36-259 (10) 131 MAPLE RIDGE RD BP-2022-0025
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-259 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Bath reno BUILDING PERMIT
Permit# BP-2022-0025
Project# JS-2022-000042
Est.Cost: $18000.00
Fee: $117.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MATTHEW KOZUCH 106644
Lot Size(so.ft.): 44431.20 Owner: MCGRATH JOHN E&NANCY T
Zoning: Applicant: MATTHEW KOZUCH
AT: 131 MAPLE RIDGE RD
Applicant Address: Phone: Insurance:
6 HIGH ST (413) 341-8893 0 WC
FLORENCEMA01062 ISSUED ON:7/7/20210:00:00
TO PERFORM THE FOLLOWING WORK:BATHROOM RENO
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.
„2i Certificate of Occupancy signatu i •, .r
FeeType: Date Paid: Amount:
Building 7/7/2021 0:00:00 $117.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
1`\
/
r \
The Commonwealth of ass.chin
Board of Building Regula ons . d Stan rc�s J FOR
iC:. Massachusetts State Buil 'ng( ;rbF :0 CMR 4909/ MUNICIP LITY
US
Building Permit Application To Construct,Rep. o a Dem, ish . Revised Mar 2011
One-or Two-Family Dwelling T°A.,'':F 6oic)
This Section For Official Use Only
Building P it Number:/9�. .0 Date Applied:
Ew (4)5 ___,Z72 -7 7 2eZt
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1'�r3o;rty�Add�s: � �� 1.2 Assessors Map&Parcel Numbers CO
;� J 1
1.1 a Is this an accepted street?� f no Map Number Parcel Number
1.3 Zoning Information: 1.4 fk gperty Dimensions: 286
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Requir Provided Required Provided
A Al /01
1.6 W r Supply:(M.G.L c.40,§54) 1.7 FI Zone Information: 1.8 Sewage Disposal System:
Public 0 Private❑ Zone: — Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wner'or Record:
GM �m�n r\. / tic P IOre AA-, _ i cs 1(;ioZ
Name(Print) / nn 11 City,State,ZIP
a \ p_ f o g e ►\d 1(15 3`4 6&5(P ►1t lad SZ_@ certcc•ae-
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building Owner-Occupied Repairs(s) 0 Alteration(s) 0 Addition ❑
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: Ra 1.rpCiM. (-Q,AVjdd ( hi# bit...-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs. Official Use Only
(Labor and Materials)
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ CIStandard 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 Amount: 111 Cash Amount:
6.Total Project Cost: S I g ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
C.S- to6GLiq- 2-r`ZZ
fe• ZCV\ License Number Expiration Date
Name of CSL Holder
1�,Q S List CSL Type(see below) (I
No.and Street J Type Description
Fib(' eA ct_ A A o i o Z Unrestricted(Buildings up to 35,000 cu.It.)
►!V V� Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
` \ SF Solid Fuel Burning Appliances
3'f ( 8S13 oN(‘I i((jef iC S 1 1.(. i$t I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) zo t/R/z-z-
ckilkt HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.f 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes No .❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize ti\A.W
a zA.)C IA(1 Lief 6 .111.1.$N 1)
�
to act on my behalf,in all matters relative to work authorized by this building permit application.
J& c. IM,c G re1 7/7-/Z
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.
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
Information on the Construction Supervisor License can be found at
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"
` 1he Commonwealth of-Massachusetts
'/, Department of Industrial Accidents
-MINN_ 1 Congress Street,Suite 100
C
;�_� __ Boston,MA 02114-2017
Near-
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information t Please Print Legibly
Name (Business/Organization/individual): t ` 1 Kl J� b Icy\.. )(?1 jO'J
Address: (p 1-Ylg� �'v .
City/State/Zip: 1,0(P Le f MA 0/06 Z Phone#: GI) 3 3 1 I g 8 .7.
Are you an employer?Check the appropriate box:
Type of project(required):
1. I am a employer with Z employees(full and/or part-time).* 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.)
9. Demolition
3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t
10 D Building addition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.: 13.1 Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.ID Other
152,§1(4),and we have no employees.[No workers'comp_insurance required.)
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: �1Am%.,,,}V 4
Policy#or Self-ins.Lic.#: WC2.-3 IS- G Zy Z pq^0(0 Expiration Date: t s/i(o il2-
Job Site Address: 1 3\ \I L R.
'\ I ci s.e & c City/State/Zip: AJa nw MA- O/C6G
Attach 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 certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: lf\A:Ker---Csil-NN..._ Date: II- /.i
2-- t
Phone If: 14) . '5L J l'C13
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):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
ANIIIPTOtt, The City of No*thampton
r?
�` Building Department
n r 212 Main Street
143?
coArEn AO' Northampton,Massachusetts 01060
Phone (413) 587-1240
Fax (413) 587-1272
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVAT ION PROJECTS)
In accordance with the provisions of MGL c40, 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,s150A-
The debris will be disposed of in: y(irts T i c_
Location of Facility vci\` kt C L`t Aj
The debris will be transported by:
Name of Hauler At,' Catv ee! r` AAuglo)
Signature of Applicant: ° / V\ Date: 3- Ir* ?