!,0 1 am a.gvnartal :tot and 1 has c burst the sob-contrwtoes itatest on Oat'Ailaiteit iMeg.
130 Roof%Taos
Tbeac Not,-tunuts Luse cc:apt-oyes-a anti has c*ottera'comp.anatatarxe.,-
14.0 6.0 Other 144 2CC 2f•OrrOF 34KNI 414,1 it.,officers has c cas.-rclact.1 thaw Nth;of....-.kernpisua per ItICAL v.
152,. 14 4i.and*a lulls.-to,tinployees,iNo*Moms'camp.nattica3ve matins&1
.Air,ifrticant ihai cs.s.i.,kw,"4 1 mot atao tiii oot(ha archon ak.'stras 4w...slog them'*ostart, 41.)CrirerVtaldoil 71,4"..': -.11,41.11SIZOC1
1 I itotile01411,014 Vriill Sisb,MIE thr,atiKiaso eashcattrati;lacy are damns Ali W OA Old thl1:1 Ittlt OVAS,Stir CiAlt1114.302-1!IVA:SillIffi4 d new affistr,it anstazating suck
`.:tonttat.tors.that check tins Iva tant'st attachcs1 an aritht tonal tisam atko*mg do:name of thlt mahvontrachat's as*1.1".1.4(*,,hello so*A thos,k,etattoca hasse
,.-traploycra It the sub-contractoas hasv cnatly,,sos.-ss.du,011t4.1 F 'sale thco ssuritcts.'taw" Nits.)ntscut.kst
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i am on t'mpioyrr that i%providing workers retatiWiTC4iitit;insurance,far aty employees. Below is the policy and job site
information.
buurance Company Name',
Polley Pt or Self-ins. Lie. 4: ... Expiration Date
Job Site Address: CiryStatelZip. ,_, .........„
Attach a cops of the starkers'compensaiton policy declaration page;stowing the policy nausber and expiration date).
Failure to secure coverage as required under Ni(iL c. 152.§25A IN a criminal violation punishable by a fine up to S1.500.00
anitor one-year unprisonnkmt,as well as civil penalties in the form of a STOP WORK ORDER and a line of up to 5250.00 a
day against the violator. A eopy of this statement nu y be forwarded to the Ofticiof Investigations of the DIA for insurance
co%crap:verification
, -
I do hereby certify under the poi 11,, and penalties o f periart that the in/Orsotin provided shave is true and correct.
Stiputurc: 4•--------- Dar..(.- I 2_ - 2 7- 2 3
Phone 4-, H 12 7L1/ -
. a
I Official use only. Da not write in this orlii,to he completed by city or town official ,hci
'-, City or Toe.: _ Perrait/Licetate a
Issuing Authority(circle otte
I. Board of Health I.Building Department 3.City/lona Clerk 4. Electrical inspector 5, Plumbing Inspector
iff
' 6.Other
Contact Perna: 7liose I:
City of Northampton
/40
Massachusetts40,
`' { `' DEPARTMENT OF BUILDING INSPECTIONS 9.
212 Main Street • Municipal Building %: ►`
-tea Northampton, MA 01060 sy
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, 554, 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: Vnl\ey �ecy�lrnS
The debris will be transported by:
Name of Hauler: se1 ( w0Oct +I)
Signature of Applicant: Date: 12-27-23
City of Northampton
Massachusetts '";. •t
DEPARTMENT OF BUILDING INSPECTIONS
212 Maim Street • Municipal Building
Northampton, MA 01060 4� 't
HOMEOWNERS'EXEMPTION E?,IGIBILITYAFFIDAVIT
Vfoockfivi (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 CVIR 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. I 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 '21 day of PQ-eQv' ber , 20 23.
(Signature)