30A-078 (4) BP-2024-0738
4 HIGH MEADOW RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
30A-078-001 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-2024-0738 PERMISSION IS HEREBY GRANTED TO:
Project# BATH RENO 2024 Contractor: License:
DOUGLAS B THAYER DBA
DOUGLAS THAYER
Est.Cost: 13000 WOODWORKING 107699
Const.Class: Exp.Date: 04/07/2025
Use Group: Owner: E MURNANE JAMES A&ARLEEN
Lot Size(sq.ft.)
DOUGLAS B THAYER DBA DOUGLAS THAYER
Zoning: WSP Applicant: WOODWORKING
Applicant Address Phone:, Insurance:
P O BOX 60322 (413)530-4785 6HUBGR15002
FLORENCE, MA 01062
ISSUED ON: 06/11/2024
TO PERFORM THE FOLLOWING WORK:
RENO 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 Drnenay 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.Si nature: 172-
Fees Paid: $85.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
1peh
The Commonwealth of Massach etts `/�1
1W" Board of Building Regulations and Land rds ✓ 41 ICF�
''
Massachusetts State Building Cod , 789w R 8 �Q�Q 4SEALITY
aT
Building Permit Application To Construct, Repair,f �k) .1"-molish a Revis-d Mar 2011
One-or Two-Family Dwelling A�"'ro2iNp
This Section For Official Use Only �'L'q 0;0ioys
Building P it Number: ea �CI_ 73� Date Applied: �.
evio 6I<o�, ��/2 -// ZOZ11
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property dress: M 1.2 Assessor Map& Parcel Numbers
tt 1 `0 J toadnv Re, Ito A- d? - cv i
1.1a 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 II) 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 yes
Municipal On site disposal system 0
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Aflepl £ Acrant f V Ildh ifedot.,
Name(Print) City,State,ZIP
4- IMi /14410t__ I
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)` Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: `
Brief Description of Proposed Work':
Pet ov&4-ioh aI" EX,' -:tj Ft}rf" Fitiry 54 fl
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item (Labor and Materials) Official Use Only
1. Building $ Cr coo I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical i $ ❑ Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ $G oQ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Fees: $Total All $
Suppression) 1f �J
Check No.jG 0 Check Amount:
6.Total Project Cost: S 1771
00 0 0 Paid in Full 0 Outstanding Balance Due:
City of Northampton
Massachusetts •
S ,. DEPARTMENT OF BUILDING INSPECTIONS
**7.. 'x' 212 Main Street • Municipal Building
Northampton, MA 01060•
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.
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 1 v 7/Q q 10/2 6
ijoKiCt4 "tituv
( License Number Expiration Date
Name of CSL FftlIder
List CSL Type(see below)
'PO geg (O39i.a
No.and Street Type Description
(( /� U Unrestricted(Buildings up to 35,000 Cu.ft.)
I I&'e(K�t. / R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
(O RC Roofing Covering
6 WS Window and Siding
SF Solid Fuel Burning Appliances
• I Insulation
Telephone Email address D Demolition /
5.2 Registered Home Improvement Contractor(HIC) 17g0 SS 1 d/2 p
7 / N S S C)O c,h1 U S ( n li c 1('v HIC Registration Number Expiration Date
Co
mp omp y N a or HIC Registrant Na e
A"uS sd—
No.and Street Email address
Flartrtc4 i ' 7 - S3o - X716
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 .n.. No ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTORR APPLIES FOR BUILDING) PERMIT
J�I,as Owner of the subject property,hereby authorize otAGA'&3 Ploy
/l oy r
to act on my behalf,in all matters relative to work authorized by this`building permit appkcation.
A \ee ' /1� n4 e ‘/7/12cL
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.
o/7 02 V
Print Owner's or Authorized Agent's Nam 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"
A
a3av:v
The Commonwealth of Massachusetts
Department of lntlustrial Accidents
I =• I` - 1 Congress Street,Suite 100
,.sees _:,
Boston,MA 02114-2017
wwwJnass.gov/die
11 hikers'Compensation Insurance A(lidos it: BuildersiContractorslElectrieians/Pluntbers.
