13-015 (3) 504NORTH KING ST COMMONWEALTH OF MASSACHUSETTS BP-2021-1907
Map:Block:Lot: 13-015-001
Permit: Swimming Pool CITY OF NORTHAMPTON
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2021-1907 PERMISSION IS HEREBY GRANTED TO:
2021 INGROUND POOL
Project# REMOVAL Contractor: License:
Est. Cost: 3000 SHUMWAY SERVICES CSL105743
Const.Class: Exp.Date:01/14/2022
Use Group: Owner: PATEL SHWETA D&PRASHANT R CHRISTIAN
Lot Size (sq.ft.)
Zoning: RI/SR/WP Applicant: SHUMWAY SERVICES
Applicant Address Phone: Insurance:
PO BOX 522 (413)549-4658()
HADLEY, MA 01035
ISSUED ON:09/21/2021
TO PERFORM THE FOLLOWING WORK:
REMOVE INGROUND POOL AND CONCRETE SIDEWALK, FILL IN WITH STRUCTURAL FILL
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.
Signature:
el )ar • .).2 (Pi
fl
Fees Paid: $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
RECEIVED
SEP 1 7 2021
T e Commonwealt1� of Massachusetts
OFPT.i ff,lAgrS i 1A . ty and Inspections
NItR�us�ft48ttiC@SUilding Code(780 CMR)
'R Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number:W.202a-/ Date Applied: 0/174474 Building Official:
SECTION 1:LOCATION
Soo . N.ly V101 4' IVUAtA 2tfyl , PM-01 06 C) mom/ 14n /Yl dte-t
No.and Street ,J City/Town Zip Code Name of Buildihg(if applicable)
13 -0l6--Do j
Assessors Map# 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 0 Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2)
Change of Use 0 Change of Occupancy 0 Other 0 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No 0?"----
Is an Independent Structural Engineering Peer Review required? Yes 0 No
Brief Description of Proposed Work: 1 "" - -TA 4 ftt4A Z (tos
F;NIA
P GCOG6ek �� l I
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) 0
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business ❑ E: Educational 0
F: Factory F-1❑ F2 0 H: High Hazard H-1❑ H-2 0 H-3 0 H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2 0 R-3 0 R-4 0
S: Storage S-1 0 S-2❑ U: Utility 0 Special Use 0 and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA D IBD IL& 0 IIB ❑ MA CI IIIB ❑ IV CI VA CI VB 0
SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit Debris Removal:
A trench will not be Licensed Disposal Site❑
Public 0 Check if outside Flood Zone 0 Indicate municipal 0 required 0 or trench or specify:
Private 0 or indentify Zone: or on site system 0 permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed 0 Yes❑ or No 0 Yes 0 No 0
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:_
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
0........„
t.&))04 pf ti d . �4 t IV, k� i Si , �fJvr?, m H-D�DG v
Name(Print) No.and Stree City/Town Zip
Property Owner Contact Information
oc1/4)'i clan 1113 -S s-4- try 7 1-13_-q3 � z
z9 G liort'hlu -mat 1nte4/,
Title Telephone No.(business) Telephone No. (cell) e-rmail address er/Yti
If applicable,the property owner hereby authorizes:
5k``M'.* 5trl,iti, (\a ''c\k 5 A ----- � lc? ,-k- 00 3,-
N me Street Address City/Town State Zip
to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1)
If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0
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
10.2 General Contractor
5(4,,,,,...7 c,,r,;c..
........._
Company Name
f\tvA 11,,,Nh.w-A� CAL j f 7Lig
Nam of Person Responsible for nstruction License No. and Type if Applicable
AQ Otkier Sal' -1-1 a 211.t --'- Q tQ
Street Address City/Town State Zip
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Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'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 builAing permit.
Is a signed Affidavit submitted with this application? Yes 0 No 0 o n I'-C.
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical _ $ appropriate municipal factor)=$ .
