225 State St demo permit1n I
File#BP-2020-0735 O w
APPLICANT/CONTACT PERSON DICKY MATOS
ADDRESS/PHONE 3 GLEN ST HOLYOKE (413)530-5335
PROPERTY LOCATION 225 STATE ST
MAP 24D PARCEL 145 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION.CHECKLIST
E OSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction:_DEMO AND REMOVAL OF SH
New Construction
Non Structural interior renovations
Addition to Existin
Accessory Structure
Building Plans Included:
Owner/Statement or License 105917
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
L..,Demolition Delaly
n4n zlv--, i I11
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
0
Department use only
City of Norirham C
CI /C tatus f Permit:
Building Depart C V
urb CLit/Driveway Permit
212 Male{Stle tE ewer/3epticAvailability
Room j100 r 3019 Water ell Availability
Northampton,;MA 10 o S sof Structural Plans
Phone 413-587-1240 Fax L413-587-197 oUsit Plans
DEPT OF GUII.DING INSPFCTI NS
NORTHAMPTON.".". ` `Other SIP
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMIL DWE`LLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
i..) SJ &'t lllt JI—i—ee.1—
Map qf) Lot Unit
611 &0 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name
Current Mailing Address:
rY yJ_ 2 7/G
Telephone
gnature
2.2 Authorized Agent:
Name(Print)
Current Mailing Address:
Signature
Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to k e Official Use Onlycompleteq_bLpermit applica it
1. Building il. JC.' a) Building Permit Fee
2. Electrical
b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) 30
5. Fire Protection
6. Total = (1 +2 +3 +4 + 5) Check Number
This Section For Official Use Onl
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings
Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to he filled in by
13uilding Department
Lot Size
s
Frontage
Setbacks Front r-----
Side L: R: L: R: y
Rear
l3uilding Height r r-• -1
I3ldg. Square Footage
Open Space Footage
Lot area minus bldg&paved
parking)
e
ot'llarking Spaces 7
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NOQ DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW n YES Q
IF YES: enter Book Page` and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO
IF YES, describe size, type and location: 1
E. Will the construction activity disturb (clearing, grading, gxcavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YESQ NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition Replacement Windows Alteration(s) Roofing
Or Doors
Accessory Bldg. Demolition New Signs [0] Decks [E3 Siding [p] Other[p]
Brief De iption of Propposed
Work: d)" San a_-J e eyaJAC / f//S l.r
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.If WW hoyise and or eddit on to exist—Ina housing.complete the fottowina:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating?Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject
property
hereby aut ize
to act o y behalf, in all 7mars relative to work authorized by this building permit application.
Z •/Z•
Of caner Date
I, as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ,
rye
Not AA pplliicable 0
Name of License Holder: ,)l L Y /'!R C J /v
l/
License Number
Aklye e r,)2130 ba,,)=e
Addr Expiratio Date
5 -533 S
Signature Telep one
9.Realstered;Man*ImplinVOMMt,Contractor. Not Applicable
020'7
Company Name Registration Number,
en S• la Deo'
Address Expirati Date
Telephone
SECTION 10-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....... x No......
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
performing work on such homes, a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note.If the homeowner has contracted with a corporation or LLC, that entity must he registered
Type of Work: Est.Cost: -/7 54 d o
Address of Work: V-- M,,Yom,d.,9S•^, ln,4 O/dy
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law(explain):
Job under$1,000.00
Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
1.2 ,13/, 9 aay lya)O s 16& a617
Datc Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
T 212 Main Street •Municipal Building
Northampton, MA 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
Please print house number and street name)
Is to be disposed of at:
ca— -ella 7014, /ylufn`Sl f1;61 d p/
Please print name and Ibcation of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
Company Name and Address)
Signature of mit Ap icant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
Ls
The Commonwealth of Massachusetts
Department of Industrial Accidents
UV_1 Congress Street,Suite 100
Boston,MA 02114-2017
wwwmass.gov/dia
orkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lead)IN
Name (Business/Organization/Individual): ID/
Address:---.. cs/ -
City/State/Zip: z d la Phone #:
rr ;'S33S
Are you an employer?Check the appropriate box:
L f project(required):
1.O I am a employer with T employees(full and/or part-time).* New construction
2.D I am a sole proprietor or partnership and have no employees working for me in 8. Remodelinganycapacity.[No workers'comp.insurance required.]
3.01 am a homeowner doingall work myself t y• Demolitiony [No workers'comp.insurance required.]
4.I am a homeowner and will be hiring contractors to conduct all work on my property.e I will 10 0 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.[:]Electrical repairs or additions
proprietors with no employees.
