17C-275 (7) BP-2024-0739
8 COSMIAN AVE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
17C-275-001 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-2024-0739 PERMISSION IS HEREBY GRANTED TO:
Project# BATH RENO 2024 Contractor: License:
DOUGLAS B THAYER DBA
DOUGLAS THAYER
Est. Cost: 12000 WOODWORKING 107699
Const.Class: Exp.Date:04/07/2025
Use Group: Owner: JUNG PATRICIA ISABEL&JULIA CHEVAN
Lot Size(sq.ft.)
DOUGLAS B THAYER DBA DOUGLAS THAYER
Zoning: URB Applicant: WOODWORKING
Applicant Address Phone: Insurance:
P 0 BOX 60322 (413)530-4785 6HUBGR15002
FLORENCE, MA 01062
ISSUED ON: 06/11/2024
TO PERFORM THE FOLLOWING WORK:
BATH RENO ON 2ND FLOOR
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: if/Z.
Fees Paid: $78.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
a
The Commonwealth of Massac use JUN - 8 Z E1 024 FOR
Board of Building Regulations an Stan lards
t Massachusetts State Building Cod , 789_w ' M ICIPALITY
n!�F Dort N, USE
Building Permit Application To Construct,Repair,-tetrovalm I{ ' aloN: Rev sed Mar 2011
One-or Two-Family Dwelling ---�'°s°
This Section For Official Use Only
Building in
it Number: Ste• _94 '73 Date Applied:
v�� �� 1 zfa›.) /� c' za
Building Official(Print Namc) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: ^O_I(Q 1.2 Assessors Map& Parcel Numbers p2 75
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)
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❑ Private❑ Zone: — Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: r
Sall q C`iin eUa h l�iatefrcce it A
Name(Print) City,State,ZIP
CQSifwl t a h adi,vav e COyw Ca5i Ives
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 Specify:
Brief Description1 of sed Work2:
RploetTiov+ /Reg)ace o 'I- ria
�hroUNI FA Liu eS
aZ pc( Flo , 3`A j l I5a#)1 - se Pw -6reter•nf
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 0 0 0 1. Building Permit Fee: $ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ 1'G CO
0 Total Project Cost (Item 6)x multiplier x
-
3. Plumbing $ - .00 0 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:,$,,
Check No. XV Check Amount: Cash Amount:
6.Total Project Cost: S 1 )� 0Ufa 0 Paid in Full 0 Outstanding Balance Due:
S 005P/it:ail
_ City of Northampton S
;; "...• Massacq. husetts `° L.
„i i
�( .' ait ,r..
' 4 + di DEPARTMENT OF BUILDING INSPECTIONS `
yk,.;. t E' r 212 Main Street • Municipal Building
r 010 60 ��.�*-100
\ "`�'�* ttorthampton, MA
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR NEW
1 & 2 FAMILY DWELLING, ADDITRO S. POO OOL D D OLACCEGORY STRUCTURES,
FENCES, G O
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. Site plan with location of proposed structure(s) and set backs.
4. Construction Debris Affidavit filled out and signed by applicant.
5. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
6. Contractors must supply a copy of CS License, HIC Registration and proof of Liability Insurance.
7. Energy Conservation Compliance Certificate (new f replacement windows).8. Home Owner's License Exemption Form filled out and signed by Homeowner (if applicable).
10.
9. Note any Conservation and/or special permit requirements (if applicable).
Driveway Permit (if applicable).
11. Proof of Water and Sewer entry fees paid (if applicable).
12. Trench Permit - public land by DPW I private land by Building Dept.
13. Stretch Energy Code - all new construction will require a HERS Rater Affidavit to be submitted with permit
application before issuance of permit.
