39A-060 BP-2024-0409
61 LYMAN RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
39A-060-001 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-2024-0409 PERMISSION IS HEREBY GRANTED TO:
Project# ADD SHOWER 2024 Contractor: License:
Est. Cost: 7000
Const.Class: Exp.Date:
Use Group: Owner: TRUSTEE MELCHER DALE
Lot Size (sq.ft.)
Zoning: URB Applicant: TRUSTEE MELCHER DALE
Applicant Address Phone: Insurance:
61 LYMAN RD
NORTHAMPTON, MA 01060
ISSUED ON: 04/08/2024
TO PERFORM THE FOLLOWING WORK:
ADD SHOWER TO EXISTING BATH
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
/ "r'-- C,6','--ii-----
1
The Commonwealth of Massachusetts 4PR
Board of Building Regulations and Stan ds 8 F( R
W
Massachusetts State Building Code, 780 MR�'f'})i'�..� E I Y
OF ,+
Building Permit Application To Construct,Repair, Renovate Orbltsll Ns;`RRevised Mar2011
E v O N3
One-or Two-Family Dwelling `"'�'�'��,�7,��ip
This Section For Official Use Only
Building Permit Number: rgp-�7-yo9 Date Applied:
4UIIlesS Z�I I-8 20Z11
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Prop rty 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 it) 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 Ow er' rd•
,�� fec c rd NO i ha Wrilnl MA- 0 to CO
Name(Print) City, State,ZIP
61 14AvYlcui, RA . 013)zit-3443 da.(eannme,(alerE
No.and tr et Telephone Email Address f j, I�i(/i
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 ❑ Accessory Bldg. 0 umber of Units Other 0 Specify:
Brief Description of Proposed Work2: Ad L4/ ✓ S h �L
CTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:` Official Use Only
(Labor a d Materials)
1. Building $ c(I) 1. Building Permit Fee:$ Indicate how fee is determined:
Z.Electrical $ 0 Standard City/Town Application Fee
0 Total Project Costa(Item 6)x multiplier x
3.Plumbing $ .V` )0 2. Other Fees: $
4.Mechanical (HV C) $ List:
5.Mechanical (Fi $
Suppression) Total All Fee —/
Chec No.��1111����``;; Check Amoun : L
6.Total Project ost: $ 7/i/oo 0 P id in Full 0 Outstanding Balance Due:
6
City of Northampton
r1'14
Massachusetts w �,
a " DEPARTMENT OF BUILDING INSPECTIONS =
212 Main Street • Municipal Building
Northampton, MA 01060 FS`fr ern\4
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS,ROOFS,RENOVATIONS,ROOF MOUNTED SOLAR,ETC.
I. 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.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 ❑ 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.
tat tate H 31221 z4
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
Department of Industrial Accident's
., —iTilVt 1 Congress Street,Suite 100
A 41114(.1 Boston, 3I4 02114-2017
t, -1.17,rj
wwigntass.govidia
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VI.4.11 kers ('ompensalion Insurance Affidavit:BuildersiContractortiElertricians/Plumhers.
it)Ht.I WED WITH TI1L PLILNIITITNG AUTIIIORITY.
ADDliC2111 Information Please Print Legiblv
Name t I:I us tness;Organtzatton:Ind tvidual l;
Address:
City'State/Zip: Phone
,kre yirci an employer?Cheek the a pprapriate box: Type of project(required):
1,0 I am a employer with ,,,,,,,employsys(hill=dim part-timer' 7. 0 New construction
20 I am a auk proprietor or partruaslup and have no employees winking for me in /I,. 0 Reinodeling
any capacity_[Nu workers'crimp,insomnia: required]
9„ -1 DcttleiiittOrl
di
an,a homeowner doing all work myself.iNo workers'conr,insurance required_r
I U 0 Building addition
I. I am a hormaywnxi and will be Inning coletrastors to conduct ull w ink on my procerty, 1 will
mtsure that all emu-actors either haxe sots comperualiOn insurance or are auk I I a Electrical repairs or additions
proprietors v.ith no employees,
120 Plumbing repairs or additions
I am a gencral contractor and 1 bast hoed tht sub-contrackns listed on the attadied sham
30 Thea42 Alb-truntrackw,Nast.employees iusd have workers'exam in. surance.: 1 Roof repairs
14.0 Other
,,,,E3 We are a corporation and Its ofticah Nava exercised their right of exemption per Alta c,
15.1.§Irkt.,and we Iowa no employees.[No workers'comp,inblaaritV it:qui/W.1
_
'Any applicant that etwrks box rrl must also fill out the section below show insi then workers'eon:pa:watt:an poliq information.
I kiineow nen who submit this affidavit nulscating they are doing all work and then hire outside einitrackies must submit a maw affidav it indicating stach
Contractor,that check this box mina attaelaNi an additiiinal J)i,t1 ALM in the name of thi:sub-contraerets and Ash:41u:the!tar not those enlitio-luVot
orpluyeel. If the sub-coniracturs haxe einplo!.ce-i.tlisy 1111.ha pro'.Ric th,:ir workers'comqi.pokey number
I am an employer that is providing worAer.s'compensation insurance for my employees. Below is the policy and jab site
in formation.
Insurance Company Name: _
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: CityiStatelZip:
Attach a copy orthe 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.(10
andior one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.O0 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
overage N,erirication.
I do herekr certify wailer the pains anti peorshiek°Uteri:to that the information provided',hove is trio and eorrea.
s .7-3-7kit___—)17LL,C Cf4--Q-4--
ignature: Date: S 1,e7.,1 Z-LF
Phone:•':
Oft7i.iat use only. Do not write in this area,to he completed 0 city or town official
City or Town: PermitiLicense#
Issuing Authority (circle one):
1. Board of Ilealth 2.Budding Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
( outset Person: Phone#:
City of Northampton
•Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS r'
212 Main Street • Municipal Building
Northampton, MA 01060 '5
y1Y
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:
VAi/bP— G, 1. i
Location of Facility:
The debris will be transported by:
Name of Hauler:
Signature of Applicant: WilL, 1� 2s✓�' � -- Date: it 2 \ Zif
City of Northampton
Massachusetts
14 y DEPARTMENT OF BUILDING INSPECTIONS ±jam~a
212 Main Street • Municipal Building '►
Northampton, MA 01060
iq
/��� HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT L
I, Dal. /mill � (insert full legal name), born'Z serf
month, day, year), hereby depose and state the following:
1. 1 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. 1 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 r_2 day of M adriAl , 20 2,9
(Signature)
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