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23D-174 (2) BP 2023-0008 30 BAKER HILL RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 23D-174-001 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-2023-0008 PERMISSION IS HEREBY GRANT D TO: Project# 2023 RENO Contractor: License: Est. Cost: 10000 MATTHEW KOZUCH CS-106644 Const.Class: Exp.Date: 09/25/2024 Use Group: Owner: MATTHEW KOZUCH Lot Size (sq.ft.) Zoning: URB Applicant: MILL RIVER DESIGN BUILD Applicant Address Phone: Insurance: 6 HIGH ST 4133418893 WC2-315-624269-010 FLORENCE, MA 01062 ISSUED ON: 01/05/2023 TO PERFORM THE FOLLOWING WORK: REMODEL 5'X8'BATHROOM 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: I ' I ' ,a • _ 1 . 1 •L4 I ' I Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner i g, ` - ` The Commonwealth of Massachusetts c`-' I I Board of Building Regulations and Standards FOR a ( Massachusetts State Building Code,780 CMR MUNICIPALITY USE ,Building Hermit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 c One-or Two-Family Dwelling --1 This Section For Official Use Only Building Permit Number: �'n3P Z025-00c Date Applied: Ajel o..,4Z65 /2 i-5.201.3 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Pro a Address: 1.2 Assessors Map&Parcel Numbers '� - 1�;11 R� D /l-t-oat l.la Is this an accepted street?yes ✓ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: IZoning 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 WA' . AU/A' NA 1.6 Water� Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public It Private CI _ Outside Flood Zone? Municipal F�On site disposal system CI if yesB� SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: m 7.xLn F/orell.cL y444 0 io6 z Name(Print) City,State,ZIP / d eoj r [Till e\c) till 3412893 mI l Er JQJ' 2 .. Marl, «( No.and Street Telephone Email Addrds SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other Er-Specify: Q a ('do/14 re/lei Brief Description of Proposed Work2: (2,e medal „5--1 x 6-f Q q-bi f-co V SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 6 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ 2. ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ Z. 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire / $ Total All Fees:$ (.o5 Suppression) °v ov Check No.07 Check Amount:Ob.:— Cash Amount: 6.Total Project Cost: $ 1 0 I`\ 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) /Writ-/ t��- CS- Number Expiration Date Name Hol� L� 1( r -fi��/ List CSL Type(see below) No.and Street Type Description 1en//� �/ym 1 D /O( - U Unrestricted(Buildings up to 35,000 cu.ft.) (/� „/ ! R Restricted 1&2 Family Dwelling Ci Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding o�f / SF Solid Fuel Burning Appliances 413' c34'! . d af3 ►�')r.��r'��V�r 6)djrria/!. I Insulation Telephone Email address v 'C.0)2` D Demolition 5.2 Registered Home Improvement Contractor(HIC) I-74 20 7 01/ 0/202 3 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 ❑ 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 this application is true and accurate to the best of my knowledge and understanding. PADMLJ M02 ) /7/23 Print Owner's or Authorized Agent's Name(Electronic Sign ) 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 oatN� ro �S Si •�'� � Massachusetts ��5 c,�` (It )" ` .