17C-245 (9) i
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85-87 NORTH MAIN ST 3P-2021-0033
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map.Block:17C-245 CITY OF NORTHAMPTON
'Lot:-004 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building ' DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL C.142A)
Category:replacement windows/siding BUILDING PERMIT
Permit# BP-2021-0033 j
Project# JS-2021-000048 .
Est.Cost: $30000.00
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Fee: $210.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: 'Contractor: License:
Use Group: JAMES MAILLOUX ELECTRIC ' 081694
Lot Size(sq. A.): 15681.60 Owner: MAILLOUX JAMES
Zoninjz:URB(100)/ Applicant. JAMES MAILLOUX ELECTRIC
:AT. 85-87 NORTH MAIN ST
Applicant Address: Phone: Insurance:.
221 PINE ST SUITE 160 (413) 585-1592 Liability
FLORENCEMA01062 , ISSUED ON.7/10/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACEMENT WINDOWS AND AND NEW
SIDING
POST THIS CARD.SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P:W. Building Inspector
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Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
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Final: Final:
Roiugh Frame:
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Gas: Fire Department. Fireplace/Chimney:
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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. I
Certificate of Occupancy Signature:
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FeeType: Date Paid: Amount:
Building 7/10/2020 0:00:00 $210:00
41 587-1240 Fax: 413 58711272
� 212 Main Street,Phone( 3) ( )
Louis Hasbrouck—Building Commissioner.
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JUL - g 2020 j
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The Commonwealth of Massachusetts
°E yu . iNc�NSFECTtONS Office of Public Safety and Inspections
y TON.MA 01060 Massachusetts State Building Code(780 CMR)
_Building ermit Application for any Building other than a One or Two=Family Dwelling
(This Section For Official Use Only)
Building Permit Number. '21 Date Applied: Building Official:
SECTION 1:LOCATION
Al � , ?2Eu6K 9062 __X41�`/
No.and Street City/Town Zip Code Name of Building(if applicable)
Assessors Map# Block#and/or Lot #
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❑ 1 Alteration ❑ 1 Addition❑ I Demolition ❑ (Please fill out and submit Appendix 2)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: S/Ai,4& �V)n-VvW-Ir
Are building plans and/or construction documents being supplied as part of this permit appIlication? Yes ❑ No __"
Is an Independent Structural Engineering Peer eview�required? Yes ❑ No w
Brief Description of Proposed Work: /h iS4 Rep/aG'no Iyi r Juw'' ling�riv L
�h/ Vj,1V1, 10 NG- (f^(!j llr
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SECTION 3:COMPLETE THIS SECTION IF EMSTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 3,4) ❑
Existing Use Group(s): Proposed Use Grow. p(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)S Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SEC'T'ION 5:USE GROUP(Check as applicable) j
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑j E: Educational ❑
F. Facto F-1 13 F2❑ H: High Hazard H-1❑ H-2❑ H-3-❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ 14❑ M: Mercantile❑ 1 R. Residential I R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-20 U. Utility❑ Special Use❑and please describe below:
Special Use Description: j
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA B IRB 13 IV ❑ VA ❑ VB 13A
SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on-each item)
Water Supply Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
A trench will not be Licensed Disposal Site 13Public❑ Check if outside Flood Zone[3Indicate municipal 13
Private 11 or indentify Zone: or on site system❑ required❑ r trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: 1%,Lk Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? ! Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction:
Does the building contain an Sprinkler System?: Special Stipulations:
Design Occupant Load per Floor and Assembly space:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner y 4
Name(Print) No.and Street City/Town Zip
Property Owner Contact information:
0I_Afevz_ fl -T6-3 -46,50 'Y13 -f95__?! ly,��1/��.X���G <c�•� 6r") ,
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes:
Name Street Address City/Town State zip
to apply for and act on the proper owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1)
If abuilding is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 13.
Otherwise provide construction control forms(see section 107 in the code)as r uired.
10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals)
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
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102 General Contractor
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Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State zip
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Telephone No.(business) Tele hone 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 0 No M
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ Building Permit Fee=Total Construction Insert here
2.Electrical $ appropriate municipal factor =$ 2,10
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ - (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here .Z SV
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 tot est of y owledge and understanding.
Please print and sign meTitle Telephone o. Date
�t s S L_L� klo rs nc� v� <<► �7 c�,,.,��1
Street Address City/Town State Zip Email Address
Municipal Inspector to fill out this section upon application approval: 1 363�
Name Date
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The City of Northampton
n � wilding Department
212 Main Street
Northampton,Massachusetts 01060
Phone(413) 587-1240
Fax (413) 587-1272
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CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVAT TON PROJECTS)
In accordance with the provisions of MGL c40, 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, sl 50A.
The debris will be disposed of in: �
Location of Facility V�
The debris will be transported by:
Name of Hauler
Signature of Applicant: Date: l G
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The Commonwealth of Massachusetts
V.—orkers'
Department ofIndustrial Accidents
I Congress Street, Suite 100
Boston,MA 02114-2017wwwmass.gov/dia
Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Alpylicant Information Please Print Legibly
Name (Business/Organization/Individual):James Mailloux Electric
Address.
221 Pine st. Suite 160
City/State/Zip:Florence, MA 01062 Phone#:413-585-1592
Are you an employer?Check the appropriate box: Type of project(required):
I.[D I am a employer with 2 employees(full and/or part-time)." 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 18. [J Remodeling
any capacity.[No workers'comp.insurance required.] y. Demolition
3.E]I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 0 Building addition
4.0 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 11.0✓ Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
50 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13Q Roof repairs
These sub-contractors have employees and have workers'comp,insurance.t
14.❑Other
6.0 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.]
.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.
tContraetors 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 jab site
information.
Insurance Company Name:NGM Ins.
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Policy#or Self-ins.Lic.#:
WCT0721Q Expiration Date:10/08/20
Job Site Address: ALL LOCATIONS 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 tine 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 un r pain n nalties of perjury that the information provided abov is tr a and correct
Signature: Date:
Phone#:413-585-159
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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:.. Commonwealth of Massachusetts
Division of Professional Licensure ,
Board of Building Regulations and Standards
C o n s�ttdMQ,"09,r v i s o r
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CS-081694 � LL E�jcpires 10116/2021
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JAMES G MAILLOUXti j kh j 'ri
276 SOUTHAMPTC1
WE AMP MA�� x7 ; tV
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Commissioner