17A-251 (4) BP-2023-0055
114 LAKE ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
17A-251-001 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-2023-0055 PERMISSION IS HEREBY GRANTED TO:
Project# WINDOWS 2023 Contractor: License:
Est. Cost: 6525 RICHARD PALMISANO CSL89485
Const.Class: Exp.Date: 03/05/2024
Use Group: Owner: A SHIMEL BRAD A&DOROTHY
Lot Size (sq.ft.)
Zoning: URB Applicant: BAYSTATE EXTERIOR RESTORATION INC
Applicant Address Phone: Insurance:
87 SHATTUCK RD (413)374-2719 6HUB-6B21339-4
HADLEY, MA 01035
ISSUED ON: 01/19/2023
TO PERFORM THE FOLLOWING WORK:
REPLACEMENT WINDOWS
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
14
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
;
JAN 1 8 2023
The Commonwealth of Massachusetts
: * i Boarkl of Building Regulations and Standards FOR
0
or putt ointc,tNSP i.;,;, MUNICIPALITY
^arHAMrToN.MA 0.MMsSdchusetts State Building Code,780 CMR USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: it./9- .73',9-5 Date Applied:
,1 „
Building Official(Print Name) ( Signature 1 D to
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
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(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 wner�of Re OA-`fr- /ln , OLD-
0.� (lJQ2 �--C
Name(Print) City,State,ZIP
11- 1-a8Z-s4—' ic '- ni2
No.and Street Telephone Email Address
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 Otherpecify:
Br'ef Descr iptioa of Propose Work2: c� c'
S S i ,
PA- ;� u) l.v �.. (A- . TB,� ���,,,.,. Lac_--�,r •
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 19,c `.6 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost3(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire
Suppression) $ Total All F es ,I ��[_
6.Total Project Cost: $ C�ftlt) Check No. `�(Check Amount: Wl Cash Amount:
�� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES _
5. onstrttction Su r 's r License(CSL) Gliv.,/ 5�
(` License Number Expiration Date
Name of CSL H (
1,� _� List CSL Type(see below) u
No.an treetJut O`��C ea
Type Description
/l A- CJ y�`o 2J c U Unrestricted(Buildings up to 35,000 Cu.ft.)
R Restricted 1&2 Family Dwelling
City/ own,State,ZIP a,{ M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
(*3)3 71/471 g ‘ eAte I Insulation
Telephone Email address • D Demolition
5 2 Registered Home Improveme t Contractor(HIC) 196 o b c? 13
kK E,X STJQ.A-T1.C, J-f C- HIC Registration Number Expiration Date
HIC __W_
C npany Name or HIC Registrant Name S 4X
No.and Street Ema address
S(
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 No .0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACT APPLIES BUILDING PERMIT
I as Owner of the subjectproperty, a l� hereby authorize i(kt aent.)
to act on my behalf,in all matters relative to work authorized by this building permit application.
CE-)14 sL ///3/a3
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my •.me below,I hereby attest under the pains and penalties of perjury that all of the information
co i ed in thi e;pl•anon is true and accurate to the best of my knowledge and understanding.
9,
. ►.. .L' (3193
Prin i wner's or Authori ed 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
;ra
r " Massachusetts
•�• am= *
. it * DEPARTMENT OF BUILDING INSPECTIONS 7i
r
212 Main Street • Municipal Building yJd., o
Northampton, MA 01060 srf. -- ,�o
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: C(,lnN
The debris will be transported by:
Name of Hauler: cii.f(al-r (2.12.,S
Signature of Applicant: Date: l•f"
The Commonwealth of Massachusetts
Department of Industrial Accidents
=' * 1 Congress Street,Suite 100
• FF4
•=u1t� Boston,MA 02114-2017
.h� ..; wwwmass.gov/dia
1%orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH 771E PERMfl 1'INC AUTHORITY.
Applicant Information Please Print Legibly
Name(13usincsalOrganization/lndnndual): Ou, 4.121) Qi c'4
Address: i 7 SLar ,lr(Z ecA,,•
-
CityfState/Zip: dzxci,[4. ILIA (t)(O3C _ Phone#: 3) 3 7 'a-7/7
Are y uu an employer?Cheek the alp capriole bus:
Type of project(required):
7 j►ji am a employer with employees(full andi'or part-time).* 7. 0 New construction
2 III 1 am a mile proprietor or partnership and have no employees working for rue in h. (�IA modeling
am capacity.[Nu workers'comp.insurance roquireiLJ ��
30 J am a humeowna doing all work myself.[No workers'comp.irouranoe required.)'
9. 0 Demolition
4.0 1 am a Immix)wu rr and will be hiring eururactun to e`onduct all work on my property. 1 will
10 0 Building addition
ensure that all contractors either have workers'compensation'insurance ur are sole I I..0 Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
SO 1 am a general contractor and I have hired the sub-contractors listed un the attached sheet. I 3❑Roof re
sub-contractors
These sub-ctractors has employees and have workers'comp.insurance.:
6.0 We are a cuaporatiun and its officers have exercised their right of exemption per MGL c. I d. Outer
IS'!f 1(4).and we hoe no ertrpluyees.[No workers'romp.insurance required]
*Any applicant that checks box 41 must also till out the section below showing their workers'compensation pulley information.
r Ilomeowtere who submit this alrnda+it indicating they are doing all work and then hire outside contractors most submit a new affida+it indicating such.
:Contractor that check thin box most attached an additional sheet stowing the nano of the cuh-contractors anal state whether or nut those entities have
employees. If the sub-contractors have employees.they must provide their workers'comp.policy number.
1 ant an empio}'er that is prodding worAers'comp isation insurance for my employees. Below is the policy ane/Job site
it[formation.
Irim;urance Company Name: ..jick crz c S
Policy#or Self-ins.Lic.#: kip b �-�'u. - csl,C3a-t3.31 —.L.1 Expiration Date: ' /3// 3
Sob Site Address: L 14 1 CityiState/Zip: a,v /ALA. O (D 626
Attach a copy of the workers'compensation policy declaration page(showing the policy number and ispiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a iine up to Si I t.00
and/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine of up to 'r I II a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage veri` ion.
1 do hereby rt y er to if I s and penalties of perjury that the information provided above i true d correct
Sienature: LitAekte Date: l' 131 ' 3
Phone#: ( 7 L -7 g l
Official use only. Do not write in this area,to he completed by city or town officiaL
1
i
C'it, or Town: I'ermitiLicense#
Issuing Authorit} (circle one):
I. Hoard of health 2.Building Department 3.('ity,TownClerk 4.Electrical Inspector 5.PlumbIng Inspector
6. Other
Contact Person: Phone#: