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15B-036 (12) U IV( "<": U lL C--Wf tHV(Vb BP-2023-1063 9 DIMOCK ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 15B-036-001 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-2023-1063 PERMISSION IS HEREBY GRANTED TO: Project# ADD 4 SEASON PORCH Contractor: License: Est. Cost: 66140 Const.Class: Exp.Date: Use Group: Owner: CARRIE GOLDSTEIN SETH B & Lot Size (sq.ft.) Zoning: URA Applicant: CARRIE GOLDSTEIN SETH B& Applicant Address Phone: Insurance: 9 DIMOCK ST LEEDS, MA 01053 ISSUED ON: 08/10/2023 TO PERFORM THE FOLLOWING WORK: ADD FOUR SEASON PORCH -HOMEOWNER CHANGED CONTRACTOR AFTER ROUGH INSPECTION -EMAIL DATED 4/17/24-HOMEOWNER TOOK OVER JOB ON 4/26/2024 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: 77°F. Fees Paid: $460.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner `ief.\\ C oA)7L 17&& C4 Qr15( q °C; ,� The Commonwealth of Massachusetts 9� ',AA Board of Building Regulations and Standards O FO IT`, Apt Massachusetts State Building Code, 780 CMR 461•1'USE Building Permit Application To Construct,Repair,Renovate Or Demolish a` Revise ar 2Q11 One- or Two-Family Dwelling This Section For Official Use Only Building Permit Number: (d P- c jQt/3 Date Applied: Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: — 1.2 Assessors Map&Parcel Numbers 9 aPrm©c .S;Gibs/1//If b/e 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: Zone: Outside Flood Zone? Public❑ Private 0 Check if ecs❑ Municipal 0 On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 56r11 4'o z-bsre7,v 66 S. /Iiit D/D� Name(Print) City,State,ZIP/��7 IA� gf/�� 9 .�,moc,�sr- 9 'a2� e No.and Street Telephone mail Addstss SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction Existing Building Er Owner-Occupied 'Repairs(s) 0 Alteration(s) 0 Addition 151/ Demolition 0 Accessory Bldg. 0 Number of Units Other ❑ Specify: �7 Brief Description of Proposed Work': d o/Ap € 74w OF la k c2 V � r-f L ,W/Gte4 An.Vg awis ,or/'v, 8 i-e.ez edzo#4: 'F'�.),4 ovezdo IT ,31°- o.a3-/0G3, SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $2Q ,QOD,O 1. Building Permit Fee: $ Indicate how fee is determined: /d po-D ' ❑ Standard City/Town Application Fee 2.Electrical $ A ❑Total Project Cost3(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire Suppression) Total All Fees: $41 l(,• 00 Check No.(�q Check Amount: 6.Total Project Cost: $ r9/ 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 ❑ 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. 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 Commonweafth of Massachusetts 7"- Department of Industrial Accidents ;lima / Congress Street,Suite 100 soy Boston, MA 02114-2017 www.mass,govidia 11'u/tiers'Compensation Insurance Affidavit: Builders.12ontractarsitketricians/Plumbers. TO RE FILED WITH THE PERMITTING AliTH()RITY, Applicant Information Please Print Legthls; Name us iness.I1fganiza t tofu Ind vtdua I)*. Address: C ity/StateiZi p Phone #: Are yea Oak enapkiyer?Check the appropriate bat: Type of project(required): 1.01 am a employer with_ __eropiorees(full andisic part-time 7. New construction I am a sole proprietor or partnaship and have no ellipkYyeet%%446,14 for me itt K. a Remodeling any capacity.[No workers.'comp.insurance requirecti St!riusi a homeowner doing all wink myself.[No workers'comp,tresurance rw4uire 9. Demolitiond,1* loci Building addition 4,CEram a lu:Jr1r.o.rW net and will he hiring contracturs to conduct all work on my property 1 04,11 Main:that all eingraxturi either ha winters'rxinmensation insurance to are sole i 0 Electrical repairs or additions proprietors with no employeos. 12..0 Plumbing repairs or additions 1 am a general contractor acid I have hired the sub-contractorri listed on the attached them. i Thew sub,coritractors have employees and have workers*coanp.insunince.: Roof repairs 14.CI Othei 6.E3We an a cwrporabori and its officeis have excrenied their right of exemption per WA_c, 152,§1(41,and ive have no omployees.[No workers*comp,insurance required.] *Any applicant that checks hos n1 mud also till out the section below*hewing their workers'cimmensation policy information, *Hoineowners Who laibnis.re theaalridasit indicating they are doing all work and than hoe outside contrachxii mud aubmit a new affidavit rathinting such, ;Contractors that check tins box mod ausslacti an additional sheet showing the name el the taiii•ciaitraoiers and an whether or not those entities_have employees_ If the sui.contraCtina litCy tittIA pros ide their workers'oomp.policy number I am an employer that is providing workers'compensation insurance for my employees. Below is the polio.and job site information. Iulauce Company Name: Policy#or Self4tis.Lic.#: Expiration Date: Job Site Address: CityiStateiZip: 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.(X) anktor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 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 d the poisnob penalti of perfury that the information provided abyve is true and correct. Signature: Date: Phone a: - /S99 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/license# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrieal Inspector 5. Plumbing impecter 6.Other „ t'ontact Person: Phone#: „ „, City of Northampton / Massachusetts +' ► «N,r I DEPARTMENT OF BUILDING INSPECTIONS $ 212 Main Street • Municipal Building . Northampton, MA 01060 4,;4' 1, HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT I, �t2 FerAw (insert full legal name), born (nisei t 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 un pains and penalties of perjury on this 861 day of i' 1— , 20 z (Signature) City of Northampton - h, 51S SI4, !. Massachusetts _ 'E jf{ w: c 1 f� I ,i E �• ( DEPARTMENT OF BUILDING INSPECTIONS \ ,r� 212 Main Street • Municipal Building 0 Northampton, MA 01060 "'""*"'"y 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: Vikttlittky1/11/1/ V- /(7 /-77-,-/a/I7 /77,46 /VO/V/`l)gPA/ Aid, The debris will be transported by: Name of Hauler: Signature of Applicant: Date: a