17A-195 (4) BP-2022-0261
18 POWELL ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
17A-195-001 CITY OF NORTHAMPTON
Permit: Exterior Res
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2022-0261 PERMISSIONISHEREBYGRANTED TO:
Project# ROOF Contractor: License:
Est. Cost: 5000
Const.Class: Exp.Date:
Use Group: Owner: HANSEN WILLIAM A
Lot Size (sq.ft.)
Zoning: URB Applicant: HANSEN WILLIAM A
Applicant Address Phone: Insurance:
18 POWELL ST
FLORENCE, MA 01062
ISSUED ON:03/17/2022
TO PERFORM THE FOLLOWING WORK:
REPLACE 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:
Gas: Final: Final: Rough Frame:
Rough: Fire Department Driveway Final: Fireplace/Chimney:
Final: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
I , 41, 1
Fees Paid: $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
A ,
The Commonwealth of Massachsetts�~ --��`
Board of Building Regulations and tan rds AR OR
��� � J � IPALITY
Massachusetts State Building Code'780 MR 20
. 22 USE
Building Permit Application To Construct,Repaii,R emolish a Revi ed Mar 2011
One- or Two-Family Dwelling' " 131'Y', 'N(,rnisp e
This Section For Official Use Only ''::_1:—�nuN
Building Permit Number: 45,- ) Date Applied:
'e6Utz /✓45 ////0 3- 17-202Z
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 P pgrtyF�dr�e �t c 1.2 Assi= essors Map& Parcel Numb
1.1a Is this an accepted street?Dyes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) 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'
2.1 O n of,Record:
i 10 �c SCE, 5tbrc�L%_ MA 01,0 ( Z
Name(Print City,State,ZIP
1 e �` es+ - cam— c3 L'II - -g�►��Yok)cp,cC
No.and Street Telephone I Email kkddress
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. ❑ Number of Units Other V Specify:
Brief Description of Proposed Wor 2.
.-T
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:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ �j
Suppression) Total All Fe �,Jtif°Check No.IIUI Check Amount: Cash Amount:
6. Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
r ' _
City of Northampton
317.74
jrMassachusetts ,it' ° sr�'tDEPARTMENT OF BUILDING INSPECTIONS,,r 212 Main Street • Municipal Building +3 , Via`
Northampton, MA 010600
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR NEW
1 & 2 FAMILY DWELLING, ADDITIONS, POOLS, DECKS, ACCESSORY STRUCTURES,
FENCES, GROUND MOUNTED SOLAR, ETC.
I. Building Permit Application signed by legal owner and filled out by owner or authorized agent.
2. One set of plans and specifications of proposed work. (Digital and hard copy)
3. Site plan with location of proposed structure(s) and set backs.
4. Construction Debris Affidavit filled out and signed by applicant.
5. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
6. Contractors must supply a copy of CS License, HIC Registration and proof of Liability Insurance.
7. Energy Conservation Compliance Certificate (new/ replacement windows).
8. Home Owner's License Exemption Form filled out and signed by Homeowner (if applicable).
9. Note any Conservation and/or special permit requirements (if applicable). 10.
Driveway Permit (if applicable).
11. Proof of Water and Sewer entry fees paid (if applicable).
12. Trench Permit - public land by DPW / private land by Building Dept.
13. Stretch Energy Code - all new construction will require a HERS Rater Affidavit to be submitted with permit
application before issuance of permit.
14. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton.
•
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 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 thi pplication is true and accurate to the best of my knowledge and understanding.
ct vt -5 \-7 •
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
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton
/ Massachusetts { �fG
(. ..
,jry¢ bitA DEPARTMENT OF BUILDING INSPECTIONS ,
212 Main Street • Municipal Building �k ^,
Northampton, MA 01060 sS ,. V%N1 ��,
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: Cc.") 0 \ Ct C'w'
r
The debris will be transported by:
Wq q
Name of Hauler: / 1/\ -2
t 1 l
0 Signature of Applicant:pp g Date: 31 -7_Z
The Commonwealth of Massachusetts
Deportment of Industrial Accidents
1 Congress Street,Suite 100
„Iv
Boston, M4 02114-2017
mass.gov/dia
oiters'Compensation Insurance Ail-Ida%it: Builders/Contractors/Electricians/Plumbers.
TO BE FILED Walt I III. PERMITIING AUTHORITY.
Annlicant Information Please Print Lettihlt,
Nal=tliustnetioi3Organtzation:lndavuluitt):
Address:
City/State/Zip: Phone
Art‘riu an enipkryert"Cheek the appropriate but: II Type of project(rill',ired I.
1.0I am a employs with _employees ittdl and,or part-timr1,* 7. CI New construction
•L'O I am a_wit:proprietor or partnership and haw no employen.winking tar tat in S. 0 Remodeling
any capacity.[No Workers'Cali*.Lami1na:1W required'
9.. Li Demolition
1 am a homeowner cluingnU%fermi myself.[No twat&camp,insurance en:pan:di'
ID Ej Building addition
4E3 I am a honieowner and*ill be haring contest-Aces to conduct all work on my property I will
talblIIII:that all contractors either have worken:coruperuation iiwunincr in are sole 1 I a Electrical repairs or additions
proprietors with no ernployci .
12.0 Plumbing repairs or additions
50 1 am a general contractor and 1 hakehired the Alb-curitrackns hilted On the attkiChest sheet
Th 3.D Roof repairs
ew sub-euraractors'save imaployecs Witt hate Workers'comp.imunince.:
14.[DOthei
6.0 We are a evaporation and it fficers have exetrie.-eil thee right of tAerription pet CrIGL,L.
152,§14.41„and we have rio employees.[No winker,'comp.nuisance required.]
*Any applicant that checks Exo.P I muss also fill out the aection below showing thou workers"Qumpensation policy iiihemation.
Homeowner),who submit tun atintio.ii end:canny the!,are doing all work and then hire ourviA0 Colstroctors must submit a new affidavit indi=ing such.
;Contraetory thol rhea this be XItluti at13.4,edan asichLitinal sheet shoo iriFtb. claims the N.tib—ezoittnictin„and state whether or n011iisaW:oolitic, c
I1 I pl I Trr:,L1,.:.'untr.actor has,:enclo,ccs.!tic!, most pro'.id,It I I LI hr.1
l am an employer that is providing worliers'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: City/StateZip:
Attach a copy or the »orkers compensation policy declaration page(showing the policy number and expiration date).
Failure to secure.CON erage its reviled under N1CiL c. 152. 25A is 5 criminal violation punishable by a fine up to SI..51/0.(X)
and or one-year imprisonment,as well as ivi1 penalties in the form of a STOP WORK ORDER and a tine 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
'•do hereby c if n the pain plaltirA of perjury that the infUrnuti 1on rt hied abate is rut'and
correct.
Sionature: , 17
Phone
Official use only. Do not write in this area to be completed by city or ton at offi(ml
City or Toytn: Permit/License
Issuing Authority (circle one):
I. Board of health 2. Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
G. Other
( nutmeg Person: Phone
„,. . , City of Northampton
H Massachusetts x, ,$ ,,,.. .,,
` *'_... '���
,- , 1
r
I DEPARTMENT OF BUILDING INSPECTIONS D,
212 Main Street • Municipal Building �,� $
Northampton, MA 01060 4:"P Ns1'
` , HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, W t to vvl 4c.0.45n4 (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 u d,er the pains and penalties of perjury on this I 1 day of Rccia4 , 20 2.Z
O.
(Signature)