14. Please provide the appropriate fee in the form of a check made payable to.. The City of Northampton.
e
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) ! 0 76 q 61
poa )Q S Male( License Number Expi ation Date
Name of CSL HdIder
List CSL Type(see below)
1 o i c,c O G v e2 r Description
No.and Street
/� U
5
FloreK<< Unrestricted(Buildings up to 35.000 Cu.ft.)
t/ ' �� R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
( r� SF Solid Fuel Burning Appliances
r��_S3G� -7G! o� I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 7470
SS I 0/01
poll bQ S -r e 4 WC Registration NumberExpiration Date
HIC Company Name or HIC Re is1tant Name
to g tt4 60447 z
No.and Street RRave17Ce _1 4 O1 6 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 .O
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 DoCifni 63 -7 V
to act on my behalf,in all matters relative to work authorized by thYs building permit apptcation.
"" -Cot)‘ C•t. 0 11-et./ atA _SLL
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 r is application is true and accurate to the best of my knowledge and understanding.
1.0 6)// - 0 V
Print Owner's or •uthorized Agent's Name(Electronic Signature) Date
NOTES:
1. n 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 stantial work is planned,provide the information below:
Total fl area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross ling area(sq. ft.) --- Habitable room count
Number f 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
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton
Massachusetts �o?�' �''$'':G
<<
/
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: ' ' J' DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building JA\
Northampton, MA 01060 4"" %N�
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: Vat)e Q'C Cii frc
The debris will be transported by:
Name of Hauler: DO )Ci 5 —Thcl ev
Signature of Applicant: Date: / 6/
The Commonwealth of Massachusetts
►*_'�' -- '� Department of Industrial Accidents
_ im.= 1 Congress Street,Suite 100
=_i:,- Boston, MA 02114-2017
www.mass.gov/dia
Watt en'Compensation Insurance affidavit:Builders/Contractors/Ekdrlclans/Plumhers.
TO BE FILET)M ITH f HE PERMITTING AUTHORITY.
Aoniksnt Information Please Print Legibly
Name(BusinessrOrganiatimulndivi&ial): 06 l,(5)u S 71i a Gt e r
Address: PO 130x 6o1Q2 2 J _
City/State/Zip: ROve3tct► i'Lk Phone #: 0 9i9 — 53O- Y-7 5
Are yea as etm pioyer?Cheek the yppreprIste be: Type of project(required):
1 am a employer with employees(f►ll mediae°port-time)! 7. Q New construction
20 I am a sok proprietor or partnership and have no employees working for me in 8. Q Remodeling
any capacity.[No workers'comp.insurance moored.]
30 I am a homeowner doing all work myself.[No workers'comp.insurance required]" 9. ❑Demolition
10 Q Building addition
41:1 I ant a hconaouner and will be hiring cosieradors to conduct all work on my property. I will
ensure that all contractors either ha(c workers`compensation insurance or are sole 1 l a Electrical repairs or additions
pruprwtvn with no c nrpluyee7i.
12.EI Plumbing repairs or additions
5C1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employe and have workers'comp.insurance,: I a Roofrepairs
46 a We are a corporation and its uf&eers have exercised their nght of exemption per MGL c. 1 Other
152_§I(4),and we have no employees.[No workers'comp.insurance required)
'Ayr applicant that chocks box pt must also till out the aretion below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Coatraelon that check this box must attached an additional sheet showing the name of the sub.exxntractors and state whether or not those entities have
employees. If the sub-contractors have crnplosecs.the', trust provide their workers' .omr policy number_
I am an employer that Is providing workers'compensation insurance for my employees. Below Is the policy and Job site
Information.
Insurance Company Name: Tr L't lilt I c Vt5
Policy#or Self-ins. Lic.#: v i S 00. A Expiration Date: I '/�fr
Job Site Address: f 2Q.5YN t'k N City/State&Zip: R eiVriltc.f
Attach a copy of the workers'compensation police 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 S1,500.00
andlor 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 the pans and penalties of perjury that the information provided above truer and correct
Signature: r\� Date: 0 Y
Phone#: / - S30-- V 7 S S
Official use only. Do not write in this area,to be completed by city or town official
Cit, or Town: Permit/License h
Issuing authority(circle one):
1.Board of Health 2.Building Department 3.Cit)(Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
A. - -- -- ..._.
City of Northampton
Massachusetts (1:7N\If- DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building �J
••""'� Northampton, MA 01060 `i4 -
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, (insert full legal name), born _ (insert month,
day, year), eby 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. 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)