38B-038 BP-2024-0045
14 LASELL AVE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
38B-038-001 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-2024-0045 PERMISSION IS HEREBY GRANTED TO:
Project# 2024 RENO Contractor: License:
Est. Cost: 15000 ROBERT WALDEN CS-075223
Const.Class: Exp.Date: 11/27/2024
Use Group: Owner: G. GEORGE, MICHAEL
Lot Size (sq.ft.)
Zoning: URB Applicant: ROBERT WALDEN
Applicant Address Phone: Insurance:
PO BOX 604 (413)695-0539
GOSHEN, MA 01032
ISSUED ON: 01/18/2024
TO PERFORM THE FOLLOWING WORK:
INTERIOR DEMO IN PREP FOR RENOVATION
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:
Cas: 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:
+ � x 1 •
Fees Paid: $98.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
<-t
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
MUNICIPALITY
Massachusetts State Building Code, 780 CMR USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 20/1
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: jQ XZ4'00 - Date Applied:
AEUIf-.3 105s /7'/ /-17-7tZ/
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
/4 -lcv Lh-56-.=-c. ,a-vL; .313 U 3 - — 001
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
UC 6 aFA1ULLf P sIDesiroC 3C1(9b SCE ft1U
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
10 t 16 >:T /5 >;-r 1 H.3'G,5 r Fr
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Ig Private 0 Zone: Outside Flood Zone?
— Municipal la On site disposal system 0
Check ifyegil
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
yn t(4 7 'L 7)4 6- NO1 1 f Pi,)e✓ mil— Q /Ola
Name(Print) City,State,ZIP
No.and Street Telephone � E ail Ad ss
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work': /,V7?vio 2 / 7YI PG/T/o.✓ /n P`36-PA 6 Fn r2
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 $ 0 Standard City/Town Application Fee
0 Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Suppression) $ Total All Fees: $
Check No./3_5g Check Amount: q Cash Amount:
6.Total Project Cost: $
j QQU , 66 0 Paid in Full 0 Outstanding Balance Due:
A
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) Cs -. Q 75ES 2 3 /(/2'7/y
A/3e2 0,f-L Qi-Ai License Number Expiration Date
Name of CSL Holder i t
a / if tj s r PO eo X Coo �f List CSL Type(see below) lJ
No.and Street / �l Type Description
A �a 3c� U Unrestricted(Buildings up to 35,000 cu.ft.)
/Y1
CF C)CJ 1✓ R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
03•-V 5 053g ned/aw ne bd.rn a i/r Cs m I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) U r7 3 0 g/D 3/, y
g ()/9) 1"" t fr£LC4 HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
h1,41U si ned /awnca horfrna,/. Corn
No.and Street Email address
,'V!A' 0/03a-
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 ❑
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
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By enterini my ame ow,I hereby attest under the pains and penalties of perjury that all of the information
contained in thi ..pli. 'on s true and accurate to the best of my knowledge and understanding.
///3-/ay
Print Own or Authorized Ag-• ' Name(Electronic Signature) Date
NOTES:
I. r •wner 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"
1
The Commonwealth of Massachusetts
Department of Industrial Accidents
(4,\ _.,,_, Office of Investigations
Lafayette City Center
2 Avenue de Lafayette, Boston,MA 02111-1750
" / wwwmass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:George Propane Inc.
Address:3 Berkshire Trail West, PO Box 102
City/State/Zip:Goshen, MA 01032-0102 Phone #:413-268-8360
Are you an employer? Check the appropriate box: Business Type(required):
1. ■❑ I am a employer with 32 employees (full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]** 11.0 Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.* Other Propane marketer/plumb/heatinc
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#I.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:Traveler's Indemnity Co
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lic. #UB8K528363-22-14-G Expiration Date:05/01/2024
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under §25A of MGL c. 152 can lead to the imposition of criminal penalties of 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 vi tor. Be advised that a copy of this statement may be forwarded to the Office of Investigations of
the DIA for insurance coverag verific
I do hereby certify, under the ai s and pknalti of perjury that the information provided above is true and correct.
Signature: r Date:05/01/2023
�
413-268-8360 2
Phone#: // ----
Official use only. not write in this area,to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority(check one):
1.0Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.0 Licensing Board
50 Selectmen's Office 6.['Other
Contact Person: Phone#:
www.mass.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the members
or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Lafayette City Center
2 Avenue de Lafayette,
Boston, MA 02111-1750
Tel. (857) 321-7406 or 1-877-MASSAFE
Fax (617) 727-7749
Form Revised 7/2019 www.mass.gov/dia
City of Northampton
�y�:I1 ljrJl V,
Massachusetts
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 IA 4 <''�
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: V141-1-'6:41/ 1QL- �CICL/N �3�/ e19-57M/'/YI�/14,
/�I0 27}� yl P�417}1 A- O /0 4
The debris will be transported by:
Name of Hauler: /nl /C 74t-L 6 & b2(o
Signature of Applicant: Date: ����/
r
111 Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building Reg lations and Standards
Const i IS145rvisor
CS-075223 -c I pires: 11/27/2024
ROBERT T V OLDEN
2 MAIN STlP.D.BO , t'
GOSHEN MA' 103 - ". 1
1
4bLI,Va>i a'
.Commissioner u- (2 ,'.
THE CCA/MONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE:Individual
Registration Expiration
162073 ;31C);++:"`?4
I
ROBERT WALDEN
ROBERT T.WALDEN
2 MAIN ST •
CG.i��r//adi
GOSHEN,MA 01032
Undersecretary
Construction Supervisor:r, -
Unrestricted-Buildings of any use gro,up,wttich contain
less than 35,000 cubic feet(991 cubic_meters);of enclosed
space.
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
•For information aboi t this license
Call(617)727-3200 or visit www.mass.gov/dpl
Registration valid for individual use only before the
expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
1000 Washington Street -Suite 710
Boston,MA 02118
Not valid without signature