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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