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38B-185 (5)
BP-2023-1246 33 FORT ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 38B-185-001 CITY OF NORTHAMPTON Permit: Addition PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2023-1246 PERMISSION IS HEREBY GRANTED TO: Project# NEW DECK 2023 Contractor: License: Est. Cost: 6000 JUSTIN SQUIRES 115236 Const.Class: Exp.Date: 09/02/2024 Use Group: Owner: POULIOT STEPHANIE & MICHAEL HOLLAND Lot Size (sq.ft.) Zoning: URB Applicant: JUSTIN SQUIRES Applicant Address Phone: Insurance: 177 E HADLEY RD 4136409647 AMHERST, MA 01002 ISSUED ON: 09/12/2023 TO PERFORM THE FOLLOWING WI 2110; Tittc, BUILD NEW DECK OFF BACK FOR HOT TUB 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: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner t yo,Gf � The Commonwealth of Massachus is v D FO I ,, Board of Building Regulations and St dar SEP ®at Massachusetts State Building Code, 7 0 C R 1 / M ICI ALITY ._, 42 U Building Permit Application To Construct, Repair, encR/b tt.►. •emolish a R: ised ar 2011 One-or Two-Family Dwelling NOATyq<<ojivGm, sP This Section For Official Use Only T oN'MA 01trnn600NS Building Permit Number: �g 4)"3.- 1 aL�Q, Date Applied: 4010 Koss /77Z q-12-2oZ3 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1 1.2 Assessors Map&Parcel Numbers 1.la 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 Ownert of Record: , Nt e_iivi e 11--01 o,J NDr-4-liawq ) n r M iA- 6 I0<65 Name(Print) City,State,ZIP C3 c0(-1 S 4 _ 14(1'3 5-7- M)/ m In o l l o‘in lu Y 0 c yvi ii I C-0'"'` No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction Rl Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': 1 i to L - - 9 — v*ddk s 1;a:v‘9 de( SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 6 o n o 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: ,\ 5.Mechanical (Fire $ \Total All � 1► Q; �.•Suppression) • Check N Check Amount: aso,ount: 6.Total Project Cost: $ (1 I.00 0 Paid in Full 0 Outstan4 _ :a .istoue: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) I I 236 0T-0;- 41 S 4--; ✓( S EA, ,(c 5 License Number Expiration Date Name of CSL Holder 177 ��I� ��, List CSL Type(see below) tA No.and Street / T e Description 1_ f O O ( U) Unrestricted(Buildings up to 35,000 Cu.ft.) V �f- "14 `l� Restricted 1&2 Family Dwelling City/Town, State,ZAP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 6117-6t 7 4(i/7 JS�1n,rcScov��yc.C.�,.Lq a - I Insulation Telephone Email address ,_/ v.,„, D Demolition 5.2 Registered Home Improvement Contractor(HIC) \- a00006 13 1a 14( HIC Registration Number Expira'on Date HIC Company Name or HIC Reg trant Name 1 1/7 f 140.4 Gc 20t 159c<<rc-S O irke.L--7 ti g Gelvkcii,ed*A No.and Street Email address 1 r5� Mil- 0\00� t(15-(ya- Tc611 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 pe't. 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 S of , re- 5 to act on my behalf,in all matters relative to work authorized by this building permit application. Pit;et4-a4 l -hr�) 1a� 0�'-91- �C 23 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 conta' ed in 's application is true accurate to the best of my knowledge and understanding. Pr' tOwne s o ized Agent's Name(Electronic Signature) Date NOTES: I. 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.) 22 I1 (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 1s .<" si r " Massachusetts 5 :. c,�c $ DEPARTMENT OF BUILDING INSPECTIONS S ` 212 Main Street • Municipal Building Northampton, MA 01060 "Ph, at31 .�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: E 0i5)-6 ci !