`I DEPARTMENT OF BUILDING INSPECTIONS a ' ' 212 Main Street • Municipal Building v� `�� Northampton, MA 01060 ssN1y 1,��'��� 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: vik I�ec The debris will be transported by: Name of Hauler: MctA1-1- Wo2%cc-L Signature of Applicant: Gi Date: 2- / S I�'t` J 1' t °2 Extension of Information Page WC 00 00 01 A Item 4. State of: MASSACHUSETTS Classification of Operations Premium Basis Rate Entries in this item,except as specifically provided elsewhere in this. Code Estimated Total An-nual Per$100 Of Estimated Annual policy,do not modify any of the other provisions of this policy No Remuneration Remuneration Premium 0001-01 MILL RIVER DESIGN BUILD LLC FEIN # 84-4134229 SIC CODE 1521 NAICS CODE 236118 6 HIGH ST FLORENCE MA 01062 CARPENTRY - CONSTRUCTION OF 5403 IF ANY 7.77 $ 0.00 RESIDENTIAL DWELLINGS EXCEEDING THREE STORIES IN HEIGHT OR COMMERCIAL BUILDINGS AND STRUCTURES CARPENTRY - CONSTRUCTION OF 5645 $ 26,114 6.35 $ 1,658.00 RESIDENTIAL DWELLINGS NOT EXCEEDING THREE STORIES IN HEIGHT TOTAL CLASS PREMIUM $ 1,658.00 STANDARD TOTAL $ 1,658 .00 EXPENSE CONSTANT 0900 $ 338.00 TERRORISM RISK INS ACT 2002 .03 9740 $ 8.00 MACHWC (SURCHARGE) 1.0418 0936 $ 69.00 FINAL TOTAL $ 2,073.00 POLICY TOTAL ESTIMATED COST $ 2,073.00 Experience Modification: RISK ID: 001175125 Policy No. WC2-31S-624269-012 Page No. 1 GPO 2923 WC 00 00 01 A WC990605 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY POLICY INFORMATION PAGE ENDORSEMENT THE FOLLOWING ITEMS(S) ARE CHANGED TO READ: THE FOLLOWING CLASS CODE HAS CHANGED FROM: STATE: MASSACHUSETTS RATING GROUP: 0001-01 CLASS CODE: 5645 (CARPENTRY - CONSTRUCTION OF RESIDENTIAL DWELLINGS) ANNUAL PREMIUM BASIS: $48 , 924 . 00 PRO RATA FACTOR: 1 . 00 RATE: 6 . 35 ANNUAL CLASSIFICATION PREMIUM: $3, 107 . 00 TO: STATE: MASSACHUSETTS RATING GROUP: 0001-01 CLASS CODE: 5645 (CARPENTRY - CONSTRUCTION OF RESIDENTIAL DWELLINGS) ANNUAL PREMIUM BASIS : $26,114 . 00 PRO RATA FACTOR: 1 . 00 RATE: 6 . 35 ANNUAL CLASSIFICATION PREMIUM: $1 , 658 . 00 THE FOLLOWING FORM(S) HAS BEEN DELETED: CNW 90 12 08-19 RESIDUAL MARKET SMALL EMPLOYER SURVEY SNW 20 03 01-19 MA CONTACT AT A GLANCE ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. The total premium and surcharges shown on this change endorsement represent the revised insurance costs for the full policy term. Any additional or return premium payable as a result of this change is shown below. This is not a bill. If necessary, a bill will be sent separately. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Policy Effective Date 05-16-2022 Policy No. WC2-31S-624269-012 Endorsement No. 001 Endorsement Effective Date 05/16/2022 Insured MILL RIVER DESIGN BUILD LLC RETURN PREMIUM: $ 1 ,517 Insurance Company LIBERTY MUTUAL FIRE INSURANCE COMPANY Carrier Code 16586 DATE OF ISSUE 06-15-22 Countersigned By 20230105_110551 jpg 1/5/23, 11:08 AM - - ,ormoraPuralth of Ilinsweltiosetn - 1)tror1memi of Ifteholtnal leridenk cs i , 4 k ,44.1 I efirtgrrn,Strerl.Smite /00 Benton. if 4 02114-291" .111....mint,Rov446* tleslitr4'(oiNtr**Nalitaft I*witty fare 1,1141 •tt Pe Oder*/hoteheliwrifirctricleatirhanibert. in at t il 1 it NN nil I III es 141Itrt#NI: NI ritetem _ 3-Deacao hkriratiss_ k A• maw rciat ixtitil. •.,m,,.....c..A44..........4.t,*..imoo'• 0),1 1\i\lc i k)r:,'..:0-, 4,•,Ic) , kthirt.'s-+ V „sato.i 4, k:I,;i C.Act ttvl.. .__txxctz. 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