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, The Commonwealth of Massac ,-m;,
Board of Building Regulations and Stands `�''.r``FAT, FOR
W
areONS CIPALITY
Massachusetts State Building Code, 780 CMR '`'� USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: 60— )-1-I(00 Date Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel ers
9 Cherry Street. Northampton. MA 01060 32A-045- 1
1.1 a Is this an accepted street?yes no Map Number r
1.3 Zoning Information: 1.4 Property Dimensions:
Residential Residential 5000 50
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 O Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Marshall Poe Northampton,MA 01060
Name(Print) City,State,ZIP
9 Cherry Street 734-255-6677 marshallpoe@gmail.com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 61 Owner-Occupied ® Repairs(s) 61 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: Repair and rebuild front porch
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ $15,000 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical S 0 Standard City/Town Application Fee
—.. - ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) J�Total All Fees:$1 /iQ/
Check No. Check Amount: t
6.Total Project Cost: $ $15,000 0 Paid in Full ❑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 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.
Marshall Poe ot July 15, 2021
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
. 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/dns
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
!�o�1 �!i Department of Industrial Accidents
— 1 Congress Street,Suite 100
�1." ;lam Boston,MA 02114-2017
c
y.��t,, www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians Plumbers.
"1"O RE FILED WITH Tin:PERMITTING AUTHORITY.
Anttlicant Information Please Print I e,.ihls
Name(Business'Organisation/individual): Marshall Poe
Address: 9 Cherry Street
City/State/Zip: Northampton, MA 01060 Phone#: 734-255-6677
Are you an employer?Cbcek the appropriate hos:
Type of project(required):
1.0 I am a employer with ___... __employees(full rnttor part-time).• 7. 0 New construction
20 1 am a sole proprietor ur purtnershtp and have no employees working for me in K. 0 Remodeling
any capuctly.[Nu workers'comp.insurance required.]
9. ❑Demolition
30 1 am a homoow nor doing all wudt myself.[No workas'rump.irsur.ince required.]'
10 0 Building addition
40 lam a bons-owner and w ill be hiring contractors to conduct all work un my property. I w ill
ensure that all contractors either have workers'compensation insurance ur are sole 110 Electrical repairs or additions
proprietors with nu employees.
12.0 Plumbing repairs or additions
5f:3 lam a general cuntra:tur and 1!save hired the sub-contractors listed un the attached sheet. 13.0 Roof repairs
These sub-contractors have employee and have workers'comp.insurance.:
6.0 We are a corporation and its officers have exercised their right of exemption per?ail c. 14.®other Porch repair
152.§1(4).and we have no employees.[No workers'comp.insurance required.]
•Any applicctst that checks box al must also fill out the section below showing their workers'compensation policy information.
t homeowners who submit this affidavit indicating they arc doing all wink and then hire outside contractors must submit a new alYidav it indicating such.
Contractors that check this box must attached an aiohtional sheet showing the name of the sub-contractors and state whether or not those oxttriles have
employees. If the sub-contractors have employees.they must pros ide their wotlers'comp.policy number.
r
I ant 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.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under NIGL c. 152,§25A is a criminal violation punishable by a fine up to S1,500.00
and/or 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
co\erage verification.
I do hereby certify under the pains and penalties of perjury that the information prodded above is true and correcL
Signature: /�!�'/(/ `,____- Date: July 15, 2021
Phone#: 734-255-6677
Official use only. Do not write in this area,to be completed by city or town official
('its or Toss n: Perntitil.icense 4
Issuing.tuthorits (circle one):
I. Board of Health 2. Building Department 3.CO flossn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
..........._SiC
Massachusetts
l�' � W!
';,' DEPARTMENT OF BUILDING INSPECTIONS Wit. 4
212 Main Street • Municipal Building yv� cam
Northampton, MA 01060 s� .• ,
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: Valley Recycling, 234 Easthampton Rd, Northampton, MA 01060
The debris will be transported by:
Name of Hauler: Applicant(Marshall Poe)
July 15, 2021
Signature of Applicant: Date:
City of Northampton
Massachusetts ,' : `°•!t
( . ' '4 , _ w *
a�, IM
,.� DEPARTMENT OF BUILDING INSPECTIONS i Kr 7
4
' 212 Main Street • Municipal Building J , ,�a
Northampton, MA 01060 SO"%�OQ
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
December 29, 1961
Marshall Poe (insert full legal name), born (insert
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. 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 15th day of July , 2021
(Signature)
Porch Plan 9 Cherry Street
(Floor Plan/Ground Floor)
Posts
24 feet
Dads!
Porch
II host If I,ri
Deck!
HOUSE Porch
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•
• •
Porch Plan 9 Cherry Street (Elevation)
Flas n
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oof
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VI ---/
Lath
/Rafter
Ct;pg/ •
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Facia Ceiling Joist/Collar Tie
Tie Tie art.
Soffit
Ledger
Post • t
Decking
Anchor Anchor
Hanger
Porch Joist
Concrete • Gravel Concrete Gravel
Pillar Pillar
Anchor Anchor
4._ Concrete Concrete
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