14 LASELL BUILIDING PERMIT APPCity of Northampton
.' Massachusetts 1
f:f c
N; s
i. DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS, ROOFS, RENOVATIONS, ROOF MOUNTED SOLAR, ETC.
I. Building Permit Application signed by legal owner and filled out
by owner or authorized agent.
2.One set of plans and specifications of proposed work (Digital and hard copy).
3. Construction Debris Affidavit filled out and signed by applicant.
4. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance.
6. Energy Conservation Compliance Certificate (new / replacement windows).
7. Home owner's License Exemption Form (if applicable).
8. Note any Special Permit requirements (if applicable).
9. Energy Code — all new construction (Gut/Rehab) requires a HERS Rater Affidavit
10. Please provide the appropriate fee in the form of a check made payable to: The City of
Northampton.
ga The Commonwealth of Massachusetts
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two -Family Dwelling
FOR
MUNIUiPALiTY
USE
Revised Mar 2011
This Section For Official Use Only
Building Permit Number:
Date Applied:
Building Official (Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address:
1 4 LTk9LL E , QN�ftiRuta A.1
1.2 Assessors Map & Parcel Numbers
¢� 8
Map Number Parcel umber
'Arl
1. la Is this an accepted street? yes_ no
1.3 Zoning Information:
Zoning District Propose Use
1.4 Property Dimensions:
Lot Area (sq ft) Frontage (ft)
1.5 Building Setbacks (ft)
Front Yard
Side Yards
Rear Yard
Required
Provided
11Zo
Required
Provided
Required
Provided
to'
is' /C
i&V / q '
zo
5 '
1.6 Water Supply: (M.G.L c. 40, §54)
Public i$ Private ❑
1.7 Flood Zone Information:
Zone: _ Outside Flood Zone?
Check if yes❑
1.8 SewageDisposal System:
Municipal p/On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner' of Record:
AA t r�lof Re /r r= a R A E /.�>-� In t� M4 e) c orb
Nam (Prim) City, State, ZIP r
Ab JAe.E3aZ e e4,6~
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply)
New Construction ❑
Existing Building
I Owner -Occupied ❑
1 Repairs(s) )I
Alteration(s)
Addition ❑
Demolition )it
Accessory Bldg. ❑
1 Number of Units 2
1 Other ❑ Specify:
Brief Description of Proposed Work': 6,?rwLC4tVa - f�G(�t I Tlotil t�
I A �Y7 fist �t $TRMcJr
—rn
C-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:
Labor and Materials)
Official Use Only
1. Building
$ $
1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
❑ Total Project Cost' (Item 6) x multiplies x
2. Other Fees: $
List:
2. Electrical
$
3. Plumbing
$
4. Mechanical (HVAC)
$
5. Mechanical (Fire
Suppression)
$
Total All Fees: $
Check No. Check Amount:
0 paid in Full 0 Outstanding Balance Due:
6. Total Project Cost:
p
$ z 0 �'
9,CoM
SECTION 5: CONSTRUCTION SERVICES
5.111 Construction Supervisor License (CSL)
C5-615-22 3 II b71t/ d6,
4 6MI- -�— to A-L QE7./
License Number Expiration Date
i 1
Name of CSL Holder
111"14 S r oG /26X & d y
list CSL Type (see below) lJ
Type
Description
No. and Street
U
Unrestricted (Buildingsu to 35,000 cu. ft.
o 5 I' zw /nAF e) !6 3a
R
Restricted 1&2 FamilyDwelling
City/Town, State, ZIP
M
Masonry
RC
Roofing Covering
WS
Window and Siding
SF
Solid Fuel Burning Appliances
y�3 [Q93"0�3 PC1 �d Wr,� 6 f Mcu , il�n
1
I Insulation
Telephone Email address
D
I Demolition
5.2 Registered Home Improvement Contractor (HIC)
Ae ;� Q rl'�i pg- 63
& g r 7
Ea
HIC Registration Number Expiration Date
ped14to (2 h&- Mai 1. (,rn,
HIC Company Name or HIC Registrant Name
a M14-1ni sT
/nO:5 -7 MA- 00131 q(3-r,9� 0�39
Email address
1 /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 ..........K No ........... 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BU WDINIG PERMIT
&b-) II
I, as Owner of the subject property, hereby authorize It N �1
to act on my behalf, in all matters relative to k audr ' ed by this building permit application.
