16B-036 (6) BP-2024-0336
92 FERN ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
16B-036-001 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-2024-0336 PERMISSION IS HEREBY GRANTED TO:
Project# BATH RENO 2024 Contractor: License:
Est. Cost: 12700
Const.Class: Exp.Date:
Use Group: Owner: TK GLEASON FAMILY TRUST
Lot Size (sq.ft.)
Zoning: URB Applicant: TK GLEASON FAMILY TRUST
Applicant Address Phone: Insurance:
92 FERN ST
FLORENCE, MA 01062
ISSUED ON: 03/27/2024
TO PERFORM THE FOLLOWING WORK:
BATH RENO
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:
172-
Fees Paid: $83.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
The Commonwealth of Massachusetts 410 6 FOR
ot Board of Building Regulations and Standards �0�� MUNICIPALITY
Massachusetts State Building Code, 780 CM USE
^l,yl
Building Permit Application To Construct, Repair, Renovate Or rkerviOish a Revised Mar 2011
One-or Two-Family Dwelling %:�,,,
This Section For Official Use Only
Buildin Permit Number: fbi ' / - 33 Q Date Applied:
l'l tu10 4t55
//!/G.� g-27 20z y
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address;., 1.2 Assessors Map& Parcel Numbers
Ltd. Sr.
1.1 a Is this an accepted street?yes i 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 Owner'of Record:
K4714 eo,q/ 614Ason (liiwsra-)1- 4 n FGo t eo ce , MP' O 1 o6 0--
Name(Print) Y City,State,ZIP Qa �GQA) S 4-- 1113'� �� �1do-604 y Gl a a,son 4z� 4 sr7AiL• coin
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) 1"1( Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work': Rep Ace lii8 5}i?ou tom WI c()k2J -A 5tFea l?R. z RePtnC�_
Ttttr , Ket /rce, I1j4/liry I AA)T f /sinfk
67 x f U ri, 't( pIR u — Wi hN 0 u) fik r cro-7-7 4
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
u1.Building $ as 1. Building Permit Fee: $ Indicate how fee is determined:
�r �� 0 Standard City/Town Application Fee
a.,Electrical $ 0 Total Project Costa(Item 6)x multiplier x
Plumbing $ 7 �gD , °D 2. Other Fees: $
4. Mechanical (HVAC) $ List: t�
5. Mechanical (Fire A.
Suppression) $ Total All
Check No.k,,A Check Amount:
Total Project Cost: $ i 0,, 7 19D 0 Paid in Full 0 Outstanding Balance Due:
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.ft.)
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 .❑
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.
3 .2-10/,2 q-*
Print 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"
The Commonwealth of Massachusetts
►,,L _`. Department of Industrial Accidents
0, F.-4 1 Congress Street,Suite 100
; {�_ Boston, MA 02114-2017
-�
' -.�Kai www.mass govidia
11 orkers'Compensation Insurance Affidavit:BuildersiContractorsiElectriciansiPlulnbers.
10 BE FILED w nil THE PERMITTING AI THORII t.
Applicant Information ,//��� � )) A /` Please Print Lesibls
�11C(Rumness Organization Individual): /�N'rrr/p'�:N !t ( i - o 7)
Address: 9A F,i) 5 f-
CityState/Zip: h?o,eiiCe_ , 4A b 16 6 d-- Phone#: V/J-3 a-0'6 61
Art yore a.errepYyer?Cheek the appropriate trot: Type of project(required):
LEI 1 am a employer with employees thin and,or part-lima' 7. 0 New'construction
2.0I am a wk proprietor or partnership and have no employela working for mew 8. 0 Remodeling
any capacity..[No svorke-rs'comp. insurance required.]
9. ❑ Demolition
30 I am a lionntsvv nee doing all Hark myself.(No worked comp.insurance r-gwnd.]"
li
10 O Building addition
fr
am a honour rein and*di be hit mg il
contractors to conduct all so .on my poverty. I nett
roons that all cuntt wlun Meet hu a wurkr ep n`eunensalrctc insuranceor our win I I Eli tri al r ins or additions
proprietors*Ali no employeeiet
12.0 Plumbing repairs or additions
30 I am a general contractor and I line hived the sums-contra tors listed on the an.ehadrise!. I 3 EIRoof repairs
These sub-contractors have etarloy cs and hese workers`comm.insurance:
6.0'N'e are a corporation and Itsofficer,ha%c cm:wised then nght of exemption per UM c_ 14.El Other
I't.'..§Ili).and vac take no employ ens.[No*oriels•coop..insurance requend.]
'Any applicant that cheeks box#1 mini also tall out the section bdtn %bossing then workers'compensation policy urfurrnatiun.
e Ilometnanen who submit this affrlavit indicating they arc thorny an cork and then hire outside contractors must submit a new affidavit mdicatwg such.
;Contractors ontractors that cheek:this box must attached an additional sheet slummy the name of the sots-cwliracturs and state v.bailer w not those cuitt»s have
canplosccs, lithe sub-contractors have employees.they must pn vide their *.Dryers`cones.polies number.
I am an employer that is providing workers'compensation insurance for nay employees. Below is the policy and job site
information.
Insurance Company Name:_
Police M or Self-ins.Lic.#: Expiration Date:
.41:p Site Address:
fir , ...,j2,41 g- City;State.Zip:_ Zo e kildDi 04,.?--
Attach a cope of the workers' compensation polio declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152.g25A is a criminal s iolation punishable by a tine up to$1.500.00
andior one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to$250.00 a
day against the violator.A copy of this statement may be forv+arde-d to the Otlice of Investigations of the DIA for insurance
ance
coverage verification.
I do hereby certify under the pains and penalties of perjury that the in_formation provided above is true and correct:
`7iignature Ct1(A ti (- Aaeaso 6'--- Date: 3 ramp/024.-
Phone,:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: PermitiLicense*
Issuing Authority (circle one):
I. Board of Ilealth 2. Building Department 3.('itsifown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
{� City of Northampton
G� ►.1.
l rl S`5 f ..I
Massachusettsti� �- ri ,4 DEPARTMENT OF BUILDING INSPECTIONS ci
Z, e
y/ 212 MainStreet • MunicipalBuilding Northampton, MA01060j:fl' 3,->>\
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: v4a lea c4/0� _
eY
The debris will be transported by:
Name of Hauler: —ZA-e— IAA L/
Signature of Applicant: &/fiPccoe-z---- Date: 3 `f
City of Northampton
tH�MPp .w
°a °1 S . s/C
Massachusetts•
, DEPARTMENT OF BUILDING INSPECTIONS y;
212 Main Street • Municipal Building
Northampton, MA 01060 Sbh •••••
ir
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, iw+i lee,l ()/e*so/► FAP-4i ,
(insert full legal name), born (insert
month, day, year), herelfy 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 g/c day of 444R.cr! , 20 2 4
01/ riee2