39A-041 (7) BP-2023-1775
88 HOCKANUM RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
39A-041-001 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-2023-1775 PERMISSION IS HEREBY GRANTED TO:
Project# FIRE REPAIRS 2023 Contractor: License:
Est. Cost: 60000 WILLIAM CHILDS
Const.Class: Exp.Date:
Use Group: Owner: MOSLEY ALBERT
Lot Size (sq.ft.)
Zoning: URC Applicant: WILLIAM CHILDS
Applicant Address Phone: Insurance:
229 WISDOM WAY (413)247-9269
GREENFIELD, MA 01301
ISSUED ON: 12/26/2023
TO PERFORM THE FOLLOWING WORK:
REPAIR FIRE DAMAGED GARAGE
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: 11)v � 1 Q•
Fees Paid: $390.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
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The Commonwealth of Mass 1 s �� �je
'f c Board of Building Regulations and fa ds (-10 FOR
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Massachusetts State Building Code, 7 ;� USE
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te�aa,,
Building Permit Application To Construct,Repair, Reno DenifIlish Revis Mar 2011
One-or Two-Family Dwelling ''v,6'%.0
This Section For Official Use Only VO,
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Building Permit Number: • 3. Date Applied:
3 I„ . la 3
Building Official(Print Name) Signature ` i Da e
SECTION 1:SITE INFORMATION
1.1 go�pgrtytVrc ress;, ( ,.� 1.2 Assessors Map&Parcel Numbers
d �`b��Q 1'L !y` `2—K r
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) 1
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 CIZone: — Outside Flood Zone? Municipal 0 On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
/ e. .`r �
SfL. . a Z"•
Name(Print) City,State,ZIP
B'r Ho�� c. w u t•+. f:c2,
No.and Street Telephone Email 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 Speci :
Brief Description of Proposed Work2: .t )pa,r -Fi t' iir7 Q a 1 .
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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:
❑ Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All $
Suppression) 3 D
Check N ‘ Check Amount:
ti
6.Total Project Cost: $ 601 00 0 0 Paid in Full 0 Outstanding Balance Due:
46, 5.' -4. )1 ierl) u4,4)(1. 4_ 9'0
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City of Northampton
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Massachusetts
' DEPARTMENT OF BUILDING INSPECTIONS
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212 Main Street • Municipal Building
Northampton, MA 01060
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.
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•
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License CSL) ` 0 1 N S 7�
WO C tt t S License Number Expiration Date
Name of CSL Holder ��
2 2— GV i` clip• / dCLI4/
List CSL Type(see below)
No.ann _Street L(J Type Description
..J,���4, p I& �/i/1* a) Q� U Unrestricted(Buildings up to 35,000 Cu.ft.)
"....JJ �l I ( R Restricted 18z2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
! 3�.q-S`73 l v Q 1E 1 Lb
l l� i , SF Solid Fuel Burning Appliances
� 3- 7 � I m3'aI.1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Gontr ctor(HIC) 4/
we ill r,�t• �1 I0� 1Cy �I) �'
lJel HIC Registration Number Expiration ate
HIC Comp N or HIC Reg' trans Name
2�4 15� � f
No.and Street 'cre4 CO, y,4. O 1 10 I Email address
I own,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 PE IT
I,as Owner of the subject property,hereby authorize A.
to act on my behalf,in all matters relative to work authorized by this building permit ap ' ation.
tc fterr- G , " to c 1 a i - ( / .3
Print Owners 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.
CcJ P G(' t l S 5
riot Owner's or Authorized 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"
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............ The Commonwealth of Massachusetts
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Department of industrial Accidents
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I Congress Street,Suite 100
Boston, ,If.-1 02114-2017
www.ntass.gor/dia
‘).01kers'('unipensation Insurance Allidas it: Builders/ContvactorsiEkctricians/Plumbers.
It)HI FILED X11111 111E PERMIITING AU1HORI1 I.
Applicant In fo rin a tion Please Print Legibls
Name istkunessAksjanizatiumindividual):
Address:
City/State/Zip: Phone g:
Are)011 ma employee Check der appropriate hot I Type of project(reqttired):
i a lam a employer with euTployreh(full antor part-tirne0 7, E3 Neu,construction
2 am a sok proprietor or partnership and have no employees,.eurking for the in
XIII
y paim[Na*miters'4.1USIV.EleilgrallIX required S. cj Remodeling,
eac
. El;..j I sin'a honso.....ner doing all wort myself.{No woliers".etstrap,insura 9 Demolition
nce minaret]'
10 El Building addition
t DI am a homeowner and AILI be hiring corithaetors to conduct all%ork on my property I ss ill
=stare that all eorttractors either have norkera"L'AftlIpLitalittilln iresurarier or are sole 1 14:3 Electrical repairs or additions
proprietor:with no einployera,
12.0 Plumbing repairs or additions
I am a ecnerai euniractur and I Isal.41 hired the sob-euntracturs listed un the attached sbei...t
1 3.173 Roof repairs
These sob-tunnaciors haw employees and bast workers'eomp.nisurance,..
n.1
14.r:10111
W er-3 e are a eurporanors and its officers have exercised their tiglit of eatinption per SIC&e.
