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2020
Mats - Imr,iNS
ty4amr o wealth of Massachusetts
ON Ana told' Regulations and Standards FOR
Massachusetts late Building Code,780 CMR NIMCIPALrFy
USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar gall
One-or 71vo-Fanily Dwelling
This ton For Official Use only
Build' Pemat Number: Da Applied:
6v1J 55 -5-76
Building Official(Prior Name) 'gnmm, Dab
SECTION 1:SITE INFORMATION
1.1 Proe rl Addfe�s: f 1.2 As so Map&Parcel Numbers
33 ri+ Jj—
I.la Is dris an accepted street?yes no Map umber Parcel Na
1.3 Zoning Information: 1.4 Property Dimensions:
Zaamg District Propoad Use Lot Area(sq ft) Frontage(ft)
1.5 Building Selbedcs(6)
Front Yard Side Yards Rem Yard
Required Provided Required 1 Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewagc Disposal System:
Public O Private O Zone: Outside Flood Zone? Municipal O On side disposal system ❑
Check ifyesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 OwnertotRe�rd:
Mn kcm rrra..l fN9 IF�`-nlyt ^4 b(o S3
Name(Prior) City,Stone,ZIP
47k .0Pfr^f SI- SfsB—E313
No.and Spat Telephone Emml Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building O Owner-Occupied 0 1 Repans(a) 13 1 Altemtimus) ❑ 1 Addition ❑
Demolition O Accessory Bldg.❑ Number of Units_ Oder ❑ Specify:
Brief Description of Proposed Work': -/'r' S red
SIMON 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs(La : 011ie§el USC Onlyba and Materials
1 Building $ 1. Building Permit Fee: $_Indicate how fee is determined:
2.Electrical $ O Standard Cityffom Application Fee
O Total Project Cost'(Item 6)x multiplier x
3.Plumbing S 2. Other Fes: S
4.Mechanical (RVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fas;-'4 �
Cheek No. Check Amami: � Amount_
6.Total Project Cost: $ �9 ,�' 0 Paid in Full 0 Omdam mg BelarMe Don:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) QQ F9S3
O -tO ] I
Dfi�Je LicenseNamber Expiration Date
l�mee ofCSL Holder
List CST Type(see below) hG
No'.tied SuIra't - TWe Description
50. Pre Ter PYI A- of , s D unmstictedBuildle u b35,000era.ft.
R Restricted 1&2 Fantib,D.1fint
Cityffow%State,ZIP M Masonry
RC Roofing Coveda
WS Windoweod Sidra
SF Solid Fuel Burning Appliances
374-a 2 o ORvC C,0FWe fM efy(t;LC./,eM I Insulation
Tel hone Email address D Demolitron
5./2�R^/e�gistered Home lmprovemLemtContnctoIr�(HIC) �$L�f� 2 �4�1a,7
y fy VC /n lrfT� 6r�frlfu/ fv"iMe U6 HIC Reparation Number Expintios Date
HIC CompanyName or HIC Registrem Nmue
No.and Strat Y`GL Email address
Cit frown,Slate,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFTWAVIT(hLG.L.c 152.$ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application Failure m provide
this affidavit will result in the denial of the Issucance of the building permit.
Signed Affidavit Attached? Yes.......... V No._........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorGz a4 L){ M/aYl
to act on,my behalf,in all matters relative to work authorized by this building permit application
Prim Owner's Name(Dectmmc Sigomum) Uste
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contamed m this application is hue and accwate to the best of my knowledge and understanding.
/1/R � 'e 471 NP/ �!/a /�oa6
Rim err s or Authorized Agent's Name(Electronic Signmme) Date
NOTES:
1. An Owner who obtains a building permit to do hissher own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will Ughaw access to the arbitration
program or guaranty fund under MG.L.c. 142A Other important information on the HIC Program can be found at
www.mass mfoes Information on the Construction Supervisor License can be fond at w my radg Scy/dos
2. When substantial weak is planned,provide the information below
Total Box area(sq.ft.) (including garage,finished basement/attics,decks or each)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number ofhathroaus Number of halUbaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. `Toast Project Square Footage"may be substituted for"Total Project Cost"
City of Northampton
Massachusetts
t C
;} D212B BNP OF BUILDING ZI ilf W }(ppp
.AF " 212 Idin Sthe Mv� 01l 9uiltllnq
NOltluvpfnn, !A 03060
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
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 MGLc 111, 5150A.
