22D-063 (3) 63 FLORENCE RD BP-2022-0106
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 22D-063 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:demolition BUILDING PERMIT
Permit# BP-2022-0106
Project# JS-2022-000187
Est.Cost: $10000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: CLAUDIO GARRIDO 89458
Lot Size(sq. ft.): 10236.60 Owner: SUMMER DEY
Zoning: URA(100)/WSP(100)/ Applicant: CLAUDIO GARRIDO
AT: 63 FLORENCE RD
Applicant Address: Phone: Insurance:
140 NASH HILL RD (413) 268-9052
HAYDENVILLEMA01039 ISSUED ON:7/28/20210:00:00
TO PERFORM THE FOLLOWING WORK:INTERIOR DEMO
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:
Driveway Final:
Final: Final:
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. I , I
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 7/28/2021 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
CThe Commonwealth of Massachus s . '
W
Board of Building Regulations and S :ndar•:. FOR
Massachusetts State Building Code 80 R �U�o '4 IPALITY
Building Permit Application To Construct,Repair, ' .o37t��. Demoltsd7 R• sed 'r 2011
One-or Two-Family Dwelling 9Ttiq4<o,
This Section For Official Use Only e' '04,,/
Building Permit Number: )a ,) y 100 Date Applied: 0 c).,
' i + 4, I i al
Building Official(Print Name) I Signature I Dat
SECTION 1: SITE INFORMATION
1.1 Pr Address: 1.2 Assesors�ap& Parcel Numbers
Fo Cry n- b Z2OG
1.la Is this an accepted street?yes X 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 I?. Private❑ Zone: _ Outside Flood Zone?
Check if yes': MunicipalA On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Pty S u M fry Xca rt, /fit 14- o 1 b�-
Name(Print) City,State,ZIP
tit 3'akyt o,,► -CI. 339-36?-016 3 of ei s v VIIWO &5"eta( l.(D Vti.
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) 0 Addition 0
Demolition J Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed W k2: i/7 y,(F i JIE p 4- .
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost' (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: $ /
Suppression) �'J
off Check No.fl3 Check Amou
6.Total Project Cost: $ L 0 • oc .) 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICESU( `l-��'
5.1 Construction Supervisor License(CSL) 5-d 0 q/
ZxtG"�D License Number Exiiiratioithate
Name of CSL Holder
t (l0 l`� 4 List CSL Type(see below) l�
No.and Street (1, Type Description
/v J Ie Unrestricted(Buildings up to 35,000 Cu.ft.)
� 1 l�L ���/z�
R Restricted 1&2 Family Dwelling
City/Town State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
q �`L SF Solid Fuel Burning Appliances
C(( 2,(cr
_ 66 C�' �t�d �GYi® I Insulation
Tel�h ���one Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) V
4g-
61 e� �i{ /ib HIC d (5�,��r o3 �1'
Registration Number E piration Date
HIC Company Name or HIc Registrant Name
No.and StreetGC-ARteL-40 7-6 �� � Cd
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 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
GLALd PI0
to act on my behalf,in all matters relative to work au orized by this building permit application.
QB7 $UM NI L- p7,// 1 7/ /biz!
Print Owner's Name(Electronic Signature) D e
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pa' and penalties of perjury that all of the information
contained in this application is true and accurate to the t of knowledge and understanding.iA10(ri.b.0 C377(.. c0.
CPrMOwner's or Authori d Agent's Name(Ele tr c gnature) Date
NOTES:
I. 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"
The Commonwealth of Massachusetts
=1Evm. Department of Industrial Accidents
Tir.kinkla' I Congress Street, Suite 100
, —:, =
Boston, MA02114-2017
www.mass.goWdia
.....11
II orkers'Compensation Insurance Affidavit: Builders(-ontractorsfElectricianstPlumbers.
'it) BE FILED IN ITH THE PERMITTING AUTDORITI.
Applicant Information Please Print Legibly
Name (Bus3nessiOrganizatiory Individual): (---.-,24)47
..., ,
Address: if yo ge-5/4 pii4, 44
City/State/Zip: 1444 Abr ./fi 1 ZZ,6.-.. 1,64_ Phone 14:61 3)1(r-T- 6%
,
Are you an employer?Cacti the appropriate bac Type of project(required):
in Jam a employer with employees(full airal'or part-timer' 7. 0 New construction
2.7ka:n a sore propnetua or parmership and have no employees working for me in 8. 0 Remodeling
y capacity.[No workers'comp.insurance required.]
9. 0 Demolition
30.1 am a homeowner doing all work myself[No works-Ts`comp.lIthuntaux required.]
10 0 Building addition
4.0 I am a homeowner and will he hiring oantraotors to conduct all work un my p/tipl'a!,_ 1 will
ensure that all contractors either!lase workers'compensation insurance or an:sole 110 Electrical repairs or additions
proprietms with no employees
12.0 Plumbing repairs or additions
.50 I am a genc-ral contractor and I liaise hired the sub-euntnicturs listed on the attached sheet
These sub-contracturs horse employees and have workers'comp.in.surance.: 13.0 Roof repairs
0 6.0 We are a corporation and its officers have exercised their ne tek 14. Otherwt of exerirption per iL c.
15.1.§Itil.and we base nu employees.[Nu workers comp.insurance required.]
'Any applicant that checks box 41 mum also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit dus atTidasit indicating they are doing all work and then hire outside contractors must submit a now affulas it indicating such.
:Contractors that cheek this box must attached an additional sheet showing the name of the sub,contractors and state w holler or not those entities have
trinployers. If the sub-contractors has,:employees.they must pros isle their is ,..mrip 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: -
Policy#or Self-ins.Lic.#: Expiration Date: _
Job Site Address: City/StateZip: _
Attach a copy of the workers' compensation policy declaration page(showing the policy number and I.s p i 1..1 t ion date).
Failure to secure coverage as required under MGL 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 OffiLv of Investigations of the DIA for insurance
coverage verification.
--- - -11••••••••111K
I do hereby certify under the 'es of perforl Mut the infortmaton preivided above is true and correct.
•
'
Signature: )
1 L lc: 6 (.6 —1-01.2 I
Phone 4: 10/Jig-s- 3-C?0,
Official use only. Do not write in this area,to be completed by city or town official
City or Town: PermitlLicense#
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
il. Other
1
Contact Person: Phone#:
City of Northampton
Dram; ., ... ri
Massachusetts ���4' .,..,:c,
go t
DEPARTMENT OF BUILDING INSPECTIONS y
212 Main Street • Municipal Building v �a
4 S_
•.
-* , ' Northampton, MA 01060 .rye ''
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: � JA // �((Z _
The debris will be transported by:
Name of Hauler: )b 6/it/I'
Signature of Applicant: Date: �� �� i