12C-115 88 RICK DR BP-2021-0070
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12C- 115 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING P E RM I T
Permit# BP-2021-0070
Proiect# JS-2021-000100
Est.Cost: $10000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use croup: Homeowner as Contractor
Lot Size(sa. ft.): 10018.80 Owner: MELLING VINCENT J&LYNN M
Zoning: RI(100)/URA(100)/WSP(100)/ Applicant. MELLING VINCENT J & LYNN M
AT. 88 RICK DR
Applicant Address: Phone: lnsurance:
88 RICK DR
FLORENCEMA01062 ISSUED ON.7/21/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Si$jnature:
FeeType: Date Paid: Amount:
Building 7/21/2020 0:00:00 $40.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
o a1zeXXd
Inr The Commonwealth of Massachusetts
AA, ' Board of Building Regulations and Standards
FOR
/, Massachusetts State Building Code, 780 CMR MUNICIPALITY
USE
ruilding Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
n y �' One- or Two-Family Dwelling
o y rev This Section For Official Use Only
Buildin nit Number: ✓ Date Applied:
o'
D Eur a�, .7-21-zt)2o
tial(Print Name) gnature Date
SECTION 1:SITE INFORMATION
1.1 PTP
Addr ss: 1.2 Assessors Map&Parcel Numbers �
1.1 a Is this an accepted street?yes--X— no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
y� Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
j 1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
j Required Provided Required Provided Required Provided
N
1 1.6 Water Supply: (M.G.L c.40,§54) 1.7 FIood Zone Information: 1.8 Sewage Disposal System:
t Public I Private❑ Zone: Outside Flood Zone? MunicipalPOn site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP)
2 1 Owners of Record: )) 'J�'J/
11,"1 `F�U�hcen Iyl�Gl r'^t `ur-est c� r/k/A (3l0 Ce,
Name(Print City,State.ZIP
V S I L a c l7,rl L113 " 8 L ` mClit� � rn4�l.e--a
No.and Street Telephone Email
n SECTION 3: DESCRIPTION OF PROPOSED WORKI(check all that apply)
New Construction❑ Existing Building 16 Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed WorkZ: 2 k.c c. U vc n r-$
1�,�
hN SECTION"4:ESTIMATED CONSTRUCTION COSTS
�
Item Estimated Costs: Official Use Only
Labor and Materials)
1.Building $ ()0,) 1. Building Permit Fee: $��Indicate how fee is determined:
2.Electrical $
)Standard City/Town Application Fee
.�v ❑Total Project Costa(Item 6)x multiplier x
y 3.Plumbing $ 2. Other Fees: S
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire
$
Suppression) Total All Fees:$ Q v cc
Check No. Check Amou l4Cash
6.Total Project Cost: $ 6, Q d O IVPaid in Full 13 Outstanding Balance Due:
The Conzmonwealtlt of Massachusetts
Department oflndustrialAccidents
I 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 PERNIITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organizatio divid`ua,: 1 e4 e,n 7LA /u1,q PV,5n d;.-1 a
Address: g=
City/State/Zip: — _ /V !U!o Phone#: 4113 —J:2_9_—a 6,39
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with employees(full and/or part-time).* 7. []New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in g, ❑Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required]t
,,__..__,,// 10 [:]Building addition
4.�1 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.❑Electrical repairs or additions
proprietors with no employees. 12.Q Plumbing repairs or additions
5. l d I hhired the listed on the attached sheet.
❑I am a generacontractor anhave e surac
13.NKoof 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.]
Any applicant that checks box#1 must also 511 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 anz an employer tliat is providing woz•kers'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 DTA for insurance
coverage verification.
do herfy under the pains and penalties of perjury that the information provided above is true and correct
/SiLmatur:1711 vDate:
/Phone#: —
14 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#:
The City of Northampton
�w4 w Building Department
212 Main Street
Northampton, Massachusetts 01060
Phone (4 13) 587-1240
Fax (413) 587-1272
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVAT ION PROJECTS)
In accordance with the provisions of MGL c40, 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, sl 50A.
6
The debris will be disposed of in: V1111all f0,41AZ&"
Location of Facility
The debris will be transported by:
Name of Hauler oe 4=Y:A
Signature of Applicant: Date
City of Northampton
.r Massachusetts ���'K Sh- .fG
DEPARTMENT OF BUILDING INSPECTIONS
S� r
- 212 Main Street * Municipal Building
Northampton, MA 01060 SNSti`.
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
Iinsert II Ie a1 name born Nmyrlt
�Jl�
month, day, year), herelnj 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 110.85.1.3.1, 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:
Persons) 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 L�_day of 20,--&
(Signa }