23 MAIN ST 23 MAIN ST WB-2024-0030
Map:Block:Lot: COMMONWEALTH OF MASSACHUSETTS
340010J000001760
Permit: Siding roofing TOWN OF WILLIAMSBURG
windows doors Comm
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# WB-2024-0030 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF 2024 Contractor: License:
Est. Cost: 29000 JCA RESTORATION 105846
Const.Class: Exp.Date: 06/03/2024
Use Group: Owner: MILL RIVER REALTY
Lot Size(sq.ft.)
Zoning: Applicant: JCA RESTORATION
Applicant Address Phone: Insurance:
30 LOWELL AVE (413)495-2861 WC5315621589012
WEST SPRINGFIELD, MA 01089
ISSUED ON: 04/19/2024
TO PERFORM THE FOLLOWING WORK:
STRIP AND REROOF N 23B
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:
Driveway Final: Final: Final: Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature: r t<2
Fees Paid: $70.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
RECEIV-
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The Commonwealth of Massachusetts' APR 8 Z024
TOWN of WILLIAMSBURG !
i t r
Ifti' Massachusetts State Building Code(780 CMR)Seventh Edition - u J
t Building Permit Application for any Building other than a One-of Two-Fa1 1yDwelling: 'T�oNs
��f�j (This Section For Official Use Only) i0
Building Permit I�Tumber:at 0030 Date Applied: Building Inspector:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
23 ► 1 ti,- Sf. 1011I1 r1.- u,r
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here 0 or check all that apply in the two rows below
Existing Building'W Renovation 0 Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 1)
Change of Use 0 Change of Occupancy 0 Other 0 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No rff
Is an Independent Structural Engineering Peer Review required? Yes 0 No 0
Brief Description of Proposed Work:
e.xi.s- nq Ro, a✓1 238 fl1Jl .ep(4ce w41., der..
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) 0
Existing Use Group(s): Proposed Use Group(s):
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 0 A-2r 0 A-2nc 0 A-3 0 A-4 0 A-5❑ B: Business ❑ E: Educational 0
F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H4 0 H-5 0
I: Institutional I-1 0 I-2 0 I-3 0 I-4❑ M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4 0
S: Storage S-1 0 S-2 0 U: Utility 0 Special Use 0 and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 0 IB ❑ IIA 0 IIB 0 IIIA 0 IIIB 0 IV 0 VA 0 VB 0
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Dis sal Site 0
Public CI Check if outside Flood Zone 0 Indicate municipal 0
A trench will not be Po
Private 0 or indentify Zone: or on site system 0 required 0 or trench or specify:
permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable 0 Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No 0
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address f Property Owner
IC AD MO KaSChi 23 /44141 5+ Wiliewsb✓z5 0l696
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
V+<e Fe.s,ap.,4- 413 _26g_ -7 9q 5 '?3-il3 _ oU/oL/ Irasc4 d')6@ 46I. (aw,
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
7 Comp c A f�eS �4 fi4�
�x an Name:
JNa AI var 2 ( L' losgyA CI p. /3 7,- q
Name,.Qf Person esponsible for o truction � r Lic No. and Type if Ap licable
� J I /T s'� As t /''l Q!o V y
iiie-to dress „ /XI - City/Town ScA Ie&-to i1d.,-‘ efa•(atn )
Telephone No.(business) Telephone No.(cell) e-mail address
k. SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes 0 No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6)=$ 2 1 U c G
1.Building $ 2 Building Permit Fee=Total Construction C x (Insert here
2.Electrical $ appropriate municipal factor)= .
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to /�
6.Total Cost $ 2 Y,GGci (contact municipality)and write check number here J �✓d'1�
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
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.
X 710 MCS filch li /---- PZ-- V P y i3 _ y33- cyo Y yi /zY
Please print and signname Title Telephone No. Date
23 Aa St- Wr/tarnsb•.-5 /14 o/096
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: /-� y �7'����
Name Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
=;01 1 Congress Street,Suite 100
3?`1= Boston,MA 02114-2017
%'' ,.�1 www mass gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual): 3 P- R......iJoc-,A-IA c,n
Address: 3 o 1-o,i. 14u Q.
City/State/Zip: G,.1, SQri‘6i F 4.14 /hA OP y Phone #: y/ 3 y ys..- 286, I
Are you an employer?Check the appropriate box: Type of project(required):
1.0 am a employer with / employees(full and/or part-time).* 7. D New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in K. 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.❑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.EI Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
i.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. 00f repairs
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. 14'❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*My 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. II ``
Insurance Company Name: L;L.at-\� i�u-tv A, I h S C v.
Policy#or Self-ins.Lic.#: ( ) C 53 1 5 61 /S 8 '0/a Expiration Date: y-a-if- 2'V
Job Site Address: 3 /t/ihv' s. tz4t City/State/Zip: ev I li.Ms bvc y M/A
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: � � Q3-G-4-ri Date: y/o'
Phone#: *3 '9s. - g'6/
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#:
Town of Williamsburg 141 Main St Haydenville
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
q
Address of the work: 2 ) a (� 5 hii/I1Q fb-'S /14� �Iv(C`°/�
The debris will be transported by: o►4'1�S g)5( (
The debris will be received by: /1/'- fLartpk, 1►er5cI.k
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
(-AFrom: / O Wias /el SC (4 2 3 Gt<, S
in Ali , a ,A..s_. b,„ /14 A-- ---O/O 9
To:
Jonathan Flagg
Building Commissioner
City of Northampton
212 Main Street
Northampton, MA 01060
The Massachusetts.Building Code, section 107.1 allows for an exclusion from requirements for
construction control in certain situations. In accordance with code section 104.10, I request that you
grant a modification to waive the requirement for construction control of the project at
2 A61(n s
because the work is of a minor nature, will not affect structural elements, health, accessibility, life or fire
safety, and will be done in accordance with the prescriptive requirements of the code.
Thank you for your consideration. •
Respectfully,