30A-032 (31) 320 RIVERSIDE DR BP-2019-1389
GIS#: COMMONWEALTH OF MASSACHUSETTS
MW BImk:30A-032 CITY OF NORTHAMPTON
Lot-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildino DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: REPAIR DECK FLOORING BUILDING PERMIT
Permit# BP-2019-1389
Project# JS-2019-002231
Est.Cost:$3500.00
Fee $65.00 PERMISSION IS HEREBY GRANTED TO.
Const.Class: Contractor: License:
Use Group: RICHARD T WEST 086947
Lm Size(sa.R.), OWner: CUMMINGS ROBERT
Zoning: SI(108)IWP(38V Applicant: RICHARD T WEST
AT: 320 RIVERSIDE DR
Applicant Address: Phone: Insurance:
10 BARSTOW LN (413) 584-8528 SOLE PROPRIETOR
HADLEYMA01035 ISSUED ON.61612019 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR 4X10 DECK
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:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 61620190:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File q BP-2019-1389
APPLICANT/CONTACT PERSON RICHARD T WEST
ADDRESS/PHONE 10 BARSTOW LN HADLEY (413)584-8528
PROPERTY LOCATION 320 RIVERSIDE DR
MAP 30A PARCEL 032 000 ZONE SI(108VWP(38U
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid .06
Building Permit Filled out
Fee Paid
TvoeofConstruction: REPAIR4XIODECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildine Plans Included:
Owner/Statement or License 086947
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKENON 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
Demolition Delay
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.
Version l.7 Commercial Building Permit May 15, 2000
Department use only
City of Northampton Status of Permit:
Building Department Curb CuuDriveway,Permit
212 Main Street Sevier/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 PIOVSit
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHAN E T R OCCUPANCY 4F,04 DEMOLISH ANY BUILDING
OTHER THAN A ONE O TW FAMILY DWELLING
JUN - 3 201
SECTION i-SITE INFORMATION
1.1 PIOoartr Address: co pletwdbyofflm
- NORTHPMPTON.MA01090
SQOtea``:11 d1R 74 pt 0 Unit
Z �Or^�.f1CA. t MO t«.f Z Zone Overlay District
...._...... _-_.....-... Etrrt at District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
o�E2"T C"&k" -Nq% �i O�ou 120c'1
Name(Pnm) Current Mailing Address�:}-T 'e 1 1
Signature Telephone
2.2 Authorize nt:
Name(Pont) Current Mailing Address.
Signature Telephone
SECTION 3.ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by perrit applicant
1. Building j 35w (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) l-fcS Uv
5. Fire Protection
6. Total=0 -2+3+4+5) n�� Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
GCw19
Building CodilitasionarlAnspector of Buildings Date
Versimi Commercial Building Permit May 15,2000
SECTION a.CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition Rei Additions ❑ Accessory Building[I
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Enter a brief description here.
Of Proposed Work: / / / /
��p tires / _X� .C�� . O'Y6-1�t'«/Z•ti C/jF��m.o
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
,USE GROUP Check as applicable) CONSTRUCTION TYPE
A Assembly13A;1 '❑ - _ A-2 ❑ A3 ❑ 1A 1:1
Aa ❑. 'A-5 1B ❑
B Business 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 13 ❑ 38
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R3 ❑ 5A0
S Storage 13S-1 ❑ S-2 1:15B ❑
U Utility ❑ Si
M Mixed Use ❑ Specify
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group: ...._.