3.Plumbing $
4.Mechanical (I VAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ 013— 1 aao (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
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.
`ft,\ ItionMiva • '13 cg7 ('
Please print andXame ,� Title Telephone No. Date
Street 1dess 5 City/Town State Zip Email Address
\--\Ot. k't 7 il-,--N (),k al, ,
Municipal Inspector to fill out this section upon application approval: / i/
City of Northampton
ofti-
zfr.P,0'' %,1` A Massachusetts + ''
twel DEPARTMENT OF BUILDING INSPECTIONS �'° M,
212 Main Street • Municipal Building 0�.: 1b�
Northampton, MA 01060 ssyy Y}‘~t
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, 554, 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:
44,i,OA di --)-0 -16,I)--e-t 5,vt. eVa,t,,/
li e Ra,i,./ rf \on
Location of Facility:
The debris will be transported by:
,cttay. C ;\111/ky) (-)-(\`--- -h&A/
Name of Hauler:
Signature of Applicant: Date: 1���
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston, MA 02114-2017
WW1V.tnass.gov/dia
du kers' Compensation Insurance AMdtvit:Builders/Contractors/Electricians,'Plumber'
TO HE FILED Willi TitE PERMITTING AtIBORITV.
Applicant Information Please Print Leei bl$
Name(liusniess.Orlianirancnilndividualt:___
Address: rt a
CityStateiZip: Phone#:
•
Are you ieimpleyer?C'beck rite apprapriate not: Type of project(required):
E3 I am leryer with crap:loves(full anitan pan-tune}.' 7. 0 New construction
ant a ataiir:FrOpratriitr rraitstetrattip and haiie an etnrkry3t88 V33/kiele, 110r roe ti3 g. Remodeling
any i-tapacity.[No%/mktg.,'ciai1p.invininee required.)
9. EKernolition
am a horricownter doing all viurir reelli[No wveliirit'comp.iitairanet required.)"
Ofl Building addition
Jam a Isurnecioner and 14itl114,taint ivearaciors to eoriduct all work on my peoperty. I will
ensiutre dui siiouknit'IM.F431 61}111.1113VC wort Darript.11811134.111.trailtritrit.8. 318.St.7131 I I f] Electrical repairs or additions
propnetora ith cmployees.
12.0 Plumbing repairs or additions
.1 ant merid contractor£311/1 J have hired the aub-cortnactorsLisiud un[he attached sheet.
1 3.0 Roof repairs
1 •ac aub-cuntracturs lune anpkryecs tad have workers' irunaratace.';
IS. We ate a evaporation and ffwrs 313 oe have exiveiathl their rishi ailexemption per Pi4GL it. 14.0other
and we have nu natployees.[No werIcas'comp.insurance reqursed.)
*Any applicant tut checks box I 1111384 ataU fill out the wrerioat below showing their..atit.4.18'competuation polio information.
t IltetAtc 12118 whu matrunt/1133 affidavit indicating they are doing all.ii,ork and them lusc outside emir-actors most submit a new affidavit andiosbag inch.
tCorietaccora that thacti ihr,bok.tret3S1 mit23.43/Titi an additional sheet show lag,the name of the itib-cuttraztor,and state whether LIT runt thine entities have
tertinloyers.. If[hit aub-contracrors have emplo,..cce.they trawl provide their work ay.comp.policy number
am an employer that is providing workers'compensation insurance far my employees_ Below is the policy and job sire
information.
Insurance Company Name:
Policy ft or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/State.lip:
Attach a copy of the waiters'compensation policy declaration page(thawing 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
andior one-year imprisonment,as well as civil penalties in the foim of a STOP WORK ORDER and a tine 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 ins penalties of per e Infarneanan provided above is and earrvet.
St=nature! Date.. 0/Aj
Philne
Official use only. Do not itrite in this area,to be completed by city or tovrt
City or Town: Permit/License ll
issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
—