12.Q Plumbing repairs or additions5.I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.: 13.Roof repairs
6.We are a corporation and its officers have exercised their right of exemption per MGL c. 14.QOther
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
Any applicant that checks box til 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 siteinformation.
Insurance Company Name:1'1 C--(>
Policy#or Self-ins.Lic.#: 146 1 x\ ks& Expiration Date:
Job Site Address:o cS Ot' ari.0 f1,rn,!jj City/State/Zip:
Attach a copy of the workers'compensation policy dee aration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL 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 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 certtf er the pains and ena s o perjury that the information provided above is true rind correct.
Signature:Date: /
Phone#:3S 3 3
Official use only. Do not write in this area,to be completed by city or town official,
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 25. Plumbing Inspector6.Other
Contact Person: Phone#:
A`,oRo® CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YYYY)
02/22/2019
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME: Heather Fleury
CHI Insurance Agency, Inc. PHONE (413)536-2685 ac No): (413)532-0889
416 Main Street E-MAIL
hfleu g yADDRESS: ry Q@chla enc .com
INSURERS AFFORDING COVERAGE NAIC#
Holyoke MA 01040 INSURER A: ACE AMERICAN INSURANCE CO 22667
INSURED 4
INSURER B:
Dicky Matos dba DMR Roofing INSURER C:
3 Glen Street
INSURER D:
INSURER E:
Holyoke MA 01040 INSURER F:
COVERAGES CERTIFICATE NUMBER:REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDL SUER TPOLICY EFF POLICY EXPLTYPEOFINSURANCEIN-RD WVD POLICY NUMBER MMIDD MMIDD LIMITS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
CLAIMS-MADE a OCCUR AAA To RENTED
PREMISES Ea occurrence $
MED EXP(Any one person) $
PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY E PRO-JECT LOC PRODUCTS-COMP/OP AGG $
OTHER:
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO
Ea accident
OWNED SCHEDULED
BODILY INJURY(Per person) $
AUTOS ONLY AUTOS BODILY INJURY(Per accident) $
HIRED NON-OWNED PROPERTY DAMAGEAUTOSONLYAUTOSONLYPeraccident
UMBRELLA LAB
I OCCUR EACH OCCURRENCE
EXCESS UAB CLAIMS-MADE AGGREGATE
DED RETENTION$
WORKERS COMPENSATION
X I
SPER
TATUTE
ERH
AND EMPLOYERS'LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L.EACH ACCIDENT 100,000AOFFICER/MEMBEREXCLUDED? NIA UB1K836443 02/12/2019 02/12/2020MandatoryinNH)
and
E.L.DISEASE-EA EMPLOYE $ 100,000Ifyes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule may be attached if more space Is required)
Certificate issued as evidence of insurance.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103)The ACORD name and logo are registered marks of ACORD
Commonwealth of Massachusetts
AM
Division of.Professtonal Licensure
Board of Building Regulations and Standards
Construction,Supervisitir
CS_05g' Expires. 03/30/2020
DICKY MATOS
3 GLEN STREET
HOLYOKE MA 01040
Ccmmissloner
Office of Consumer Affairs and Business Regulation
One Ashburto-i Place - Suite 1301
Boston, Massachusetts 02108
Home Improvement Contractor R6gistration
Type: Individual
DICKY MATOS Registration: 166207
3 GLEN ST. Expiration: 05/06/2020
HOLYOKE, MA 01040
SCA 1 0 20M-05/17 Update Address and Return Card.
nriraavrnPrr lli n^r'r,;arr•urrlf
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Recistration valid for individual use onlyTYPE:Individual before the expiration date. If found return to:Registration Expiration Offi:e of Consumer Affairs and Business Regulation16620705/06/2020 One Ashburton Place-Suite 1301
DICKY MATOS Boston,MA 02108
DICKY MATOS 0 Com.
3 GLEN ST.C
HOLYOKE,MA 01040
Undersecretary Not valid without signature
3 Glen St
Holyoke, Ma 01040
413-530-5335 0
CS105917
HIC-166207 Date Dec 10, 2019dkiRILSOWN., CT- 0639705 P.O.
Terms
Bill To
Forge Property Management Ship Via
225 State Street
Ship DateNorthampton, MA 01060
cameroncarswell @yahoo.com
Qty Description Unit Ext
1 Demolition 4,750.00 4,750.00
Demolition of Barn located at:
225 State Street
Northampton, MA 01060
Total(1) 4,750.00
y Si natu 7gnatu
Ute`\- ---- -
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