23A-004 (10) File #BP-2023-0152
APPLICANT/CONTACT PERSON:DOUGLAS B THAYER DBA DOUGLAS THAYER WOODWORKING
P 0 BOX 60322 FLORENCE, MA 01062(413)530-4785
PROPERTY LOCATION 25 MEADOW ST
MAP:LOT 23A-004-001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
fi
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Building Permit Filled out
Fee Paid $65.00
Type of Construction: DEMO GARAGE
New Construction
Non Structural Renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
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
1( Demolition Delay
ertiatv.., ,..Xv1 C1/9-3 •
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.
A_\ ,.
The Commonwealth of Massachusetts
, * ! Board of Building Regulations and Standards FOR
-f,m Massachusetts State Building Code,780 CMR MUNICIPALITY
F co USE
i Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
co One-or Two-Family Dwelling
'v This Section For Official Use Only
Building Wrmit Number: 5Q.-2o23--0 152. Date Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property ddress: 1.2 Assessors Map& Parcel Numbers
of S pado- 0--- a-21 A aoet co St 1
1.1 a 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 Private CIZone: _ Outside Flood Zone?Check if yes❑ Municipal On site disposal system 0
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:3-4Ve S+aYt /�.2 5 / leaol ,- S
Name(Print) City,State,ZIP
Fh,tro Jk1A at o6a
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 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 8000- 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ 0. List:
5.Mechanical (Fire
Suppression) $ Total All Fees: $ (D5,`"
Check No. ipr. Check Amount:66% Cash Amount:
6. Total Project Cost: SO Paid in Full 0 Outstanding Balance Due:
ASBESTOS REMOVAL
All residential, commercial and institutional buildings are subject to Massachusetts Department of
Environmental Protection (MassDEP) asbestos regulations at 310 CMR 7.15. Therefore, owners
and/or operators (e.g. building owners, renovation and demolition contractors, plumbing and heating
contractors, flooring contractors, etc.) need to determine al asbestos containing materials (ACMs),
both friable and non-friable, that are present at the site, and whether or not those materials will be
impacted by the proposed work, prior to conducting any renovation or demolition activity.
Examples of commonly found ACMs include, but are not limited to, heating system insulation, floor
tile and vinyl sheet flooring, mastics, wallboard, joint compound, decorative plasters, window glazing,
asbestos containing siding and roofing materials and fireproofing materials.
Failure to identify and remove all ACMs prior to its being impacted by renovation or demolition
activities, can result in significant penalty exposure, and higher clean-up, decontamination, disposal
and monitoring costs.
A DOS certified asbestos consultant must be contracted to determine if asbestos is present and
whether removal/repair is necessary. If the building is a state owned facility, contact DCAM and DOS.
DOS provides a list of licensed asbestos abatement contractors and consultants. You may wish to
inquire if a contractor has any history of violations. Only DoS licensed and DOS certified asbestos
abatement contractors and consultants may be hired to perform asbestos related work in
Massachusetts.
Received by:
Print Name Title
Signature Date
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor}- _ License(CSL) S ' 070 C'
'Do ck [S I I1�`P,� License Number Expiratio D e
Name of CSL Hol r J
List CSL Type(see below)
6 0)( Go-y as
No.and Street Type Description
RO'S QAl l n U Unrestricted(Buildings up to 35,000 Cu.ft.)
City/Town,State,ZIP .11
! 1 R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registeredl Home Improvement Contractor(HIC) 79 Q SS 1d �k�a
tt lUS I h4 HIC Registration Number E piranon ate
HIC Compaq Name or HIC Registrant Name 1 nn
No.and Street V045 F 5 av lY �r1tQ.:,
Email gddress
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 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 VOtc lc S 7/1 Q et
to act on my behalf,in all matt elative to work authorized by thi?building permit aplication.
Prin er s Name lm
Electronic Si atur Date
(
SECTION 7b: OWNER'OR AUT• I RIZED AGENT DECLARATION
By entering my name below,I hereby attest under th; pains and penalties of perjury that all of the information
contained in this application is true and accurate . the best of my knowledge and understanding.
