36-310 (6) 133 CARDINAL WAY BP-2021-1539
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-310 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Deck BUILDING PERMIT
Permit# BP-2021-1539
Project# JS-2021-002560
Est. Cost: $5000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 18164.52 Owner: PELIS ANDREW S
Zoning: Applicant: PELIS ANDREW S
AT: 133 CARDINAL WAY
Applicant Address: Phone: lnsrcrance:
21 FERRY AVE
NORTHAMPTONMA01060 ISSUED ON:6/24/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:POOL DECK
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.
I r
Certificate of OccupancySignature: � • r � '
FeeType: Date Paid: Amount:
Building 6/24/2021 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
%.
The Commonwealth of Masdachu CNAN
/ G� N
Board of Building Regulations and'S . ); . • FOR
vt Massachusetts State Building Code, 781 :. r ti (lc,/ r MU LITY
o,
Building Permit Application To Construct, Repair, Renovat- I •lish . R/ SE
d Mar 2011
One-or Two-Family Dwelling ��o;�r'
O O4
gg This ection For Official Use Only /
jPermit Number: (i-+of/-'�✓j3 Date Applied: /
vl>v /� / 6-as-zoz)
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address / �� 1.2 Assessors Map&Parcel Numbers
1.la Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: S /
ff- c��j-ti.�, c , -r c e rtl /d F e--
Name(Print) City,State,ZIP
/ 37 Cq ic.t , / G( n y qt.) 755' 2i ,f,a 6e s ` itir,-/ ,.,,,L"-ree- . e
No.and Street / �O
Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition ❑
Demolition 0 Accessory Bldg. 0 Number of Units Other bl Specify: #'a'.+ / Qc&k
Brief Description of Proposed Work': , --ft% fi -/ 6 ,c/c� d e e ' /a At y
2 .5 /--.c.:4/ / . / 2.-1� his$ C Z-IO 1�'c�4H5 Hcft-icrk.
'ems i5 5 w 4-cr. AleArer, , z')
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ j— c., ., 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ 0 Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Suppression) $ Total All 1/e�es)5 £'
Check Amount: Cash Amount:
6. Total Project Cost: S 5— 1 ' 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.)
City/Town,State,ZIP R Restricted 1&2 Family Dwelling
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 0 No 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES R BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authori by this building permit application.
/eZ 04-e /ele .0 4/
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 applicaf and accurate t the best of my knowle -and understanding.
Print er'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.) 24- G (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
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
•
SIDE YARD ♦ SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton
rrxr-r Massachusetts �% 1
7
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 It z
"~~
77.7
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:
4 Location of Facility: (/ //e / 6 4 r io N),,,71"° r "`
The debris will be transported by:
Name of Hauler: 4, e1..--e t--' P 1 1
/ 7 /z1
Signature of Applicant: ' Date:: /
The Commonwealth of Massachusetts
o
't—..,,,,,,..e Deportment of Industrial Accidents
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a '1 I congress Street,Suite 100
1
sal ,,..=, Boston,MA 02114-2017
www.mass.govidia
11 orters'Compensation Insurance Affidat it:Builders/('ontrartnrsiElectririansiPlumhers.
it)BE FILED Willi I IIE PIERNIIIIING A11111Htllattli.
Applicant Information Please Print Leeibls
Name 4 lausincxs ormanizaibunelndividual): ."4-1,9i.A!c....-- ,C 6# J
Address: /J I C a •-•.1- —cf / ii7
7
City/State/Zip: - '7-r- e" /14 a fe)e e— Phone#: 4/13 egir-- 7 * Z 7
Are pill alli elimployer?Cloth the Appropriate boa: Type of project(required):
10 1 an"a entpkryer with employees(full aridOr parr-risn4..* 7. 0 New construction
20 I am 3 wile proprietor or pintnership and have no employees working for me in S. ci Remodeling
any capacity,.(No um-kers'comp.insurance required.'
9. 1:1 Demolition
3 ill I am a Ik111100V114:(doing all work myself.(No workers'caw.insurance requird"
10 0 Building addition
4.C1 1 ani a husisoo.w111.7 and will be hiring migration"to conduct all work on mry property. I will
ensure that all cormactotx either Iss‘c workers'ourripanation imurancc or are sole i i a Electrical repairs or additions
proprietor,VI itli no ornployecs.
12.0 Plumbing repairs or additions
SC3 Ian';1 innicral coal:mot mid I have hired the sub-coatracioni listed on the anarted sheet_
I30 Roof repairs
These Nab-contractors have onploycm and have workers'comp.Illkialallele.'
14. 1.0ther Doc
6.0 We Mixa coma/ration and its officers have exercised their nest of exemption per kkill_c_
152.§1{-11.,and we fume au employees.[No workers'comp.immune':rt.-quirt:J.}
•Aiini applicant that chocks boA ttl mum also fill out the section belou sliow ing their k orkers'compeNtilfilla polity inforrnation.
t lioinoirA nem uho h An n a am affirkiw indicatinm they are doing all w ork and then hoc outside catiOnclurs mast sagging a Ilik atiklas it indicating such.
:Contractor%that check the,box mug attached an additional slam slowing the name of the stils-conimeiors and mate intiet..-L.i.or not Hulse oolitic,.him:
cmployo:A. II Ilk:sub-coritracrors hamc employeei..they must proviiic dicir utokina'comp.rube)number_
I am an employer that is providing worhers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: _
Policy#or Self-ins_Lie.#: Expiration Date:
Job Site Address: City Stale'Zip:
Attach a copy of the workers'compeasation policy declaration page(shooing the!milk', number sued 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
andfor one-year imprisonment,as well as civil pena tt les 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 In',cstigations of the DIA for insurance
eo‘erage 1,crilicatitori.
I do hereby cericrfy under the pains and penalties of p ' ,that the information provided whore is true d correct.
S Eniartilc: --- ----P--"---- -- . 1).11,-... 7 f 7
7
ph,..,:. -!,/ 4,5,s -'zi ? '
Official toe only. Do not write in thi area,to be completed by city or lewd official
( its or Uom,n: _ Permit:license 4
I soiling.tothority(circle one):
I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
' Contact Person: Phone#:
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS . r
y212 Main Street • Municipal Building yJy �b
Northampton, MA 010607/0
rs •1 ���
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT //
I, 2-
/at d•-e "e*t f (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 / 7 day of `-I U , 20_�
nature)