25C-125 (15) BP-2024-0720
14 ELIZABETH ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
25C-125-001 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-2024-0720 PERMISSION IS HEREBY GRANTED TO:
Project# BATH RENO 2024 Contractor: License:
Est. Cost: 19100 BRIAN WORGESS 106973
Const.Class: Exp.Date: 03/31/2025
RUSSELL, ALEXANDRA BRYANT &ROBERT,
Use Group: Owner: BRANTON JONES TRUSTEES
Lot Size (sq.ft.)
Zoning: URB Applicant: BRIAN WORGESS
Applicant Address Phone: Insurance:
680 BAY RD (508)680-6271
AMHERST,MA 01002
ISSUED ON: 06/11/2024
TO PERFORM THE FOLLOWING WORK:
2ND FLOOR 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: ii://Z.
Fees Paid: $124.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Buildins Commissioner
ret EC-f V E
The Commonwealth of Massachus s
:. kV Board of Building Regulations and Sta dat 1N - 6 2024FOR
�,f' Massachusetts State Building Co4'e, 78 CMR M ICIPALITYUSE
Building Permit Application To Construct,Repair, l 3rit� Re ised Mar 2011
ORTH41on,,_,,, ECTIONs
One-or Two-Family Dwelling- ►MOO
This Section For Official Use Only
Building Permit Number-d-y-Y"7,4,Q Date Applied:
gvir...)&s., // 2 6 l 6-7.62_
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
I.I}Prep Addres� •
64, 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 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 IEK Private❑ Zone: „ Outside Flood Zone? Municipal Cd On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: I
Aie RvssetI i -- 5 �or�4o�✓, 14 Oi0c0
Name(Print) [[ � 1L City,State,Z1P 11 SG L t
111
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building fir. Owner-Occupied 191 Repairs(s) 0 Alteration(s).1 Addition 0
Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify:
Brief Description of Proposed Work': Serer J<J -F( or 6a' i.GWtpcie-1,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ et i MO 1. Building Permit Fee:$ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ gi
t 0 Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2
/ 00c) 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:
Check No. irrCheck Amount 011 Cash Amount:
6.Total Project Cost: $ I q,) 100 ❑Paid in Full ❑Outstanding Balance Due:
City of Northampton
- '
• Massachusetts
4-1 i I DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building v ��
�� Northampton, MA 01060 "PS), 3�`��
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR NEW
1 & 2 FAMILY DWELLING, ADDITIONS, POOLS, DECKS, ACCESSORY STRUCTURES,
FENCES. GROUND 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. 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 / replacement windows).
8. Home Owner's License Exemption Form filled out and signed by Homeowner (if applicable).
9. Note any Conservation and/or special permit requirements (if applicable). 10.
Driveway Permit (if applicable).
11. Proof of Water and Sewer entry fees paid (if applicable).
12. Trench Permit - public land by DPW/ 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.
.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS-10 6R 7 7� B3/3 t l z5 •
g(143.1
o(� /
(fj S License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
Street tQ `
No.and Type Description
D� D
M�7 U Unrestricted(Buildings up to 35,000 cu.ft.)
�` �1 `w v R Restricted 1&2 Family Dwelling
City/Town, State,ZIP ' M Masonry
RC Roofing Covering
WS Window and Siding _
( &) (4°
_ 6211 p r SF Solid Fuel Burning Appliances
b ® I Insulation
Telephone Email address but t D Demolition
5.2 Registered Home Improvement Contractor(HIC) �t CO
in zo-4- [ bzozg-
Bc.av l et r0lP 55 HIC Registration Number Ex ration Date
HI man Name or HI RRe stran ame
WO 3a_ Q . 6("�4@ 9'stsiers 6 W / /0
o. d St •
O 0
0-2- -- C/�603-6z*1 Email address
City/Town, ate,ZIP' Telephone i (/vO/- I Lp ► I ) ,
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 AG ENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorizeF(t OI Ai IT p es s 116.
to act on my behalf,in all matters relative to work authorized by this building permit applin7 /zoz
Airf54\ --. 471'�44 Aco-eq 6y
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 -o the best of my knowledge and understanding.
gAIANi U40A 64Ss . ° 6/b 1 zCZI
Print Owner's or Authorized Agent's Name(Electro c W 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"
p
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 44 C.
