32A-101 (13) BP-2023-1337
12-16 MARKET ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
32A-101-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2023-1337 PERMISSION IS HEREBY GRANTED TO:
Project# roof 2023 Contractor: License:
Est.Cost: 60000 FORREST DEVINE 095779U
Const.Class: Exp.Date:07/07/2024
Use Group: Owner: TRUST MARKETSQUARE CONDOMINIUM
Lot Size (sq.ft.)
Zoning: CB Applicant: DEVINE CONSTRUCTION INC
Applicant Address Phone: Insurance:
129 LOVERS LANE (413)478-9691 2001W89165
GRANVILLE, MA 01034
ISSUED ON: 09/26/2023
TO PERFORM THE FOLLOWING WORK:
STRIP AND REROOF
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
FA 1 ,V1per
Fees Paid: $420.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
7\ c\r-,
•
The Commonwealth of Massa • :ettsck,
Office of Public Safety and lnspecti O ��
Massachusetts State Building Code(780 CMIC-:, ��.
Building Permit Application for any Building other than a One-b'• • Familpwe ' 5)
• a
(This Section For Official Use Only) o 9chi
S•
Building Permit NumberA.3' (3.37 Date Applied: Building Official: �A�
SECTION 1:LOCATION b�oox
/Z t' /6 t'l 4 sr- Street W o r44w. -?t•e nr
No.and Street City T , ( Zip Code Name of Building(' :. . icable)
Assessors Map# Block#and/or Lot #
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair lir Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2)
Change of Use ❑ Change of Occupancy 0 Other 0 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No'
Is an Independent Structural Engineering Peer Review required? Yes 0 No(
Brief Description of Proposed Work: Ze.'tiNc a Ego c5if 14..k Qe0 -1$ Lod l+4t tit•.i.
/VLt.v N'3v11}a-caNI N!.- Ecij)Nt 1200.F
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 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business I!it) E: Educational 0
F: Factory F-1❑ F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0
I: Institutional I-1 0 I-2❑ 1-3❑ I-4❑ M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4❑
S: Storage S-1❑ S-2 0 U: Utility 0 Special Use 0 and please describe below:
Special Use Description.
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA CI IB 0 IIA 0 IIB 0 IIIA 0 IIIB am, IV 0 VA 0 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:
Public Check if outside Flood Zone Cit Indicate municipaW' A trench will not be Licensed Disposal Site 0
required,llaOr trench or specify:110.4 (—
Private 0 or indentify Zone: or on site system 0 permit is enclosed 0 TITU c C
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review ocess:
Not Applicable' Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed 0 Yes 0 or No��j Yes 0 No)120
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
6 e ,r12 Ze r c4cA— t eef N 6 r u��-��: !�J DI C26 U
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information
(9 w ►.e.f 1113-586-723 I eh 3 ,r?-76 I( MC'g.tN V) evA1
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes:
fce5�'�ev l2oj (Olier 5 A•+c (c nx/tvj 1 e ' 4- ' (O'3 5(
Name 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 C.
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
_-
0 IQ
Company Name To tre - de t!►.til 0?
.I 77
cr
Name of Person Responsible for Construction License No. and Type if Applicable
12? tover5 ic( 6retAm frl'r 010 341
Street Address City/Town State Zip
- - *5-4'1 x l6?( Ae 7E GALA-i i,COV‘k_____
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 building permit.
Is a signed Affidavit submitted with this application? Yes 0 No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ 6g Coo Building Permit Fee=Total Construction Cost (Insert here
2.Electrical $ appropriate municipal factor)=$ .
