23A-044 BP-2022-0482
19 WEST CENTER ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
23A-044-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2022-0482 PERMISSIONIS HEREBY GRANTED TO:
Project# KITCHEN RENO Contractor: License:
VALLEY HOME IMPROVEMENT
Est. Cost: 62000 INC 077279
Const.Class: Exp.Date:06/21/2022
Use Group: Owner: CARLSON BIRD MARK J& SUSAN M
Lot Size (sq.ft.)
Zoning: URB Applicant: VALLEY HOME IMPROVEMENT INC
Applicant Address Phone: Insurance:
P O BOX 60627 (413)584-7522 0055030215
FLORENCE, MA 01062
ISSUED ON:05/04/2022
TO PERFORM THE FOLLOWING WORK:
KITCHEN 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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
Ii; • r . CP
II
Fees Paid: $403.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
V1��
1----- TheCommonwealth of Massachusr if( y •
Ii Board of Building Regulations and St/indar 3 FOR
Massachusetts State Building Code, 780 oF� LIP ITY 20(2�
Building Permit Application To Construct, Repair, Ren{vote R ised ar?011
rON SpFc
One-or Two-Family Dwelling Mq orn��Ns
This Section Fox Official Use Only
Buildina Penriit Number 8P A) N t 2— Date Applied: .
f ie°11) d 252 _ 162 5•11-Z0Z2
Bui 1 di ng Official(Print Name) Signature Date
SECTION 1:SITE.INFORMATION
1.1 Prop erty Address- 1.2 Assessors Map Le—,Parcel Numbers
lot w - °c-erg- S --
1.1 a 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(rt)
Front Yard I Side Vmds Fear 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 CIZone: Outside Flood Zome7 Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2 1 Owner t o ecor d: -
- Name(Print) may.State,ZIP
lc\ U -- (f.'.nke.r S y c —SBLt--CoS(1 o
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2 (check all that apply)
New Construction 0 Existing Building,, Owner-Occupied 0 , Repairs(s).❑ Alterations) Cl Addition ❑
Demolition E3 Accessory Bldg. ❑ Number oft.Inits Other Q spec*:
. Brief Description of Proposed Work2: !<:Nl:Ns", . re...0,14
SECTION 4:ESTIMATED CONSTRUCTION COSTS
-Item Estimated Costs: • Official Use,Only
(Labor and Materials) .
1.Building $ 6c Y, 1. Building Permit Fee:$ Indicate how fee is determined:
t7 Standard Citytfowtr Application Fee
2.Electrical S K ❑Tatal Project Costa(Item 6)x multiplier x
3.Plumbing $ t- K 2. Other Fees: $
4.Mechanical (HVAC) $ List: • -
5.Mechanical (Fire $Suppression) Iota!All Fees:
Check No.1? 1 Check Amount: 44V Cash Amount
6.Total Project Cost: $ 6 2 I t l'aid Fa. 0 Outst ndingBalance :
SECTION 5: CONSTROCT'ION SERVICES
T--
5.7 Construction Supervisor License(CSL) 9
a_C-___xtr—a. V . — license Number Expiratieuu Date
Name or CSL Holder
List CSL Type(see below).,
P• C_J _ Type DescriptionNo. and Street
U Unrestricted(buildings up:a 35,v0J cu.it)
Ore) C. D1 (� R Restricted I&2FamilyDvctellin$
City/Town, ,e .11' M . Masonry
RC - Roo rin C Overing
/ WS Window and Siding
/ F SF ' Solid Fuel Burning Appliances
14V5 r ' ti�522. i insulation
• Telephone Email address D Demolition
5.2 R�epstered Horne Improvement Contractor(HIC) 1 nssck3 g i zz i Z�
_\�'4.4\ �t\ e frl ,r q-A BIC Registration Number Espirati on Date
ETC Comp Name or RIC R egistrlent Name
lda.and Street + 12Y�t3.j 1 „�2- ,r2il a '^°s
City/Town,State,ZIP "G Telephone G-
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.g 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 slif 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] -� + e� ,i 1 ve rtu/
to act on my behalf,' all matters relative to work authorized by this building permit application.
