12C-046 (6) 38 LEENO TER BP-2021-0985
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12C-046 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2021-0985
Project# JS-2021-001655
Est.Cost: $12000.00
Fee: $78.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: KEITH GUYER 095143
Lot Size(sq. ft.): 13982.76 Owner: BODZIKOWSKI ELENA
Zoning: RI(100)/URA(100)/WSP(100)/ Applicant: KEITH GUYER
AT: 38 LEENO TER
Applicant Address: Phone: Insurance:
60 RIVER ST (413) 768-0607 WC
BERNARDSTONMA01337 ISSUED ON:3/9/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:KITCHEN/BATH RENO, NEW WINDOWS AND
DOORS IN BREEZEWAY
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 Signatur., 1 0 y2 3)'I •
, I
FeeType: Date Paid: Amount:
Building 3/9/2021 0:00:00 $78.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
-( C11LLE0 3-U LET i-i , - ; ____�,
/..� rizo2 Pc-A '' 8�
14 The Commonwealth of Massachusetts' 202/
Board of Building Regulations and Standards. F R
Massachusetts State BuildingCode'780 C1Vl1Zar I PALITY
y i0-44kir'�r4I"SPECTp SE
Building Permit Application To Construct, Repair,Renovate Oi DenaMiSli n+a6o vise Mar 2011
One-or Two-Family Dwelling —"""'-
55s�ection For Official Use Only
BuildingP it Number: �' �/'q�
/ Eul� um S Date Applied:
//' -Y 3-q-2UZi
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
2)% Lems.nc TtrracQ..
1.1a Is this an accepted street?yesx 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 0 Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system 0
I Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2. Owner'of Record:
IL\a - Z A. i, \Ln.a,\\(..:- NQrdle.,...e t JAA
Name(Print) City,State,ZIP
01( LAC+4-t't--- Si- 611- VI t -1140 e.&em u C n.,$5X-% G (aL\ue c,6r-1
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building lit Owner-Occupied 0 Repairs(s) lid Alteration(s) VI Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work': S.nsd'a,\,\.x44,-(.1. 8`2..t,.i W,da.a S `, tZ rS Si
- to \ it-P )
s Q Lr. -1,c� r1 1 1e1• c C ,nv1- n Q(ar :,,., l,- t bata,iv,.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $'g0120 60 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 0 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 $
Suppression) Total All Fees ,'�
Check No. Check Amoun : Cash Amount:
6.Total Project Cost: $ j 066 .a) 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) O \ 4.43 02 143 oZ 2
16zA)rti ,p f License Number Expiration ate
Name of CSL Holde
r List CSL Type(see below)
Cob C
Type Description
No.and Street
ll rN M� O\�3� U Unrestricted(Buildings up to 35,000 cu.ft.)
C R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
(p ) 4 �
Sl) \�1h-q�yts. ,S+,— pen4v--1 I Insulation
TelepF(one (UJ 'Email address(at E,.,..,L D Demolition
5.2 Registered Home Improvement Contractor(HIC) 65 1f
HIC Registration Number Exptlratio Date
HIC Company Name br HIC Registrant Name �� �
(30 vt.r Oh.9Jt-t'f'/ _e CuCuSF°ry1
o.atnd Street VU ` Email address V(�
K.es P\p, C11 �\‘.5):1'34 CO 6'r ev f% . CAS
City/Town,State,ZIP elephone
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 0
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 1GtAIN & V COS 1Un, Cf+i-r(ryN
to act on my behalf,in all matters relative to work authorized by this bililding permit application.
741c� �.e ZcAr1�A1�w' t (3I� l
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'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.
16--e-vg-t I Sio--k
Print Owner's or Authored 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"
The Commonwmdth of Massachusetts
Department of Industrial Accidents
'.:ET,WrilE(cT
I Congress Street,Suite 100
• ,-Itzrar. .. Boston. MA 02114-2017
www-ntass.goridin
liA otters Compensation'noir:thee Affidavit:Builders/ContractorsiEkdriciansfriumbers.