Print Owner'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 Improv ent Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under .G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Informatio on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is p ed,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 bathroo Number of half/baths
Type of heating sy em Number of decks/porches
Type of cooling stem Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
City of Northampton
zir
Massachusetts
{
+s * DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building �,%,
t^+-' Northampton, MA 01060 iA ,',
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: V a 1LA.._ �QC T---
v
The debris will be transported by:
Name of Hauler: a R9-6 Poci cli
___/5_45
Signature of Applicant: Date:
•
<1:\.illivirm,
The Commonwealth of Massachusetts
Department of Intlastrial Accidents
tA.„,. •
-.4.9 1 Congress Street,Suite 100
1.ZZ,:•''--W '-e'
--t-
1 Boston, MA 02114-2017
WWW.mass.govidia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO DE FILED WITH THE PER.S1117Dit;AUTHORITY.
A ,Resat Information P - le Print ._,
,
Name(BusincsVOrgarnzationAnctividuall„. 5 A i
Address: it
., 1 h c' f..1 .....
City/State/Zip:
Are yeti an cruployer?Cheek the appropriate bat: Type of project(requiredl.
1.41 1 am a employer wah employees(full and?or pars-time 1_* 7. 0 New constructi
al i am a sole proprietor or partnership and have Ito employms working for me in 8. 0 Remodeling
any capacity [No winters'curnp.ittilltlinlV required]
9. •1 , II `tn0i.itiOn
qjI am a liorneowInzr doing all work myself NO workiss"comet insuruni.^e required.]'
II 0 But ding additio
-CO I am a hurraxiwner and will be hmarg connas:nirs to conduct all wink un my reopen!, I will
ensure that all contractors either have workers"C4x1igx-1tiatron insurance or am sole i 1.0 Electrical *1' or tulrlitims
proprietors with no..,employees
12.0 Plumbing ri.Tra' • or additions
I..in a itene.-ral euntraelin and 1 bat e hired the nili-eunteresurs listed on the Annithed sheet
IlleNC Alb-cuntr2tctors have employees mil hav e winker's'camp.insurance.: l 1E]Root rtvatrs
6.0 We ant a corporation and its officers has c exereisiod their risk of exemption per 1,44GL c. 14.0 Oth
152.§1(.1).and we have no employees.[No workers'eclair.insurance regimes/1
Any applicant that checks but at must also fin out the section below showing their 14 oritts eonspentision policy infinnuateuet
l'llomeostriers who submit dus affidavit indicating they are doing all work and then hue outside contractors must submit a new affulia it mdi ,tins such.
:Conlr.iclura that check this box must attached an additional sheet showing the name of the sub-contractors and state Y'r briber in nut those an:es ltsv c
eniployees. li the../.ii*.-t!Ltilit'JintAT%6..1.,'emplt.v2,eiN..the must priv.ide their A ACES't...urap.policy number.
. _
I am an employer that is providing waders'compensation insurance for my employees. Below is the policy and job.site
information.
Insurance Company Name: t1 a va.kJ 5 Sajekte —
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: CityiState 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 punishable by a tine up to S1.500.00
andior one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S230.00 a
day against the violator. A copy of thp, ,tatement may be forwarded to the Office of Investigations of the DIA for insurance
co'erag,e verifiunion.
.. ..
I da hereby certify under the pains an .naltin of perjury that the itit;
trintition ironit/cif i it'.'iv true erne!correct.
I-L.:,
Si*nature:
Phone
Official use only. Do not n rite in this arra,to be completed by city or town official
CHI'or Town: Permit/License
Issuing Authority(circle one):
I. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
(.111listet Person: Phone#: 1
1
BUILDING DEPARTMENT
DEMOLITION PERMIT SIGN-OFF SHEET
Date: U
Address: ea 5 MEnso 4 S7 Building Use:
Owner: /1r- M &Tri Phone:
Owner's Address: as menDlinf sr-F/oience_.
No uf1/,-leS 'n
UTILITY CUT OFF *'tirs
(Signature of Authorized Representative of Utility Department required
As required by the Massachusetts State Building Code (780 CMR), a permit to demolish shall not
be issued until a release from the utilities is obtained, stating that their respective service
connections and appurtenant equipment have been removed or sealed and plugged in a
safe manner.
Eversource (Gas)
Signature Title
National Grid (Electric)
Signature Title 0112
DPW (Water) Kg-ifIN.&ioioki J Ni W
Signature Title `7,1 `Zy
DPW (Sewer) K.-6 It/�.. (-� I
Signature Titl Mt*
DPW (Storm water) SJ2-01/4/4-Aibli-U2
Signature Ti
DPW (Tree Warden) t . �a t d Rc- TAa Waldo`'
S' ure Title
DPW Director _
ig re Title
Historic Comm. Review
Signature Title
'i 1141.rr . - i -..