It DEPARTMENT OF BUILDING INSPECTIONS y
e. 212 Main Street • Municipal Building vti D
Northampton, MA 01060 �'ph, .3,7‘���
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 n
Facility: �a� `"" Sterb.0►'� �
The debris will be transported by:
r
Name of Hauler: � ��1� \\JOC /-55
Signature of Applicant: ti Date: iC2 V 2-/
The Commonwealth of Massachusetts
. Department of Industrial Accidents
w' I Congress Street,Suite 100
=, {:�_- , Boston,MA 0211 d-2017
-�- wow mass.go�/din
rS� 11uikris'Compensation Insurance Affidavit: BuikJers/('ontractorvElectririans PIu III hors.
7O 13E l ii.ia)¶%Ill II l ill':PERMlITIs(:AUTNUR1 I 1.
Apltlirant Information { Please Print Lr_ibls
battle iBusiness,ch1;dnvution Inds utuall:.�rlOfJ 1 r es "" Cs t�j Z.5 t(Jl(ci i,1&:: a)` i iN
Address: e ((JJ /Ego - --1----___`_.-- - ------- - -
City/State/Zip: ,4I4 Cti- Phone Cs-0 clgo 6Z11
Are y«an ewiplwer!t•hetk the appropriate boa: I Type of project(required):
LC]1 am a errpihiytr with employes ifull and or part-trnwl.• 7. [I Ness construction
201 am a sole pnoplwiur or partnership and base no employees working tot me in 8. IC�Intxleling
any capacity.(No workers'comp.insurance required.) L•�
.la I am a&Wilco%ru-r doing all work myself.(No workers'comp.insurance nyturcd.('
9. D Demolition
40 lam a hdnravwncr and will be hiring contractors to conduct all work on my property. I vsill
10 0 Building addition
ensue that all contractors eithrt hase workers'comp sattun insurance or arc sole 1 1.Q Electrical repairs or additions
proprietors In ith no employees_
12-D Plumbing repairs or additions
vil i ant a general contractor and I lime hard the Sub-contractors listed on the attaches!sheet
I se sub.cunlraetor lase cmpluyrrs and least wurke»'comp.uasugrne 130 Rout repairs
6. w e are a corporation and its officers base exercised their nght of exemption per%K a-. I 4.❑Olhr!
152.4144 and we base no employees.(No workers'comp_insurance respirited-(
`An)applicant that darks boa at muss also till out the icetion below showing their caulkers.eompenaation pokey inf rmation.
t Iknneowners who submit thus alrulasit indicating they sic doing all work and then hue outside eoritraekrs must submit a new at'tidas it indicating such
:Contractors dint check this his mual attached an additional sheet slow in the name oldie sulrcontraetous and state whether or not those asiities has.-
employees. lithe subcontractors lase employees.thy!, taro,1 rruside their workers'comp.polies nunoh:r
l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: --�
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: C'ityrStatc'Lip: _
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under M(iL c. 152.§25A is a criminal violation punishable by a fine up to$1.500.00
and'or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a
day against the siolator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
enscrage verification.
l do hereby certif•under,th pains and penalties of perjury that the in/ormativm provided above is, true and correct.
Signature: ►1 d VVirlprV'e.--------
Date: Co I v 1 Z"--1
Phone x: C566 WO a bi
3--k
Official use only. Do not trite in this urea, to he completed by city or town official
( its or Town: Permit/License#
Issuing Authority (circle one):
I.Board of Health 2.Building;Department 3.(•its,'Eown Clerk 4.f kctrkal Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
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Scale: 1/2"- I'
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