TO RE FILED w nu THE PERNII FONG At 411(IRFIT,
Applicant Information Please Print Leeibls
Name(nusines,LI)%inizittionfintlividuall: ICA3..A.\t/1. ,,,,2 ez-- C ta)S..4—`6 c'-'. C_irc-f-ti
Address: p L.
City/StateiZip..., &,2_/ -3_5-1-or% /AO 01'537 Phone
Art you an eittptm eil Cheek the appropriate toss: Type of project(required).
arn a eirmleyer with ,1 , ,,01111113- i!Vh chill anchor pandinrek. 7. 0 New construction
2[3 I ant a sole pruprietor or panniershap and bane no employees winking for me nit 8. 0 Remodeling
any impaerty flio workers'eon,.insurance rt sorrel"
9. El Denitiiithdit
ICJ I ant a homeowner doing all work triNa.elf.No VilarkeWC4.10141 Mitirilii..V.imputed]'
i 0 Ej Mit Ming addition
410 Ilea a linineestrner and will he hiring emu:radon to oundoet all WtItk On thy property I will
mum dial all contramors either have stank etampenttatinti insurance or an sole i la Electrical repairs or additions
pfilptiettaft OPItli no employees.
12.0 Plumbing repairs or additions
sa.ant a gelorat eswitrattdr and I Imov tuned tile sub-contractors fisted on the enacted sheet
114-3 Roof repairs
Those suboaiimaieas issse employees and haw workers'comp.iliStitMet.;
14.120thff yv_,,,..3
613 We ate a labilISICAILM and its tamers have eterthed then nght eit otiummuti per MU c,
151,4 Ir 4k.and we have nu einployees,[No workers"teei insarance mituted.1
An appborn that checks brut al mud ako an out the Neaten helm* but int3 their Worktft'caarnpemabetti pulley surimmunism
*HtStritimiturs who submit atit orattovu indicating dley are doing all work and then hirr oniwitle Citoltif&V-Ital must submit a ism uffidesit instituting suck
:t'ontractors that check this box nand attached an adebtainal sheet show mg.the maw oft&imis.contimtois and state a limner or not those manic Ic.o.c
plef3,0:* If die stsh,0111%.0:1:0T.,lupe curly}ets.they most}lowish.Men winkerf VIM .polio,number
I am on employer that is providing workers"compensation insaralree for my employees. Below is the policy and job site
information.
Insurance Company Name:. I J-r.s. ___
Policy#or Self-ins.Lie.ik L•A,C S—1 t5 - (.,.2%,40% -6\0 Expiration Date: t-k
lob Site Address: T t-e,e,0 1 Q....-- City/State/Zip 101a5--AIN:4-,—oe' b''\. ,ftV10.- Ol.0 V..)
Attach a copy of the workers"compensation polky derlarittion page ishowing the policy number and expiratiott datet.
Failure to secure coverage as required under IsIGE c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
andOir one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$2501X)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 wader the palm and penalties of perjury that the Information provider!above is trate and correct.
Signature: . Eklie 3 I fr
Phone t; Cc(c3),,P-1 c)-- ( LC
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Perntitilicense*
Issuing Authority(eke*one):
I. Board of Health 2.Dulkfing Department 3.ChytTawa Clerk 4.Electrical inspector 5, Plumbing Inspector
O.Other
Contact Person: Phone#:
City of Northampton
4S rc
-'' Massachusetts A.w.e .._ <, ..
-i DEPARTMENT OF BUILDING INSPECTIONS �`• 1` ,ram
212 Main Street • Municipal Building 0, C�'t,
\s - Northampton, MA 01060 S/.yI \'��
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: (-ter -,mob,,, MP
The debris will be transported by:
Name of Hauler: S YPa-t-vs, -Cc Q C-C,r rt
Signature of Applicant: 0 • ,�_,A j Date: s 3 (2¼