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30A-053 (8) 56 LIBERTY ST BP-2021-1001 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:30A-053 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-2021-1001 Project# JS-2021-001665 Est.Cost: $10000.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 19514.88 Owner: BOURNE ALDEN&JOELI HETTLER Zoning: URB(100)/ Applicant: BOURNE ALDEN & JOELI HETTLER AT: 56 LIBERTY ST Applicant Address: Phone: Insurance: 387 PROSPECT ST NORTHAMPTONMA01060 ISSUED ON: TO PERFORM THE FOLLOWING WORK:RENOVATE STORAGE SHED INTO WRITER'S STUDIO 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. f ,f . a' � Certificate of Occupancy Signatur': • FeeType: Date Paid: Amount: Building $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Z4 f,n, e/to c'en -J The Commonwealth of Massachusetts 10) Board of Building Regulations and Standards FOR z MUNICIAL`1"Y o 0 Massachusetts State Building Code, 780 CMR USA 1-- Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised V 011 c- W Q One-or Two-Family Dwelling 1 `" =` This Section For Official Use Only � CV (5 c EF Buildjin�Permit Number: 01/- / / Date Applied: i(� Dec �,r�ui►.� ss 3 126Z OM Building Official(Print Name) Signature D — G SECTION 1:SITE INFORMATION 1 1 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 6 G L: h-'&-1 �-1- 1.1 a Is this an accepted street?yes 1/ 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 ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2 Ownert of Record: 1 _ L A A ) / ��er G ,/r( 1��(r �".lt� `Fl ortrce , MA © 1 0 6 . Name(Print) / City,State,ZIP �G L•, ),,,rdi St. 111 - %l6 -?W1 Amu ' cGN1AA5t o/ No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building ll Owner-Occupied 0 Repairs(s) El' Alteration(s) le Addition 0 Demolition ❑ Accessory Bldg.0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: t&1;A r e,.t c -{f t--d .,)Ae c/ 4-0 C o',.J-r-+ 1 v' t..fiv:r 0.v- a l-ec-c" G1� • C.A0 .f crl1 t�1 t�ar.ry.- iv"�v lv1t�o.- o\'t-'147 (9fe( Co(=� .l�rrr.rl .Az 4I 'VI le 0 'J 40 ih.G i etC 'g" t— ou.i S et,I `1' 7`1 l✓+ ‘ SECTION 4:ESTIMATED CONSTRUCTION COSTS ot'-1 't,1Q°cl pihlci Item Estimated Costs: Official Use Only J (Labor and Materials) 1.Building $ kc 0 d 0 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 000 ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ 000 List: 5.Mechanical (Fire $ Total All Fees:$ Suppression) Check No. (Kj Check Amount: (iash Amount: 6.Total Project Cost: $ to 1 0 0 0 ❑Paid in Full 0 Outstanding Balance Due: 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.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D 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 ❑ No .❑ 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 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: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. Ald Ne J1 ����� Print Owner's or Authorized Agent's Name(Electronic Signature) ate 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 Commonwealth of Massachusetts .. tit4 Department of Industrial Accidents 1 Congress Street,Suite 100 f � y ' Boston,MA 02114-2017 www mass.gov/dia 11 Ul kers'Compensalion Insurance Affidavit:BulidersK.ontroctors/EieetricbinhlPlumbera. 1(l to_ Ell_ v %till I Ht: Pt:R'1I1TING AIITHORITV. Applicant Infurutaflow / Please Print Legibly Name(Bosons+t huanktanon lndividuall. /�I o`/ei �vrc Address: 5( City/State/Zip: to re <, MA O 1 OC cc Phone#: 17'S fir "01 37 Are yarn>rr ewe Jnrvrr?(reek the appr prtaae hear Type of project(required): t.Q I ant a employer with _employees(full aad•'on part-time)• 7. D New construction 20 I am a sole proprietor or pushup and have no employees working fur me in 8. LJ itRemodeling any capacity.[No work ,'OM*mra aunce reregnant)regnant)er 30 I am a homeowner doing all work myself.(No workers'comp.uauramx c uinal.)' 9. ❑ Demolition 401 one a homeowner and will be hiring contractors to candd du all work on tin property. 1 will I Building addition eruure that all contractors ether haw workers'aarnprasatsat Insurance a are sole 11.�E[ectrieal repairs Or additions pndprrrtors with no empluyedmt. 12.0 Plumbing repairs or additions 50 lam a general contractor and I have hired the sub-contractors listed on the attached abet t—y� 'these subcontractors base employees and have workers'comp.itesurame. I3 oaf repairs 6.0 We am a euaparauo l'fx n and its oers have exercised their right of exemption per MGL 14.0O1iter 152,f lf4),and we have no employees.[Nio workers'comp.insurance required.] *Any applicant that chalks boa 41 must also fill out the section below showing their worker,'.ontperuation policy nil-mutation. f Human,.nem who submit this affidavit indicating they are(hang all w irk and then hire outside contractors must subnut a new affidavit indicating such. Contractors that check the,box must attached an additional sheet allow rat the meet:of the sub-crartraet<x,and state w hethcr or nut those entitles has e ernplld.,ce, It the tub-cunlra:trns bat a erttpluyccs,they must pros ide thee- u orken'e enp.pd:I. manbcr i am an employer that is providing worbers'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: CitytState+Zip: Attack 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 certi •under the pains and penalties of perjury that the information prodded above is true and correct Signature: - Data "3/e./ d- / Phone#: ( 1 — CJ ( G - "1 5'� Official use only. Do not write in this area.to be completed by city or town official. ( its or Town: Permit/License# Issuing Authority (circle one): I. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector (,.Other Contact Person: Phone#: City of Northampton / y. OsH. S/C / ?•-a Massachusetts tea? , ` d DIEPARTMEW OF BIIILDING INSPECTIONS s; 212 Main Stro•t • Municipal Building ,— h-"""' Northampton, MA 01060 144 3/01 HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT q3"""'` (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 CMR 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 ?day of kr..(c ,20AI. (Signature) City of Northampton atHAM�,. �✓�°` ���. Sys ', .p��i Massachusetts N t '# t DEPARTMENT OF BUILDING INSPECTIONS y o 212 Main Street • Municipal Building Northampton, MA 01060 ssN ♦4� 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: C aGre 11 I- WU rrsi-'`‘4,' oil of NA Location of Facility: ''6 Me;,- J M o I_/ 01, , MA The debris will be transported by: Name of Hauler: f 1 11 <PI ,(7047 / S-e ry I C S Signature of Applicant: Date: '44r