TO 1W FILED vi I t ti THE PER:sifT1`1Nt;At 1'HOR17.1.
Applicant Information Please Print Legibly
Name(Huseness&U nuzatianllndividuai} DO(tg'I .� -O'L4��y --
Address: Po 1lo� 603a� U Flv ei,e0 if OIoG '
City/State/Zip: Phone#:
Are you au employer?Cheek the appropriate box:
Type or project(required):
1 employer with. . ...........employees 41141 asaalor part-nine t-• 7. D New construction
20 1 am a auk etas or rah: and have no loves workin• for ox in
proprietor t� pt; K. 0 Remodeling
any capacity.[No workers'comp.insurance required]
9. ❑Demolition
0 I am a Iutmrww Iter doing all work myself.iNo work,:rs'cun{r_trnuratax rettttired.}"
11.0 lam a trunxwwu.-tr and will be hiring cuntraaanrs to cvtrduct all work on my .}r nrlretty. 1 will I Q CI Building addition
rtc;ure that all contractors either have winters'compensation Mtn-aril-1;or are:Pole Ha Electrical repairs or additions
proprietors wish nu empluycasc. 12.0 Plumbing repairs or additions
4c3 I am a general contractor atul I have hin'cl the suls-contractors listed on the attached sheet. 13 ri Roof repairs
These soh-contractors have employees and have workers`comp..insurance.;
6.0 We are a corporaanon and its off►ceis have exercised duo right of exemption per MUc. I .❑other
152 'l{4)..and we hose no anployees.[No workers'comp.insurance n quireil.}
`Any applicant that cketkx box al mesa also fill out the section below showing their workers compensation policy information.
r iterneowners who submit this affii avit indicating they are doing all work and then bee cwtaide contractors smut submit a new afftdas it indicating such.
*Contractors that check this box must atrarbral an additional sheet showing the name of the sulrcuntracwcs and state whether or not those entitles have
employees.. if the sub-cuntraetors have esmplovees.they'must provide Pair worker,'comp.policy number_
l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: It Ave(ieV5 - _.
Policy#or Self-ins.Lie.#: (IR IS 0027 Expiration Date: 1O/13
Job Site Address: t1 h jl oph n 624 City/State/Zip: 010.
Attach a copy of the worriers*compensation policy declaration page(showing the policy number and expiration date).
failure to secure cov'erdge as required under MG,c. 152,.$25A is a criminal violation punishable by a tine up to S I,50(LOO
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 site violator.A copy oft is statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage tic c n t ic ation.
1 d'hereby ccrti f i•under the pcutt,s uarid penalties ofpea jury that the information provided oho 'e is true and correct.
Signature: 4------
te S a ,�`� Da
Phone#: V(1 5 3o / 73-5
offiicial me only. Do not write in this area.to be completed by cite or town official
City or Town: Permit/License#
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
,,_ Massachusetts �4r
!
* �
A. ( )J
DEPARTMENT OF BUILDING INSPECTIONS Northampton, MA 01060
i
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: V
G(l`.Q �N 1> _G
The debris will be transported by:
Name of Hauler: DO `u-S 1-1,cte.
pp
Signature of Applicant: j\-(\—)
44--.\ Date: ‘77 �S
g
City of Northampton
,0 M..
� �,y,f•\'�'�
Massachusetts •' _ t�
• ,` DEPARTMENT OF BUILDING INSPECTIONS
`u-'n 212 Main Street • Municipal Building `3;:\
Northampton, MA 01060
W~3�
Y
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
1, (insert full legal name), born_ (insert
month, day, year), hereby depo and state the following:
1. I am seeking uilding permit pursuant to the homeowners'exemption to the permit requirements of the
Massachu tts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or
work o parcel of land to which I hold legal title.
2. 1 not engaged in, and the project or work for which I am seeking the aforementioned homeowners'
xemption, 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 1 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)
C " (0 ,4 r a- wt le -)- 1 h
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