�s ar � '— Z
AmLdiAwks
Name (Electronic , gnaturo ate
SECTION 7h: OvelVERt OR AUTHORIZED AGENT DECLARATION
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.
Pnnt Owner's or Authorized Agent's Name (Electronic Signature) ate
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 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.aov/dps
2. Wben 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" maybe substituted for "Total Project Cost"
File # 21
APPLICANT/CONTACT PERSON:GEORGE, MICHAEL G.
P.O. BOX 102 GOSHEN, MA 01032
PROPERTY LOCATION 14 LASELL AVE
MAP:LOT 38B-038-001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Building Permit Filled out
Fee Paid' $30.00
Type of Construction: ADD NEW BULKHEAD FOR BASEMENT ACCESS, ADD 2 ROOF CANOPY
EXTENSIONS
New Construction
Non Structural Renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
Driveway Grade %
THE FOLLOWING ACTION HAS BEEN TARN ON THIS APPLICATION BASED ON INFORMATION
PRESENTED:
Z'Approved Additional permits required (see below) For all prajects that need additional revsews ffl0PX4ffiffl
as checked below, please see the Office of Planning & Sustainability Permit page or scan here CT
PLANNING BOARD PERMIT REQUIRED UNDER:§I..
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 ' ermit DPW Storm Water Management
Demolition Delay
////Z _ 3- 2 2- 2bZ
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.
t
File No. .21
}
j MAR 19 2024
__ ....�........ AQWNG PERMIT'APPLICATION 0
PDF or
the Building Inspector at the Building
check and money order (payable to t
1. Name of Applicant: M,12��)
Add
2. Owner of Property:
Address: I k—IejI
3. Status of Applicant: Owner �„'J `_\Con
4. Job Location: 3 � t AA-C -< { 1
print and hand -write all information and return to
Department (212 Main St.) with the $30 filing fee by
City of Northampton) or credit card (in person only).
Email,G�� �" �a (9 0) Par�'.^O-'-e • C1
�7'/A o �lephone: t%77=T�y
+ retepnone:
Purchaser Lessee Other (explain)
U
Parcel Id: Zoning Map# Parcel# District(s):
In Elm Str t bistrict In Ce�tra! Business District
�,
e,
(TO BE FILLED IN BY THE BUILDING - PARTMENT)
5. Existing Use of Structure/Property: ,
6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary):
r4[a Id �,� - S
S
1
7. Attached Plans: Sketch Ln D Site Plan Engineered/Surveyed Plans El
8. Has a Special Permit/Variance/Finding ever been issued fqY/on ,tke site?.
NO F4 DONT KNOW E1_YES IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO El DONT KNOW E1_ YES
IF YES; eAter Ronk Dann andi r f1......r. eRt #
9.Does the site contain a brook, body of water or wetlands?- NO . 54 DONT KNOW E]— YES 0—
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ❑ Obtained El—, date issued:
(Form Continues On Other Side)
6/7/2023
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/�RT:IAPPTOr1� HA "13iia. • wr
Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building Re ulations and Standards
Cons= rvisor
w .y
CS-075223 _ E�#pires: 11/2712024
ROBERT TV�j4LD
10
2 MAIN STIPD. 80 O
GOSHEN MA;1
1OI,LV 3i1:
3
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs a Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE: InAiv dual
Registration Expiration
162073 08/03/2024
ROBERT WALDEN -_
ROBERT T. WALDEN
2 MAIN ST.n'CG.1�
GOSHEN, MA 01032 -
Undersecretary
Constriction Supervisor, f.,C� -- --
Unrestricted - Buildings of any use qFo -ch contain
less than 35,000 cubic feet (991 cu*, ,V.m,, Orsl pf enclosed
space.
