32C-311 (12) BP-2023-0457
25 HENRY ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
32C-311-001 CITY OF NORTHAMPTON
Permit: Demo
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2023-0457 PERMISSION IS HEREBY GRANTED TO:
Project# DEMO SHED Contractor: License:
Est. Cost: 200
Const.Class: Exp.Date:
Use Group: Owner: SZAWLOWSKI JEROME S &MICHELLE L GOULET
Lot Size (sq.ft.)
Zoning: URC Applicant: SZAWLOWSKI JEROME S&MICHELLE L GOULET
Applicant Address Phone: Insurance:
31 HENRY ST
NORTHAMPTON, MA 01060
ISSUED ON: 04/18/2023
TO PERFORM THE FOLLOWING WORK:
DEMO AND REMOVE SHED
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:
Fees Paid: $30.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
''.. 1 ( [*•'-'''P-----r\------"r,:Z.;1---,---:-.7-.___
023'1 : ::::71 -7
yc ev ( / tokf a body
Gym6, ( APR 14 2
The Commonwealth of Massachusetts
A * PI Board of Building Regulations find Stan, IFOR
PALITY
Massachusetts State Building Cede, 780« ith'iv,; ispecrio-- USE
Building Permit Application To Construct,Repair, Renov to Or a ' ° R ised Mar 2011
One-or Two-Family Dwelling
t This Section For Official Use Only
Building Permit Number: 6- Date Applied:
Building )? V, i
Official(Print Name) Signature i/ 1Dat�
gn
SECTION 1:SITE INFORMATION
1.2 Assessors Map&Parcel Numbers
1.1 a Is this an Vcepted 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'
44 e 0/0[,,)4/ friffilly/la? / 414 0/06 0
Address''
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
11111111111111101111 Work2: I "mutt/ 0 Shei
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:
0 Standard City/Town Application Fee
2.Electrical $ 0 Total Project Costa (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) otal All Fees: $
Check No. Check Amount:
-6.T 0 Paid in Full ❑Outstanding Balance Due:
C4L( 04
r - -. ,
City of Northampton
flet A4‘.,
s, �... j
��9 Massachusetts ,;
` Q DEPARTMENT OF BUILDING INSPECTIONS ' 11 0-
212 Main Street • Municipal Building '-, ^;*
/� Q Northampton, MA 01060 ist, ,,,,,
S
\ 0, )/`
'k.n5O0JJ
•
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS,ROOFS,RENOVATIONS,ROOF MOUNTED SOLAR,ETC.
1. 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. Construction Debris Affidavit filled out and signed by applicant.
4. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance.
6. Energy Conservation Compliance Certificate (new /replacement windows).
7. Home owner's License Exemption Form (if applicable).
8. Note any Special Permit requirements(if applicable).
9. Energy Code—all new construction (Gut/Rehab) requires a HERS Rater Affidavit
10. 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. tt.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP 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 this application is true and accurate to the best of my knowledge and understanding.
•
rint Owner s or ized Agent's
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"
. *NN
The Commonwealth of Massachusetts
Department of Industrial Accidents
Tao 1 Congress Street,Suite 100 It: 4-.) Boston, MA 02114-2017
www.ntass.goildia
1$'4Arkers'Compensation Insurance ffiday it:BuiklersiContrattorsfEketricians/Plumbers.
TO BE EILED S I III I IlL PERMI fEs 6 AUTHORITY.
APPliCilitt Information Please Print l_egibls
Name i hlualpess,'Organizahon:individual 0:
Address:
C'ityiState/Zip: Phone g:
Art your OS eanployte. Cheek thr appropriate box: Type of project(required):
1.0 I am a employa.writ] empioyets(full main part-time 1„• 7, 0 New construction
S.!,[3 I am a.ok pruprictor or purtneralup and have nu uniployee.working for ine m 1i. C3 Remodeling
V ;on capacity_Nu*utter.'iomir%insurance required i
9. El Demolition
3Ifil am a homeowner dams all*cut rnyrelf.{No work .comp.insurance rcutoraL)"
10 0 Building addition
.1:I am a ionsa and wits be hothe.contractora to conduct all work ou my property„ 1 will
atuar that all contracton either hare workers'conspensation insurance or are tiulc 1 1.0 Electrical repairs or additions
prurineturN with no ariploycea_
1 2„.0 Plumbing repairs or additions
!CI I am a 00131111 contractor and 1 Mot hued the Nub-contractor..listed on the attached.licet.