___1 2-- L1A L( -2 w _-cz
Piiat Owner's Name etronic Sign_it-e) 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 knowled d understanding. /2
V ,jre .i/V) S-.) /...Ve17241n) -..,- , -'4,
e/goir2___
Prise Owner's or Authorized Agent's Name(green / / Date
NOTES:
I. An Owner who obtains a buildingpermit to do his/her own-work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(IIIC)Program),will not have access to the arbitration
program or guaranty hind under M.G.L.c. 142A.Other important information on the HIC Program can be found at
uww.mass.aov/oca Information on the Construction Supervisor License can be found at www.mass,cov/dns
. 2. When substantial work is planned,provide the information below. .
Total floor area(aq. il.) (kindling garage,finished basement/attics,decks or porch) .
Gross living area(sq.ft.) Habittable room count _
Number of fireplaces Number ofbedronnxs •
Number-of bathrooms Number of halfhaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
City. of Northampton
S`S ..'
i ' LFassachusetts v� �— ��
€ ! ' fir+e,... ,s .:r1
i I '. 7'�A.,t DEPP_RTI SENT OF BUILDING INSPECTIONS �., • 1
` "'': -�''Y 212 Main Sheet v Municipal 3uild+_ng �i• 3`b
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 dis-posal facility, as defined by Ma c 111, S 15GA.
The debris will be disposed of in:
Location of Facility: \la 1,1C,e) ' OCCt._)--l\._,.. 1 '.\-(' iC) . ,4-k ---1
The debris will be transported by:
Name of Hauler: 4 _ .54— •
,(
Signature of Applicant:
Date:
/ .
/ — --a00)-a
•
--' The Commonwealth of Massachusetts
(3 Departnett of itdstr ialAccidents
-� .47:1 1 Congress Street, Suite.1.00
k • Boston,MA 02114-2017
wpvw.mass.gov/dia
v 1-Y4rkers' ContRens.atian Insurance Affidavit;RnitdersICantrarmorsiElectririans/Pluxnbe-s.
TOtr'Zr Fit. .11 WITH T'n'r.rs;,RM1TTINi:AilirleiRITY.
Applicant Information Please Print Legibly
Name (arisines:iOremizai.innirnriividuai): \ -(^�(r, ym i J� ���1 �� i(
Address: -ll i - 0 . Ca,G _(ca pC0 a-
City/State/Zip .0 cb_2C2_..k-t,G-G1062.-- Phone#: 4 - SSt-t- 1 S2 2._
Are you an employer?Check the appropriate bar: Type of project(required)
1.EgI am a employer with l employees(full and/or part-time)!' 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employes working forme in $. ®Remodeling
any capacity,[No workers'comp.insurance required.)
9. ❑Demolition
3.1 l I am a homeowner doing all work myself.Rio workers'comp.insurance required.!
' 10 U Building addition
4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will
cesw'e that all conuactors either have wor12eia'component cn+•ner}rsn ce or ai a sole • . MO.O Ekctnicai repairs-Or.additions •
propii etc s with no employees.
12.0 Plumbing repairs or additions
5.0 T am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0Roof repairs
These sub-contractors have employees and have workers'comp.insurance.
6.a We are a corporation and its officers have exercised their right of exemption per h1GL c. 14 Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
`Any applicant that checks box 41 must also ill out rho section below.showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
+Ciro acwrs that diet-kilns box m•attaeit:d•an ad.dutivnai Meet slauwistathe mane trf the srtb=eoutcastors 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: A( i\c,.... rtx,5k_ .ia ry (st f>
Policy#or Self=ins.Lic. #: CO`.)St'D b21 Expiration Date: 1 1 i 9J_
Job Site Address: i 1 )-.rf: C-c. 1 v . City/State/Zip: O,/-0-la'1hpC,hZ Ws O)CcC
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$25 0.00 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 e ins and penalti -ofper' e information provided above is true and correct •
Signature: Date:
Phone#: k.., 1 -—1 22-
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
1.Board of Health 2.Building Department 3. CitylTown Clerk 4,Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: • Phone#: