22B-040 (19) 221 PINE ST-#130 BP-2021-0032
GIS#: COMMONWEALTH OF MASSACHUSETTS
M Block:22B-040 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL_c.142A)
Category:renovation BUILDING PERMIT
Permit# � BP-2021-0032
Project# JS-2021-000047
Est.Cost: $6000.00
Fee:$100:00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:` JAMES MAILLOUX ELECTRIC 081694
Lot Size(sq.ft.): 145926.00 Owner: BRUSH WORKS THE LLC r
Zoning: SI(115 /�15)/WSP(1)/ Applicant: JAMES MAILLOUX ELECTRIC
AT. 221 PINE ST -#130
Applicant Address: Phone: Insurance:
221 'PINE ST SUITE 160 (413) 585-1592 Workers
Compensation '
FLORENCEMA01062 ISSUED ON:7/10/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.-SUBDIVIDE SUITE �.30 AND FLOOR REPAIR
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Buillding Inspector J
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foulndation:
Driveway Final:
Final: Final:
l Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke:. Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy signature:
FeeType Date Paid:f Amount:
Building 7/10/2020 0:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
UL - 9 2020 he Commonwealth of Massachusetts
Office of Public Safety and Inspections
OF 6UtLp� Massachusetts State Building Code(780 CMR)
NORTHAMPTM knit pplication for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Nwmbex: "1`i 3-Z -Date Applied: Building Official:
SECTION 1:LOCATION
No and Street City/Town Zip Code Name of Building(if applicable
04-C�
Assessors Ma # Block*and/or Lot #
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all:that apply in the two rows below
Existing Building❑ Repair 13Alteration Addition E3Demolition ❑ (Please'fill out and submit Appendix 2)
Change of Use ❑ Change of Occupancy 13 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes X No ❑
Is an Independent Structural Engineering Pee Review requited? Yes C1 No
Brief Description of Proposed Work: i 1 CL
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
.Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
i
No.of Floors/Stories(include basement levels)S Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicabl
A: Assembly A-1 13A-2 13Nightclub El A-3 ❑ A-4❑ A-5 13B: Business E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R. Residential R-10 R-213 R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as a plicable)
IA [3 M ❑ 11A. ❑ IIB E3 IIIA ❑ MB C3 IV 13 1 VA E3 VB E3
SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 fox details on-each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit. Debris Removal:
Licensed Disposal Site 13Public E3 Check if outside Flood Zone C3 Indicate municipal 13A trench will not be . P
Private El or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Re<<iew Process:
. Not Applicable❑ is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes O No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s);" Type of Construction:
Does the building contain an Sprinkler System?: Special Stipulations:
Design Occupant Load per Floor and Assembly space:
i
I
i
i
SECTION 4: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
5m,u ,uwoaks LL C X71 �� Sk.SNk_1Q0 Fes.
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information: r
,�[ the ' l na 13- Ug- Z'Tl 9 = s"""'`- � ti 0 t).
Title Telephone No.(business) Telephone No. (cell) e-mail ad ss
If�applicable,the property owner hereby authorizes: L
NA_OMi i t6Se 1 -1-L1 Pon& 8+. �w 0` 114 —10re-eLe4 aQ62
Name Street Address City/Town State - Zip
to app1y for and act on the proper owner's behalf,in all matters relative to work authorized by this building perrnit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix I)
If a building is less than 35,000 cu.it.of enclosed space and/or not under Construction Control then check here❑.
Otherwise provide construction control forms(see section 107 in the code)as required.
10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals)
Name(Registrant) Telephone No, e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2General Contractor
Company Name
:�,\RW&& rr N1L'Lou CIs-0,169
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No:(business) Telephone No.(cell) e-mail address
SECTION 11:WOR1,MZ5 COMPENSATION INSURANCE AFFIDAVIT(M.G.L..c.152.§25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes❑ 'No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE '
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ 4 Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ rb, (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the airsge and penalties of perjury that all of the information contained iri this
application is true and accurate to the b of edand understanding.
Please print and sign ani Title Tel hone bio. ,pa e
� Tine � Z A0 a 2E�'te .1114 0 1062-. Ma.,/��p['��++1 f��i�11 C,a�•.
Street Address City/Town State Zip Email Address
Municipal Inspector to fill out this section upon application approval:P P P PP PP
Name UUDafe
hm f The City of No thampton
-� Building- Department
J •�f
ME
s• r 212 Main Street
Northampton,Massachusetts 01060 1
Phone(413) 587-1240
Fax (413) 587-1272
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVAT 10N PROJECTS)
In accordance with the provisions of MGL c40, 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, sl 50A.
I�
The debris will be disposed of in:
Location of Facility
The debris will be transported by:
Name of Hauler A
Signature of Applicant: Date:
G
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
• www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITI.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):James Mailloux Electric
Address:221 Pine st. Suite 160
Cite,/State/Zip:Florence, MA 01062 Phone#:413-585-1592
Are you an employer?Check the appropriate box: Type of project(required):
1.E✓ I am a employer with 2 employees(full and/or part-time).* 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in S. E]Remodeling
any capacity.[No workers'comp.insurance required.] ❑Demolition
3.E]1 am a homeowner doing all work myself.[No workers'comp,insurance required.]t
10 Q Building addition
4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0✓ Electrical repairs or additions
proprietors with no employees. 12.Q Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
'I 14.❑Other
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c.
152,§1(4),and we have no employees.(No workers'comp,insurance required.]
*Any applicant that checks box#1 must also fill out the section 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.
$Contractors that check this box must attached'an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.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:NGM Ins.,
Policy#or Self-ins.Lic.#: p WCT0721Q Ex iratil nDate:10/08/20
Job Site Address: ALL LOCATIONS City/Stade/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 MGL c. 152,§25A is a criminal violation p lunishable 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 fine of up to$250.00 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 th as nd a al s-of perjury that the information provided above is true and correct.
Signature:
Date:
Phone#:413-585-1592
Official use only. Do not write in this area,to be completed by city or tows:official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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Commonwealth of Massachusetts
Division of Professional Licensure 1,
Board of Building Regulations and Standards
Cons"-d%'Aboprvisor
CS-081694 yy EE5cpires 10116/2021
JAMES G MIiLLOU �
276 SOUTHAIMPT�I�
WESTHAMPTOJV
Tf Mz {141;R ` 13f S Q�
Commissioner
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• •- d • •
221 Pine St. Florence MA
• o o Suite 130 Improvements.
Drawn by:A. Schneider, 7/5/2020
Scale: 3/16"=1'-0"
Notes:
A: New partitions, 2x4 SPF studs
with 5/8" drywall both sides.
B: Typical sprinkler head location
C: Hot works area, 1/2" cement
board floor.