The debris will be disposed of in:Location of Facility: V v� �tir ��[ � �/ �¢r� rI- col AMcrk".,
The debris will be transported by:
Name of Hauler: ✓' `� ��T'�
Signature of Applicant: Date: `t [ '16 >_�
The Commonwealth of Massachuseas
Department of Industrial Accidents
I Congress Street,Suite 1O0
Boston,,NA 02114-2O17
low www.mass.gos/dia
-" Uwken'('ampensa lion insunnre AlOdas it:Builders/Coelndorx/RlerlrkiamlPlumhen.
10 Ilk FILED WITH 111F PERSIM ING.hlr1'11ORITF.
\s iicanl Infornmtiou Pin,,Print I.o•ibi,
Name(Bounniruri a anatioalmtvdudi: C. M 1 e r z L L G
Address: 3Y7 NGJbare &J-
City/Sttlte/Zip: 15a t4llc* "Il'' Phone,: .37y--C> J
an yin m onpryen fhwh the appmpWe hwa: Type of project(required).
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3�lam alw.mv.neJuina all xw4 ntpel(.pw.wkuitq.imam. .'arsil, 9 kerroinion
a❑lam a Form.x andrdl Fe ham,aw•xmn m onJmt dl.uk oo my pnwvty, I will 10[]Budding addition
mdsa,11,maowmeaMhrves-k--err evom maman.ewan-le I I C)Eleculeal robot,ur additions
poaret a.hhmeou'l—es, 12.[]Plumbing nryutn or Adm.,
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�nPlma�. ti flu wb.umrxt.,6n.nrylnrns.Wvv mint pn.•de tM1eir .tM..n'.umn.plue1nun6r.
I am an emplofer that is pravldiag workers'compeasanon imarance for my rmploym, Below Is the poliey and joo slum
information.
insurance Company Name: 2✓C L J. .a
Policy 4 of Self-ins.Lie.4: b L 2 3 1 F.`1 S. iG -1 e Expiation Date:
Job Site Address: ,77 y S46 4k -----City/State7jp: I-e-A A*
Attach a copy of the worhen'arom atloa policy declaration page(showing the policy number and expiration daft).
Failure m sectrm covemgc as required umkr MGL c. 152,$25A is a criminal violation punishable by.fade up to f 1,500.00
atld'or one-year impaisonmenk as well as civil penalties in the form ofa STOP WORK ORDER and a fine of up to 5250.00 a
day against the Noleaor.A copy of this sfalemrit stay be fir wardod to the Office of Imesugations of the DIA for insurance
race snnficmion.
I do herebf rerHfy undo,tar pains and penalties ofpoviany foal the Infwft"on""videdab~n true and,.,m'c
Sr>mmattae: � On.
Phone 4: 3 7 l/- o-7 S?ggri
Official use a fly. Do not wrier in this area to he romplrtrd br'riq•or lawn official
Cie or Ton n: PermiUEiceme 4
1%,uing.i ulhority(circle one):
I.Board M llnlib 2.Building Department d.CBy?own Clerk 4.Electrical lmlwwlor S.Piwnhiny ln,psttur
6.01her
('annul Perms: Phnnr t:
MOrP5 GMT 10/22/2020 11 :53: 13 AM PACE 2/002 Fax Server
"^ CERTIFICATE OF LIABILITY INSURANCE D"�OAMDOn ^'
ATE 0 ISSUED AS A MATTER OF'MFORMATION ONLY AND CONPERS NO RNiNTa UFON THE OERTFCATE HOLDER. THIS
ERTIPICATE ODES NOTAFFNIMATNELY OR NEOATNELY AMEND,EXTEND OR ALTEISTHE COVERAGE AFFORDED EY'THE POLCIn ERLOW.
THIS CERTIFICATE OF INSURANCE ODES NOT CONSTITUTE A CONTRACT RETWEEN THE MSUIND INEURER43),AUTNORDDED REPRRSENTATNE
MPORTANT.NmeoO MMerNen AODIRONALINSURED,tMPngay(tss)mustMendorsee. I/SURROOATION ISWAMD,sN)edm the
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