31C-018 BP-2024-0897
22 FORD CROSSING COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
31 C-018-001 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-2024-0897 PERMISSION IS HEREBY GRANTED TO:
Project# FIREPLACE MANTLE Contractor: License:
Est. Cost: 3000 JUSTIN SQUIRES 115236
Const.Class: Exp.Date: 09/02/2024
Use Group: Owner: MARGARET BABBOTT
Lot Size (sq.ft.)
Zoning: PV Applicant: JUSTIN SQUIRES
Applicant Address Phone: Insurance:
177 E HADLEY RD 4136409647
AMHERST, MA 01002
ISSUED ON: 07/16/2024
TO PERFORM THE FOLLOWING WORK:
REBUILD FIREPLACE MANTLE
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: 6/2-
Fees Paid: $75.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
RECEI
RFD
The Commonwealth of Massachuse s JUL 1 6
•
w Board of Building Regulations and Sta Bard. ZI.v FO
Massachusetts State Building Code, 7 Cl r oFAtortr r M IUI •• LITY
Building Permit Application To Construct,Repair, Renovate • !r- - it►gaF• ; ,ised ar 2011
One- or Two-Family Dwelling aAo,, �• s
nL Section For Official Use Only
Building Permit Number:g 44 Er' ov 7 Date Applied:
4.0 as /��2 -7-/L-2Dz''
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
as Ford Cr05s;x4
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 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 0 Private 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system CICheck if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
(V10Aaq Grt-1- 3exioba NoC;lnc 4 Ion , Me\ D i06 0
Name(Print) City,State,ZIP
aa- o(d e(Oi'S ;1 1113-557-SN67 VACt(ciodd- 7G,bba "@ )cI aka .Lo/''1
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Buildinga21 Owner-Occupied 0 Repairs(s) 0 Alteration(s) ❑ Addition 0
Demolition 0 , Accessory Bldg. ❑ Number of Units Other 0 Specify:
Brief Description pf Proposed Work2: RR Ad 1-nig G;t'4P l of(4._ .ln.a it\.-)t J;4-1,‘ Aryw cal
�G r W O X ( YOc:hi 1- 1/4->n n 41 1%r-‘
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ a'70(1` 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ Set 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All $
Check No. heck Amo t: Cash Amount:
6.Total Project Cost: $1 01513 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
11S 6 04-n2- 20 ZY
JS �t (eS License Number Expiration Date
Name of CSL Hold*
�1 r Had
( L` - List CSL Type(see below)
No.and Street d �T e Description
p C uJ Unrestricted(Buildings up to 35,000 Cu.ft.)
v"h P(-54`, M� Q 1 U C O R Restricted 1&2 Family Dwelling
City/Town.State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
V SF Solid Fuel Burning Appliances
Li -C40-9 047 j S 9tn:t'es COn4fc.Cd n�j �qfi 1 Insulation
Telephone Email address ✓ D Demolition
5.2 Registered Home Improvement Contractor(HIC)
a000s�
ct,.L v• Sqqu re5 HIC Registration Number Expiration Date
HI Company Name of HIC Registrant Name
1k Sg1n i(CS Gon•t.c4-:{"l eiwo.:.I cotY-
No.and Street I Email a dr ss
,
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 0 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 pennit 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.
PIN( c 'C4- 8ct1)bai+ o ?- i - zoa
Print O er'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"
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton
r -•" • Massachusetts ��"
1 Gt A• Y v
DEPARTMENT OF BUILDING INSPECTIONS r
212 Main Street • Municipal Building vti �°
w'. ..�,_4' Northampton, MA 01060 "f rW .4,-,\\
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: VecItflj Reycli h
The debris will be transported by:
Name of Hauler: '-"I-v-,S J1 ,;,,1..e S
Signature of Applicant: Date: 00 - ) A- Ioa(.(
The Commonwealth of Massachusetts
Illtrii Department of industrial Accidents
1= F 1 Congress Street,Suite 100
-:reigns / Boston,MA 02114-2017
`;:,.41 i .es www.massgov/dia
11 in ker,'('ontpensation Insurance Affidavit:Builders/Contractors/El ctricians/Plumhers.
TO BE FILED WITH THE FERMI-rut NC AIfl•IIORl1 '.
Applicant Information Please Print l.eeibly
Name(Husines;iOrganitatiit►tlndividual): 3—.` cci k k% f e 5 _ Co .c,c v��
` V.A.
Address: 11 7 (•may V.A
City/State/Zip: A.►,n\fkr cS i-t M4 8 I CO 2 Phone#: y I - 6 NO - °1 9 Z _. _ . _
Are yea as anplrn er?('heck the appropriate Mn:
Type of project(required):
LEI I am a eniploycr with cr p r..es tt WI aodkie part-time d-• 7. O New construction
tfa1 and a stile proprietor or pormaalnp and bat C li t cenplh'y►es working for mein 8.El Remodeling
.�--iy capacity.[No*otters'comp.insurance nn(wrnd_[
9. ❑ Demolition
30 I am a Bonne IwiiaY doing all wink myself.[No w.ttkera'euii'p iroorance nquttoi.]'
10 Q Building addition
IEI l am a homeowner and will Ise hmne contractors to conduct all work on my property. I will
cumin:that all contractors either hate workers ,:verspeibation nburance or arc sole 1 10 Electrical repairs or additions
prupnctofs isl7 Ilh no bplJyel^!_ 12.0 Plumbing repairs or additionss
SO I am a gcncial ctnizactor and I have hired the,ub-contractun listed on the attached shut 13❑Roof repairs
Thee wb-eoatraewn hair employs, ia and has c weaker,'cotµ+,ni]trr mac.
I4.❑Othcn
60 We are a corporation and its officers hate eactriscd don nght of exemption per M(iL c.
152,11(4 and we has:no employees..[No wirers'comp.insurance required.[
"Any applicant that clocks butt ItI must also fill out the weetion below showing.their workers'compensation policy information_
t Homeowners who submit this affidavit indicating tli* an dialog all work and then hire outside contractors meat subnrt a new affidavit indicating such.
YContranon that check this box must attached an at:Ldutiunal sheet showing the name toile sub-couractors and state whether us not dates entities has:
crnployetm. If the sub-caitrackas Isar ciuplu'ees.they rvusi rcui'idc their worker..'comp.pulic',number
1 ant on employer that Is pro ridini workers'compensation insurance for my employees. Below is the policy and job site
Information.
Insurance Company Name: AO- f'(c$ iv..SU.Yavl L n:. lotev.Li
Policy#or Self-ins.Lie.#: j X T g3 y y.>< )y -go- Ej 1. Expiration Date: %O-a 3- .C.y
Job Site Address: ai. (o(C ((ass., rC{ City/StatelZip: him--N.q e4-enn,t,,IA a t 066
Attach a copy of the workers'n,ontpenxatio&policy declaration page(showing the policy number and apinition date).
Failure to secure coverage as required under 1ACL c. 152,§25A is a criminal violation punishable by a tine 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 line 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 nd r the pains and penalties of perjiirr that the in formutio:provided above is true and correct
Signature: 1( Date: 01 - 1 tS )..0) -(
Plane#: 14I3 b Lf / C ' 1
Official use only. Do not invite in this area.to he rompkted bl'city or town official
( it) or Tow n: Permit/License#
lksuin;;.kutburii (circle one):
I. Board of health 2. Building Department 3.('ityTossn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
•
i�•"fi `� Massachusetts �� • r
• DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building s6. , OC
Northampton, MA 01060 svh;•• ..
PC
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, (insert full legal name), born _ (insert 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 qualifij 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 qualifij 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)