13:j Rtiof repairs
Pies.:sub-contractor.have employee.and tau c worker.'comp.ornonnace.:
14. Other
tt.C3 WC cue a corpus-anon and its offi(er.limo exercised data right or rumptitxt per 1‘161..c.
I.'.&2.,§1141•and w c ita...e no amsloyecs.(No wurlern'comp.insurance requm.41.1
Any applicant that checks box a I must alao fill out the section below%bow me.then'0.oiler.'comperuation pola.-y rrilsitminime
+ ttornoowescrs who,ribald din affidavit abdicating they an:&mug all work and them tort OuhiLle contractor'must satinut a sew affidavit indicating such.
Contractor%that ELIA this box mug attartheil an additional abort nho‘.4 in g the name of the inb-eormactors mid gnu.' In:thea in riot those entitie,have
employee. If the Nub-cuniraccorn ha,,c orir7luyec.s,die-,,,,.=0 pnwide their workers'comp.pulicl.number
1 ant an employer that is providing molders'compensation insurance for my employees. Below is the policy and Job site
infornoilialt.
Insurance Company Name: _
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address; City StatelZip:
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 SI.500.00
and or one-year imprisonment.as well as civil penalties in the form°fa 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
coverage verification.
I do hereby eertifi'under the .Foim an 'et allies ofperjury that the information provided iebove i....true an I correct.
Phone. :
7 '4.-- IIIIIIIII 0.5 2,3
Official use only. Do not write in this area.to be completed by city or town qficiat
City or Town: PermittLicenie#
Issuing Authority(circle one):
, 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
b.Other
Contact Person: Phone#:
City of Northampton
7"r +0 .0 Massachusetts r
li S DEPARTMENT OF BUILDING INSPECTIONS x.
212 Main Street • Municipal Building
Northampton, MA 01060 ^'hr i ,y"
CONSTRUCTION DEBRIS AE .IDAVIT
(FORTLL DEMOLITION A 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: / 2(5I/ 4, , t
I
The debris will be transported by:
derCii7
�'Name of Hauler: CDZa...C.0/1- //
Signature of Applicant: „�'/ Date: -.7X3 ZJ
City of Northampton
Massachusetts ' e--
10.
I !I 1" DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 N
117
Y 4
S
f
I, (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 home.' ners'exemption to the permit requirements of the
Massachusetts State Building Code, codified at 78' CMR 110.R5.1.3.1, in connection with a project or
work on a parcel of land to which I hold legal titl•
2. I am not engaged in, and the project or wor; for which I am seeking the aforementioned homeowners'
exemption, does not involve the field erectio of manufactured buildings constructed in accordance with
780 CMR 110.R3.
3. I qualify under the State Building Code'. definition of"homeowner"as defined at 780 CMR 110.R5.1.2:
Person(s) who owns a parcel of ,nd 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 f. m structures. A person who constructs more than one home in
a two-year period shall not •- onsidered a home owner.
4. I do not hold a valid Massa usetts construction supervision license and, except to the extent that I
qualify for and will abide by • Massachusetts State Building Code's requirements for the supervision of
the project or work on my .arcel, I am not engaged in construction supervision in connection with any
project or work involy. g construction, reconstruction, alteration, repair, removal or demolition
involving any activity r gulated by any provision of the Massachusetts State Building Code.
5. If I engage any other .•rson 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 under the pains and penalties of perjury on this day of , 20_.
(Signature)