35-082 (9) i
1255 BURTS PIT RD BP-2021-0036
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:35-082 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:Bathreno BUILDING PERMIT
Permit# BP-2021-0036
Project# JS-2021-000051
Est.Cost: $9000.00
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Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License: j
Use Group ROBERT GOULD 90940
Lot Size(sq.ft.): 17859.60 Owner: MCGRATH DANIEL . I
Zoning- Applicant: ROBERT GOULD
AT 1255 BURTS PIT RD
Applicant Address: Phone: Insurance:
62 LYMAN ST (413) 531-1391
GRANBYMA01033 ISSUED ON.711012020 0:00:00
TO PERFORM THE FOLLOWING WORK.-RENO BATHROOM, REPLACE WINDOWS
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 Fire place/Chimney:
,1
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.
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Certificate of Occupancy signature:
FeeType: Date Paid: Amount:
Building 7/10/2020 0:00:00 $65.00 ,
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
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J Department use only
City of Northa pto - of emm
Building Dep rt me t ~` k Cut/ tiveway Permit
j; 212 Main tree AA 10 ?o Se,' `r/Se ticAvallabihty
Room 00 0 W ter/W I1;Availability
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Northampton T o Se of'Structural Plans
phone 413-587-1240 Fa_z 4F� �spE otiSi Pians
01030 ther pecify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE-OR,DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
* Thissect�on to,be completed by office
1.1 Property Address: .T
S t,Ma r Lot :,lJnit
Zone xOverlay Distract
Elm'St�tStrIC1<}` a {, x :CB Drstr�ct
SECTION'2. PROPERTY OWNERSHIP/AUTHORIZE.D AGENT
2.1 Owner of Record:
10 i
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Name(Print) Current Mailing Address: i
t4 1� - -.45w7 -!q /_
/fes Telep o e��—
Signature
-2.2 Authorized Agent:
pace mA ,
Current Mailing A dress:
ie 33'
41 S� -
Si a ure Telephone
SECTION 3:ESTIMATED"CONSTRl1CTION COSTS'
Item Estimated Cost(Dollars)to be I Qffcial,Use Only
completed by permit applicant
1. Building (a)Budding Permit Fee,
2. Electrical (b)Estimated Total Cosfiof
Construction from''6
3. Plumbing Budding Permit Fee
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4. Mechanical(HVAC)
5. Fire Protection / O
14
6. Total=(1 +2+3+4+5) VtJ✓ Chick Number (d
This Section For;Of ditil.Use:On1
._Building.Permit`;Numbe� r„: .;,Issued..
;Signature
Buildm Commissioner/Ins ector of.Buddin 's f
9 p 9 Date,,
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
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SECTION.5 DESCRIPTION OFPROPOSED WORK(check.all applicable)
1
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors D � F
AccessoryBldg. Demolition
g. ❑ New Signs 10] Decks j(=j Siding[fes] Other[ML
0
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Brief Description of Proposed<--
Work: IL9M ��2 � ! r c�crrv��— f .��u�S LIQ. +�� �rze
Alteration of existing bedroom Yes tL No Adding new bedroom Yes /L No
Attached Narrative Renovating unfinished basement Yes _se-,_ `No
Plans Attached Roll -Sheet
sa.If.NeI+r.Nogse ard,orFaddition to.:existing,hotlslna `co'mulete•the followlrig:
a. Use of building:One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
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h. Type of construction
L Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No
1. Septic Tank City Sewer Private well City water Supply
SECTION7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERSAGENT OR CONl'RACTOR APPLIES FOR;BUILDING HERMIT f
as Owner-of the subject
property
hereby authorize
to act on my behalf,in a I matters relative to work authorized by this building!permit application.
Signature of Owner Date
1, �.C ,as Owner/Authorized
Agent her-65j declare that the statements and informatio the foregoing application are true and accurate,to the best of my knowledge
and belief.
Si ed under the pains and penalties of perjury.
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Print
e) eal
Signature o wner/Agent ate
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not
Applicable
❑
Name of License Holder:-7( ( ? Ci&'?!i (-I
License Number
dress Expiration Date
Sign ture Telephone
P9: Re isteredHome;lm rove'ment:Contractor Not Applicable ❑
Company Name (Registration Number
Address Expiration Date
Telephone
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SECTION 10 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M
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...... ❑
G
City of Northampton
Massachusetts
DEPARTMENT OF BUXLDING INSPECTIONS P�3.s
212 Main Street •Municipal Building vy,
Northampton, MA 01060
Debris Disposal Affidavit
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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 1111, S 150A.
The debris from construction work being performed at:
(Please print house number and street name)
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Is to be disposed of at:
SD
(Plea(Pleade print-nameand location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
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(Company Name and Address)
Sign ture of Permit"icant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
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The Commonwealth of Massachusetts
d Department of Industrial Accidents
a 1 Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORIT i.
Applicant Information Please Print Leldbl
Name (Busin
e
ss/Organization/Individual):
Address: �
City/State/Zip: /PY & _ Phone#: / S'S
Are you an employer?Check the appropriate box:
Type of project(required):
1.Q I am a employer with employees(full and/or part-time).* 7. New Construction
2-0,_
- I_am a sole proprietor or partnership and have no employees working for me in 8: Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.[J I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 Q Building addition
4.p 1 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 11.Q Electrical repairs or additions -
proprietors with no employees.
12.Q Plumbing repairs or additions
5. 1 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.t 13.❑Roof repairs
6.F1 We are a corporation and its officers have exercised their right of exemption per MGL C. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t 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. r
I do heree a pa is idnd penalties of perjury that the information provided',above is true and correct.
Si afore: Date:
Phone#: V-/ <3l— 2qf
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#:
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