Failure to possess a current edition of thp.Massachusetts
State Building Code is cause for revocation of this license.
'Oor irdarrnation about dais license
Cap (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
1
Not valid without signature
City of Northampton
Massachusetts
F: 1=1 `s
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
s67y .3'7�1,
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:
The debris will be transported by:
Name of Hauler: %&U/z& -'
Signature of Applicant:
Date: �- ��
The Commonwealth of Massachusetts
_ Department of Industrial Accidents
l
I Congress Street, Suite 100
Boston, MA 02114-2017
www.ntass.govldia
Workers' Compensation Insurance Affidavit: BuilderslContractorslElectriciatts/Plumbers.
TO BE FILED N'rl'H THE PERMI"I'fl\C, AUTHORITY.
Name (Husin=.,organimtioniindi idualy
C.
Address: 3d&8e3Hz& -1_rQ4/L 42&1T A 66K /Oa
City/State/Zip: `P (_!Z0 /039 Phone #:
Arc You an emplayre Chock the appropriate Irox:
1.®1 um a eanploya with _ __cnhpluytcx (full and'ur pan -time)
2f:] 1 am a sole proprietor or pamtcrtship and have no employov working for na: in
may capacity. [Nu wVAcri emnp. iwsumnm required]
30 1 an, a leumww ner doing all wuA myxlf. [No wmkcni curr{r. inwraue nguiral.]'
401 am a humanwaer and will be hiring otnwaetms to rneaduct all work on my paolx�W. I will
enure that all cvntractua cithcr lave wrmkeri compntartion imuratim or ate sole
pnrpruum with no ernplw•ea.
so 1 am a gencrul cunaactur and I have hired the snb-cunuucsom listed on the auac$cd sheet.
There sub-contraam% have nnpluyecs and have wvrkem' mmp. insurance.
F.❑ We are a cvrpuratiun amt its officers have exercised their right of exenyrtim per MGL c"
I S2. § Ilil, and we have no emi,luys:es. [Nu wurkm' camp. inxmance reyuind.]
Type of project (required):
7. ❑ New construction
H. ® Remodeling
9. ❑ Demolition
10 ❑ Building addition
11.0 Electrical repairs or additions
12-0 Plumbing repairs or additions
131:] Roof repairs
14.❑Other
'Any appliemn that ch%x:6 box al most also fill out da iectphn bduw showing their wurken' cm rpeosatiun pulley information"
a Ilonwownen who subina dux affidavit indicating dwy'am daring a11work and then hue outride cmana:T rs moot submit a new atYalavit ind icming such.
IC'unutwo rs dint check this box mail attached an additional Am show ins th name of dw rub-emmracwrs and mute %hether or nut those runic., have
empluyecs. If the subcuntructors have cmpluyme . dray mersl provide their workeei cornp. policy number.
1 ism an emplotrr that is providing workers' compensation insurance for my employees. Below is the policy and Job site
information.
Insurance Company Name: 60
Policy # or Self -ins. Lic. fi: 6FC4Pa? J L� - G Y— n00 Y05-00 Expiration Date:
Job Site Address:Iy b E SELL .%-V,',- City/statezip: N/%&-I �/Jnrt//yt�la/OG�
Attach a copy of the w'orker's' 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 fine up to S1.500.00
and+orone-year impriso t, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.Of1 a
day against the violator. A coAv of s tement tray be forwarded to the Office of investigations of the DIA for insurance
coveraee verification.
1 do hereby
a a/P1-9-3
that the information provided above�is trite
Official use only. Do not write in this area. to be completed by city or town official
Citv or Town:
PermittLicense N
Z
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
G.Other
Contact Person: Phone