� P�G�� 4 4 _ The debris will be transported by: Name of Hauler: 5-C 1 Signature of Applicant: Date: o°( 2 0275 \ The Commonwealth of Massachusetts tM cl Department of Industrial Accidents �' i Congress Street,Suite 100 : - .y Boston, MA 02114-2©17 WPM.mas.goa/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH'1'IIl PERMITTING Atrl'NORITI'. Applicant Information Please Print Lean* Name(tiusttus,r)rksnt,:stitnb'individual): , 1 R5i -1 Yl <SCl (P 5 Address: ( -7 E r)-ctd Ley City/State.'Zip: i'VAV\ fA 0\a 0 Phone#: �k- Li 0-• Are yea an employe[?(`[reek the appropriate inn: ""�[nil'of project(required): I.01 am a employer with employees lfWt aortic part-turn)-' 7. New construction , 1 am a yule proprietoror partnership and have sat employ nor s working for in K. ® Remodeling ?�' may capacity.[No workers'camp.insurance required" 3.0 1 am homeowner hceowner doing all work myself.(14o workers'comp.iaeturarr regwiiire t g ❑ Demolition 4.0 I am a lanneowner and will he hiring coractars to Conduct all work on my property_ I will 10 Building addition ra Cnoun that all contractors either have workers'crornpmeativa enurancc or are sale 11.0 Electrical repairs or addition, proprietors with no employees. 12.0 Plumbing repairs or addilieii� SC:j I am a general contractor and I have hired the sub-con tractors fisted on the attached sheet 130 Roof repairs insurancinsurance.:These sub-contractors have employees and have workers'comp.insurance.: _ p 6.0 We an:a corporation and its officers hate exercised their night of etcrnption per MGL c. 14.0Other 152,41(4),and we have oo employees.[No workers'comp.insu ir.cc requital "Any applicant that Checks but tit truest also fill out the section helrrw showing their smothers'compensation policy information_ Homeowrnrs who submit this afftavit indicating they are doing all work and then hire outside rontracturs meet submit a new affidavit imiieatiag such. teontractors,that check this but roust aatacls d an additional sdrect showing the name of the sob—contractors and state whether or nut those entities have c-rnple'tires_ If the sub-cumractras have employ ccs.they mint prot ide their workers'arnnp.policy number. I am an employer that is providing workers"compensation insurance for my employees. Below is the padry and Job slit information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: 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 tine up to SI,500.00 and/or one-year imprisonment,as well as civil 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 coverage verification. I do hereby c y wide the ruins end penal:lev Of perjury that Elie information provided above it true rant!c•r+rre d. Signature: Date: 0' — (1 — ZO 23 Phone#: I - b tiO y1 Official use only. Do not write in this area,to be completed b)'city or town official ('it or Town: Permit/license# Issuing Authority(circle one): I. Board of llealth 2.Building Department 3.('ityrrown Clerk 4.Electrical Inspector S. Plumbing Inspector (). Other ( unhrcl Per,sut: Phone#: i f I i 1 1 __ cS7Z•)1.b reit-mat!-ftl 1(II 7,06f 5 , I ( blec -91-1-1- )-0 b/ ! Iv\ cs_i0 )Ri___,-) \-1 \\ \_ . i , \_,Ar (-) d- S12).2i O., w' i ) 1 S o3 \,J )( \77, )iiii—, ' . k ' \e\AY)Q_) (0' vytocroo ,i )\) i 1-- (* ',D_ i . i . . J ftw 'ItHH1 J -11 . 1 L 1 I 1 I i 1 c I,1 ti ri I C ik L . , J , , t 1 , 1 li 1--)•'3- NI 1 1 1 ' I I 1 )9 u \I) . ! 1 9A 1- A 1 , , i __ . 1 , y i1— I I ,ic,,,D " 0 ' glil L i'' f ! L IIII 11111111 ' III 't I III I 2,1111 I L I 1 I I Illimilrillilla -1- I ' - 4 111.1,111. ... .. 1.1. • . r A,* 4Ik I i