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ 60, O U O (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 m o ge and understanding.
g; �— 1'7e� Lmix� 014,4.ti- y 3-.emu'?CV 2,3
Please print and sign name Title Telephone No. Date
(Z�' (pv•-r5 �Lc I"aIL v. _AL& Dt o3y c3rre5or-a(e.vt-.e T Q 9 At,q.t Levis,
Street Address City/Town State Zip Email Address /
♦C
3/Municipal Inspector to fill out this section upon application approval: � -' ► ' ��
Name Da
City of Northampton
y ,;y Massachusetts ,,0 'e
wi it
DEPARTMENT OF BUILDING INSPECTIONS Sti
212 Main Street • Municipal Building O% a�
t, Northampton, MA 01060 f: -,• 0'o
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: / t & i54-- 1-rvG
The debris will be transported by:
Name of Hauler: 4.(4- �r5(1- 4-1\vGt<
Signature of Applicant: Date: Z572_3
The Commonwealth of Massachusetts
e I Department of Industrial Accidents
1 Congress Street,Suite 100
Boston, MA 02114-2017
•
wwwmass.gov/din
Workers'('ompensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
I'<)BE FILED WITH THE PERMITTING AUTHORITY.
Applicant information /� Please Print Leeibis
(l Name(Business•' rganrzation individuall �LU�..� (�(J'7t S- oAJ--
Address. A'Z ci 10,e f T If ...._ . _
City/State/Zip: 6‘cetni„4 tic M,y Qt oy Phone#: art 3 4/7 g-- 76?
Are y.rt as employer?Cheek the appropriate Sox: Type of project(required):
am a employer with employees(full and''ar part•timel.• 7. 0 New construction
20 I am a sole proprietor or partnership and have no employees working for me in 8. U Remodeling
any capacity.[No worker'comp.insurance required.]
9. ❑Demolition
ICJ I am a homeowner doing all work myself.[No workers'comp-insurance required.]'
1 U❑Building addition
i.a 1 am a dwmeownee and will he hiring evnuaelurs to conduct all work on my property. I will
ensure that all contractors either have workers`coniperosation insurance or are sole 110 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
50 1 am a general contractor and I have hired the sob-eunuacturs listed on the attached them
These soh-contractors hake employees and have workers'comp.insurance. i 3. f repairs
t+.E3 We are a corporation and its officers have exercised their nght of excmptwn per M(iL c.
14.Q Other
132_§ilak and we have no employees.[No workers'comp.insurance required.)
•Any applicant that checks lax#1 must also fill out the section below showing their workers'compensation policy infonnatioa.
t Homeowners who submit this affidavit indicating they are ding all work and then hire outside contractors mint submmt a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-comraclors and state whether or not those entities have
employees. If the sub-contractors have Lmplolees.they must pros ide 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: \P/Lk VickfA-i / —
Policy#or Self-ins.Lic.#: ZOO( I) $ 1 6 S Expiration Date: Ili of!ZY
Job Site Address: 4 Z— (6 M d44- 5 f re_e City;StateZip: iv 41,9-
Attack 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 S 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 S250.00 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 unde • d penalties of perjury that the information provided above is true and correct
Si ature: Date 71Z5/7--3
Phone#: y(3 7 e
Official use only. Do not write in this area.to be completed by city or town official
( its or -1 0+'.n: Permitiiicense b
I�suin;.1uNutrits (circle one):
I. Board of Health 2. Building Department 3.( it�,Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: Phone#:
CONSTRUCTION CONTROL WAIVER
From. u/r Cc7Y1Sr rtie-Y"i 01\3
Vz.g 1oc-Je r5 icz c
C)rq/Lvi (fP k ( a Di/.
To:
Jonathan Flagg
Building Commissioner
City of Northampton
212 Main Street
Northampton, MA 01060
The Massachusetts Building Code,section 107.1 allows for an exclusion from requirements for
construction control in certain situations.In accordance with code section 104.10,I request that you
grant a modification to waive the requirement for construction control of the project at
I a-16 r cZek- -r��-
because the work is of a minor nature,will not affect structural elements,health,accessibility,life or fire
safety,and will be done in accordance with the prescriptive requirements of the code.
Thank you for your consideration.
Respectfully,