32A-004 14 WALNUT ST BP-2021-1511
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A-004 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: SOLAR ELEC I RIC SYSTEM BUILDING PERMIT
Permit# BP-2021-1511
Project# JS-2021-002506
Est.Cost: $20898.00
Fee: $75.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: FREEDOM FOREVER MASS LLC 110253
Lot Size(sq. ft.): 12980.88 Owner: KOWALCZYK STEPHEN
Zoning: URC(106)/ Applicant: FREEDOM FOREVER MASS LLC
AT: 14 WALNUT ST
Applicant Address: Phone: Insurance:
68 GOLD ST (413) 291-5992 0 WC
AGAWAMMA01001 ISSUED ON:6/17/20210:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 15 PANEL 5.4 KW SOLAR SYSTEM ON
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 Signature:
FeeType: Date Paid: Amount:
Building 6/17/2021 0:00:00 $75.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
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The Commonwealth of Massachusetts\ do o� \C-1
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Board of Building Regulations and Standar '9T 6,
Massachusetts State Building Code, 780 CMR by AT�•4,, ��c-! ,S
Building Permit Application To Construct, Repair,Renovate Or D 1 R v, sed M 2011
One-or Two-Family Dwelling q°lo°>,
This Section For Official Use Only BLS
Buildin Permit Number:60..2/• /GJ 1 Date A lied:CUTA� " 55 )1 20Z)
BuildingOfficial(Print Name) it/
Signature Date
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SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
14 WALNUT ST
1.1a Is this an accepted street?yes 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
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
STEVEN KOWALCZYK NORTHAMPTON MA 01060
Name(Print) City,State,ZIP
14 WALNUT ST 203-415-0369 permitsma@freedomforever.com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other ® Specify_pv solar panels.
Brief Description of Proposed Work':
Install roof mounted PV solar panels.System size 5.400kW. 15 panels. 100A.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 4,179.60 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $16,718.40 ❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ �(
Suppression) Total All Fees: fJ J-r
74-
Check No !Check Amount: Cash Amount:
6.Total Project Cost: $20,898.00 ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
CS-110253 12/01/2021
Daniel Kelley License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) t lnrectrintart
323 HIGHLAND ST No.and Street Type Description
HOLDEN,MA 01520 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
413-265-1101 oermitsma(&.freedomforever.com I Insulation _
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(H1C)
198080 03/01/2022
Daniel Kelley/Freedom Forever Masssachusetts LLC HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
68 GOLD STREET
No.and Street permitsma@freedomforever.com
Email address
Agawam.MA.01001 413-265-1101
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 El 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 Freedom Forever Massachusetts LLC
to act on my behalf,in all matters relative to work authorized by this building permit application.
STEVEN KOWALCZYK 06/10/2021
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.
Daniel Kelley 06/10/2021
Print Owner's or Authorized 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"
City of Northampton
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,� ,, Massachusetts
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. DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building ''' '
Northampton, MA 01060 <s''4 3-1w'
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: 68 Gold St.Agawam,MA 01001
The debris will be transported by:
Name of Hauler: Freedom Forever Massachusetts LLC
Signature of Applicant: 'afrcr.I A ' /4 _ Date: 06/10/2021
/
The Commonwealth of Massachusetts
• Department of Industrial Accidents
1 Congress Street,Suite 100
Boston, MA 02114-2017
www mass.gor/dia
— Workers'Compensation Insurance Affithivit BuilderarontractorstElectrkians/Plumbers.
TO SE FILED WITH TIIE PERMITTtNG AUTIltiilt I
Annlicant Information Please Print t.reitoiN
Name(Businemi;OrganszationIndivIdual): Freedom Forever Massachusetts LLC
Address 68 GOLD STREET
CityiState7ip: AGAWAM, MA 01001 Phone : 413-265-1101
Art yen an unpin!,r? lattl clic appropriate box: Type of project(required):
am a crivlayer with 7essatiopere tfull rindsia p -h ) 7 0 New construction
20 I am a Alit:proprietor to partianiskap and haw m istatkryers working fur trk.15CI Remodeling
my capacity,[No workers cam.irattrum imatiod]
9. [11 Demolition
am a hormownita&ME rk wo tetyvelt(No wittionist comp,iresirman
Ei Building addition
ig.C3 am a isirreintamer arid will he Maas centnicaore to coot:hart wink on my peoporty. I Will
niaifire that all contractors either have stories'coillaitiniatiiin te r15nem aer an1 a Electrical remits or additions
piorrictiVi with rio employees.
1 2.0 Plunibing repairs or additions
51 I am a amend wan-actor and I lane hired the saiii-contrasera hated on the attached ahem,
1 3.1:3 ROaffrepairs
These arabattattraetom hate employee%and have workest emir neattranec.l
14.M Other PV solar panels
6,E3 We are amerpotation and its officer%have Mereiseal rhea natal oftderisphot per hitaL L.
152, 1141_and we have no employees.[No weaken'comp_iiesurance itcaaactil
'Any app4tieant that check Irma mats fill oat the sectien below showing thcii-ivorktra"compensation policy anferattatima
t lionatownovas ha manila this affidavit inaticathe they are diaing oil*AA and than hoc mesa&contrecters nest submit a new affidavitindian1i suck
Contractors that cheek this hex mean athiched an siddional sheet showing the name arta suiveractos and shate whether or not those cairtitirea have
istpleyeca If the aortsmiarectein have caterloyees.they mmt provide their maims*tamp.poliey narrava
/am an employer that is providing workers°compensation insurance far my employees. Below is the poliey and job site
information.
Insurance Company Naint: Milestone Risk Management&Insurance Services
Polk-y#or Self-ins.Lic. FRWC215868 Expiration Date: 01/01/2022
Job Site Address: 14 WALNUT ST. CityState,Zip! NORTHAMPTON MA 01060
Attach a copy of the workers'compensation policy declaration page(stunting the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,-§25A is a criminal violation punishable by a tine up to SI,500.00
arid,or one-year imprisonment,as well as civil penalties in.the Point oft:STOP WORK ORDER and a fine of up to S250,00 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: -71/1-atl2(14.r.o-771/ZaA/e/ta.krt, Daie:
phone 413-265-1101
„ - -
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):
I 1.Board of Health 2..Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6,Other
Contact Person: Phone 4:
_ ,