III.§I fit,and use lia.we nu employees.(No workers"comp inn nninee required.]
*AnIs applicant that ellecka,box l itliA also fill out the iV4tin below%bon inn their%Mors'compensation policy information.
t ilOTEXUSLEICri%shu SLIMIlit this atraial.it intheating they are doing all work and then hire miriade contractile+must sahnut a btu atiiidai,it indicating stab
..(: ors that check this box must attached an additional sheet show in the name a the mkb-tontracturs arta tiace w h4AILT lYt ZIL,t Iilln51::saitsties have
sinp1010..1 II the sots-evntrietoi,I....s,e eliirds.:,cc,.th...., moue in uo,..i,ic ih,'r A,,,,4„-:,'comp,pii".1.nutrilvi
I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
In.surarc Company Name: _
Policy#or Self-iris.Lic.#: Expiration Date:
Job Site Address: . City'StatelZip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration dates.
Failure to secure coverage as required under NIGL c.. 152. §25A is a criminal violation punishable by a line up to 51,500.00
andior one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine 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 certify under: .,tains a ,en ties n e ry that the Information provided above is true and correct.
4,)
Sit:nature- /VA JC-__
Date:
Phone
1
Official use only. Do not write in this area,to he completed by city ar town official
City or Town: PertnitiLicense#
Issuing Authority (circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone 4:
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City of Northampton
.z Massachusetts ' 'r
DEPARTMENT OF BUILDING INSPECTIONS = x.
'
.w1(i _ 212 Main Street • Municipal Building *3,. ,,..'
iiV'm Northampton, MA 01060
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:
I 'G1. I ��
Location of Facility: V CI GIF
✓1.9 _
The debris will be transported by:
Name of Hauler:
\Y)Signature of Applicant: Date:
City of Northampton
, Massachusetts .,v ,. '
, if DEPARTL�NT OF BUILDING INSPECTIONS r
, ,,` 212 Main Street • Municipal Building >� .''�
^�—"'•i°°"" Northampton, MA 01060 S54'. V 'tip
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
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 homeowners'exemption to the permit requirements of the
Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or
work on a parcel of land to which I hold legal title.
• 2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'
exemption, does not involve the field erection of manufactured buildings constructed in accordance with
780 CMR 110.R3.
3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2:
Person(s) who owns a parcel of land 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 farm structures. A person who constructs more than one home in
a two-year period shall not be considered a home owner.
4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I
qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of
the project or work on my parcel, I am not engaged in construction supervision in connection with any
project or work involving construction, reconstruction, alteration, repair, removal or demolition
involving any activity regulated by any provision of the Massachusetts State Building Code.
5. If I engage any other person 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)
Commonwealth of Massachusetts
Division of Professional Licensure
Office of Public Safety and Inspections
1!I W; 1000 Washington Street, Suite 710
%o1M o�
Boston, Massachusetts 02118
=5vev
Phone (617) 701-8600
https://www.mass.gov/dpl/opsi
REQUEST FOR DUPLICATE RENEWAL FORM
PLEASE EMAIL THIS COMPLETED FORM TO OPSI-INFO(a�MASS.GOV WITH THE SUBJECT
LINE "REQUEST FOR DUPLICATE RENEWAL FORM" —OR— MAIL TO THE ADDRESS ABOVE
ATTN: REQUEST FOR DUPLICATE RENEWAL FORM
Print/type clearly the information as it is NOW SHOWN on your license:
If your email or mailing address has changed, you must
also complete a change of address form, available here.
Name: William R Childs
Address: 229 Wisdom Way
City/Town: Greenfield
State: MA
Zip code: 01301
Business Name:
Under the penalties of perjury, I declare that the information provided herein is a truthful and
complete statement of the information required.
OTHER REQUIRED INFORMATION
Type of tb' tructionSupervisor Telephone Number(413) 329-5737
License No: CS-014572 Date: 12/20/2023
Expiration Date: 10/31/2023 Signature:
Email Address:
dchilds@childsbookkeeping.com
HOW WOULD YOU LIKE YOUR RENEWAL FORM SENT? Check the appropriate box(es).
By mail By e-mail
X
Please be advised: Licenses are eligible for renewal 60 days prior to their expiration date. When a
license becomes eligible for renewal, we automatically send a renewal form to the email and mailing
address on file.
Revised on June 2020
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