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
3m 3,e
4in
4r,
Total Area(st) Total Proposed New Constmction(sq
Total Height(h)
Total Height it
7.Webr Supply(M.G.L.c.40,$54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public Private ❑ Zone Outside Flood Zone❑ MunicipalK On site disposal system❑
Vcmionl.7 Commercial Building Permit May 15,2000
B. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
Thu robe filled e M
B„ilding ne Dcpim,w
Lot Sia
Frontage --_ ---_. -- —
Setbacks Front -— --
Rear
Building Height
Bldg.Square Footage '7
Open Space Footage
(Id w mivue 6118 a pv 1
)
#ofparldng spaces
Fill:
vo &Laurpnl
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW ® YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued
C. Do any signs exist on the property? YES ® NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,excavation,or filling)over 1 acre or is it part of a common plan
that vdll disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9.PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 730 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Registration Number
Address
Expiration Dale
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Tekphore Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Dale
9.3 General Contractor
-/)10X,l(l / /ys�s71— Not Applicable [I
Company Name
/?114-4
4/"/–
Responsible
Responsible In Change of Construction
/O tea ✓ .�n c , / c��t /ylr�®/off
Adtl�ress/Jj. //�. c
Si nature � Tebphone
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes Q No
SECTION 11 -OWNER AUTHORIZATION-TO BECOMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, t � _ (� /v/r/%/7�/i%/ as Owner of the subject property
hereby authorize _..yG�LAI� � Y/�-%� to
act on my behalf, In all matters relative to work authorized by this building permit application.
Sgnalureo Owner Dale
as Owner/Author¢ed
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penahties�of p rlury. _..
Print Name
_/ _—
Signature of Owner/Agent J Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
/ �-
Name ofLicense Holdar'. �y/6/rN/1_',/ ...� �� 65 -00(G/ /Y—
License Number
/0 -���� �4 e / / C4/, IV,a
Atltlres Z Empidlfioni
!3
Signature Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(8))
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 O
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined
by MGL c 111, S 150A.
Address of the work: 3aa /.ice. S/i�P -,
The debris will be transported by: y�c�.�� /�drif
The debris will be received by: !/ � 11,
Building permit number: �7 /
Name of Permit Applicant .
Date Signature of Permit Applicant
The Commonweafth of Massachusetts
Department of IndustrialAccidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.goP/dia
Ulkorkers'Compenstation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business OrgmizatioNlndivldua0:
Address:
City/State/Zip: Phone M
Are you an empoyert Check,me appropriate hos: Type of project(required):
LE]l am a employer with emNoysss(full andNm pan-time).' 7. ❑New construction
2.nt lemasolepmprietorarpmmmhipandhavemempmyeeswo&mg formem 8. ❑Remodeling
any mpomty.[No worker'comp.mummotce retained]
1F I am o homeowner doing all work myself(No wodxrs'comp.urswancerequa rd.l' 9. ❑Demolition
4.❑I mo a homcowver and will be hours contranons to condtot all won on my pcoperry. I will 10❑Building addition
oe amt A conttamoo either haus workers'eompematimi ..orare tole 11.❑Electrical repairs or additions
pmpneron with m employee. 12.[]Plumbing repairs or additions
5,[3 1 oma general emartwtor and 1 have hoed the tub-coormoom listed on theaaachcd athirst. 13.❑Roof repairs
nksas subtio arwu s have enmloy«s and have worker'comp.mossamer.:
h.❑we area em Borman and to mins.have a tecixd their right ofexemgion per MOL c. 14.❑Other
152,§114),and we have tw employees.Mo utaumnce slurred.]
'Any applicant that checks box#1 must also fill out the section below showutg their workers contpemetion policy Nf tion.
,Homeowners who submit this attidavit indieming they me,doing all work and then her outside contractors most submit a new affidavit urheaung such.
:Cmu eavers that check due Not must attached an wi fitiunal sheet slowing the name of the sub-contractors and some whether or not those entities have
employees. If the subcummetun have empiuvm,they most mvide dwir workers compwhev number.
lam an employer that is providing workers'compensadon insurance far my employers. Below is rhe polity and job she
information.
Insurance Company Name:
Policy#or Self-ins.Lic.If: 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,p25A 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.
/do hereby certify un erthep ns autdpenalfiesalpperjury that the informationprovided above istrueand correct
Sienature�7 ���/'V Date: 1,1411
Plume ii' r,r2 7 r
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):
L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Peron: Phone#:
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 ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustce 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 shat l not because of such employment be deemed to be an employer."
MGL chapter 152,k25C(6)also states that"every state or local licensing agency shag 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)nates"Neither the commonwealth our 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)models),addresses)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. Alan be sure to sign and date the affidavit The affidavit should
be resumed to the city or town the the application for the pemdt 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
the 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 the has been officially stamped or marked by the city or town may be provided to the
applicant as proof the a valid affidavit is on file for future permits or licenses. A new affidavit mug 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
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel.#617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia