Permit applicationThe Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code (780 CMR)
Building Permit Application for any Building other than a One- or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: ____________ Date Applied: ______________ Building Official: _______________________
SECTION 1: LOCATION (Please indicate Block # and Lot # for locations for which a street address is not available)
______________________ ____________________ _________ __________________________________ ________ ________
No. and Street City /Town Zip Code Name of Building (if applicable) Map and Parcel
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 Alteration Addition Demolition (Please fill out and submit Appendix 1)
Change of Use Change of Occupancy Other Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes No
Is an Independent Structural Engineering Peer Review required? Yes No
Brief Description of Proposed Work:__________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
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)
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 Nightclub A-3 A-4 A-5 B: Business E: Educational
F: Factory F-1 F2 H: High Hazard H-1 H-2 H-3 H-4 H-5
I: Institutional I-1 I-2 I-3 I-4 M: Mercantile R: Residential R-1 R-2 R-3 R-4
S: Storage S-1 S-2 U: Utility Special Use and please describe below:
Special Use:
SECTION 6: CONSTRUCTION TYPE (Check as applicable)
IA IB IIA IIB IIIA IIIB IV VA VB
SECTION 7: SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply:
Public
Private
Flood Zone Information:
Check if outside Flood Zone
or indentify Zone:
Sewage Disposal:
Indicate municipal
or on site system
Trench Permit:
A trench will not be
required or trench
permit is enclosed
Debris Removal:
Licensed Disposal Site
or specify:
MA Historic Commission Review Process
Is their review completed?
Yes No
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: _________ Use Group(s): __________ Type of Construction: ________ Occupant Load per Floor: ______________
Does the building contain an Sprinkler System?: _________ Special Stipulations: ___________________________________________
Is your project within 100 feet of any wetland? Yes No
If yes, you must contact the Conservation Commission.
86 Masonic St Northampton 01060 Northampton Vision Specialists
8
✔
Renovate interior of building. Millwork, furniture, partitions, cosmetic finishes.
Business No change
FLR 1= 3103 SF FLR 2= 2652 SF no change no change
5755 24 FT no change no change
✔
✔
8 BIIB31
No
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
__________________________ ______________________________ ____________________________________________ ___________
Name (Print) No. and Street City/Town Zip
Property Owner Contact Information:
_______________________________ _____________________ _____________________ _____________________________
Signature Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
______________________________ __________________________________ ___________________ ______ _____________
Name Street Address City/Town State Zip
to 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 2)
(If building is less than 35,000 cu. ft. of enclosed space and/or not under Construction Control then check here and skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
______________________________ ___________________ _________________________
Name (Registrant) Telephone No. E-mail address
______________________________ ______________________________ ______ _________
Street Address City/Town State Zip
_____________________
Registration Number
_______________ _______________
Discipline Expiration Date
10.2 General Contractor
__________________________________________________________________________________________________________________
Company Name
_________________________________________ _________________________________ __________________________________
Name of Person Responsible for Construction Signature License No. and Type if Applicable
______________________________________________ __________________________________ ______ _____________
Street Address City/Town State Zip
_________________________ ___________________________ ________________________________________________
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 No
SECTION 12: CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost (from Item 6) = $_________________
Building Permit Fee = Total Construction Cost x ____ (Insert here
appropriate municipal factor) = $________.
Note: Minimum fee = $________ (contact municipality)
Enclose check payable to __________________________________
(contact municipality) and write check number here ______________
1. Building $
2. Electrical $
3. Plumbing $
4. Mechanical (HVAC) $
5. Mechanical (Other) $
6. Total Cost $
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.
______________________________________________________ ____________________________ _________________ _________
Please print and sign name Title Telephone No. Date
______________________________________________ __________________________________ ______ _____________
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: ____________________________________ _____________
Name Date
Theresa J. Ruggiero 86 Masonic St Northampton 01075
Theresa J. Ruggiero (413) 586-5002 eyetjr@hotmail.com
Raymond R Houle Construction 5 Miller ST Ludlow MA 01056
John Landry 413 587 3050 John@route9designbuild.com
104 Elm St Northampton MA 01060
30257
Architectural 08/31/2018
Raymond R Houle Construction
Ryan Pelletier CS-109244
5 Miller ST Ludlow MA 01056
413 547 2500 ryanp@rayhoule.com
71,747.00 .007
Not under this contract
19,200.00
Not under this contract
Not under this contract
90,947.00
90,947.00
Ryan Pelletier Project Manager 413 547 2500 01/18/2108
5 Miller ST Ludlow MA 01056
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location (Please indicate Map # and Lot # for locations for which a street address is not
available)
__________________________ ___________________________ ____________ ____________
Property Owner No. and Street Map # Lot #
For the above described property the following action was taken:
Water Shut Off? Yes No Provider notified, Release obtained? Yes No
Gas Shut Off? Yes No Provider notified, Release obtained? Yes No
Electricity Shut Off? Yes No Provider notified, Release obtained? Yes No
___________________ Yes No Provider notified, Release obtained? Yes No
___________________ Yes No Provider notified, Release obtained? Yes No
___________________ Yes No Provider notified, Release obtained? Yes No
Others (if applicable)
86 Masonic STTheresa J Ruggiero
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark “x” where applicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm (may require repeaters)
6 HVAC
7 Electrical
8 Plumbing (include local connections)
9 Gas (Natural, Propane, Medical or other)
10 Surveyed Site Plan (Utilities, Wetland, etc.)
11 Specifications
12 Structural Peer Review
13 Structural Tests & Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investigation
16 Energy Conservation Report
17 Architectural Access Review (521 CMR)
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other (Specify)
21 Other (Specify)
22 Other (Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein. Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction. Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
______________________________ ____-_____-___________ _________________________
Name (Registrant) Telephone No. e-mail address
______________________________ ______________________________ ______ _________
Street Address City/Town State Zip
_____________________
Registration Number
___________ _______________
Discipline Expiration Date
______________________________ ____-_____-___________ _________________________
Name (Registrant) Telephone No. e-mail address
______________________________ ______________________________ ______ _________
Street Address City/Town State Zip
_____________________
Registration Number
___________ _______________
Discipline Expiration Date
______________________________ ____-_____-___________ _________________________
Name (Registrant) Telephone No. e-mail address
______________________________ ______________________________ ______ _________
Street Address City/Town State Zip
_____________________
Registration Number
___________ _______________
Discipline Expiration Date
413 587 3050 John@route9designbuild.com 30257John Landry
Architectural104 Elm St
08/31/2018 01060NorthamptonMA
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 sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) 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) and under “Job Site Address” the applicant should write “all locations in ______(city or
town).” 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 Department’s address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/diaRevised 02-23-15
South Hadley
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers’ Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):______________________________________________________
Address:__________________________________________________________________________
City/State/Zip:_____________________________ Phone #:________________________________
*Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information.†Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.‡Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees, they must provide 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:____________________________________________________________________________
Policy # or Self-ins. Lic. #:__________________________________________ Expiration Date:____________________
Job Site Address: City/State/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 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 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 the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone #:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: ___________________________________ Permit/License #_________________________________
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other ______________________________
Contact Person:_________________________________________ Phone #:_________________________________
Type of project (required):
7. New construction
8. Remodeling
9. Demolition
10 Building addition
11. Electrical repairs or additions
12. Plumbing repairs or additions
13. Roof repairs
14. Other____________________
1. I am a employer with _________employees (full and/or part-time).*
2. I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers’ comp. insurance required.]
3. I am a homeowner doing all work myself. [No workers’ comp. insurance required.] †
4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers’ compensation insurance or are sole
proprietors with no employees.
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers’ comp. insurance.‡
6. We are a corporation and its officers have exercised their right of exemption per MGL c.
152, §1(4), and we have no employees. [No workers’ comp. insurance required.]
Are you an employer? Check the appropriate box:
Raymond R Houle Construction
5 Miller St
Ludlow MA 01056 413 547 2500
✔30
✔
AIM Mutual Insurance Company
WMZ-800-8005579-2017A 12/31/2018
86 Masonic St
04/09/2018
Northampton MA01060
413 547 2500