30B-075 (6) • BP-2021-2221
150FEDERAL ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
30B-075-001 CITY OF NORTHAMPTON
Permit: Demo
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2021-2221 PERMISSION IS HEREBY GRANTED TO:
Project# demo garage Contractor: License:
WESTERN MASS DEMOLITION
Est. Cost: 8000 CORP 106022
Const.Class: Exp.Date:05/11/2022
Use Group: Owner: KLEKOT MARIE A& SUZANNE M DOUVILLE
Lot Size (sq.ft.)
Zoning: URB Applicant: WESTERN MASS DEMOLITION CORP
Applicant Address Phone: Insurance:
30 SUNSET DR
WESTFIELD, MA 01085
ISSUED ON:11/30/2021
TO PERFORM THE FOLLOWING WORK:
demo garage
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.
Signature: .59 To
Fees Paid: $30.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Buildine Commissioner
OK
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR MUNICIPALITY
USE
Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: , P—• t " ,-). / Date Applied:
.Tfr►,, li 30 al
Building Official(Print Name) Signature Dake
SECTION 1: SITE INFORMATION
1.1
itsO 746ex S b 1.2 Assessors�Map& Parcel Numbers
} 30 MapNumber,? Parcel Number
1.1a Is this an accepted street?yes � no
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private❑ N Zone. - Outside Flood Zone'? Municipal 0 On site disposal system 0
1 Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own of`c ,`\ ( V.tk d1' UM
Name(Print) City,State,
2`t 5O -7V ?-7X2 ea—ssmr.wi.c.6 c
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) ❑ Alteration(s) ❑ i*ion ❑
Demolition Gr. Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Propowl Work2:
"i: e44,41YY :w• -e creceAY
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost; (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Suppression) Total All Fees: $
Check No3CO2-,Check Amount:A Cash Amount:
6. Total Project Cost: $ t rl6-60 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor icense(CSL) �L l6 c ( ZZ S. \`• ZZ
v� Qc ` License Number Expiration Date
N ofuncCSLH Holder
List CSL Type(see below)�+ .A �No.and S Type Description
e
tt'X4t 4` MIN/IN 0,, to U Unrestricted(Buildings up to 35,000 Cu. ft.)
Restricted 1&2 Family Dwelling
City/Town,State,ZIP VV\l R
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
Re
5.A2 ,, is
` tered Home Improvement Contractor(HIC)
'Je.1 at`• ..S 1\ze.A" (.44() HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
took t1.3 ra lE r rz L,, ww aw•At cure.(,A.
=tree% Email address
City/'Town, state, /.1 P ` VI siTeck-V l ct) 1 r.c E t o U c o -p•Co rki
ephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Wo•kers 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 le No ❑
—
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER1 OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
taine¢in this ap/ph'cpt is true and ace ate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on'the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) 2C. (including garage,finished basement/attics,decks c.,)frch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms _ Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
BUILDING DEPARTMENT
DEMOLITION PERMIT SIGN-OFF SHEET
Date: ik • ‘o•Zk
Address: 15-"b t-cbcc Building Use: C.V.-'C(
15.
Owner: Matt_ Y L(..00c Phone:4. Sc —'(I—i- ZZ'5Z
Owner's Address: TA �\R '--
OCG• CW6(014
UTILITY CUT OFF
(Signature of Authorized Representative of Utility Department required)
As required by the Massachusetts State Building Code (780 CMR), a permit to demolish shall not
be issued until a release from the utilities is obtained, stating that their respective service
connections and appurtenant equipment have been removed or sealed and plugged in a
safe manner.
Eversource (Gas)
gnature Title
National Grid (Electric) 10/N
Signature Title
DPW (Water)
Signature Title
DPW (Sewer) 1O III\
Signature Title
DPW (Storm water) kVA%
Signature Title
DPW (Tree Warden) `l)/‘
Signature Title
+ ,
DPW Director 14,
Signature Title
Historic Comm. Review
Sig ature Title
ASBESTOS REMOVAL
All residential, commercial and institutional buildings are subject to Massachusetts Department of
Environmental Protection (MassDEP) asbestos regulations at 310 CMR 7.15. Therefore, owners
and/or operators (e.g. building owners, renovation and demolition contractors, plumbing and
heating contractors, flooring contractors, etc.) need to determine al asbestos containing materials
(ACMs), both friable and non-friable, that are present at the site, and whether or not those
materials will be impacted by the proposed work, prior to conducting any renovation or
demolition activity.
Examples of commonly found ACMs include, but are not limited to, heating system insulation,
floor tile and vinyl sheet flooring, mastics, wallboard, joint compound, decorative plasters, window
glazing, asbestos containing siding and roofing materials and fireproofing materials.
Failure to identify and remove all ACMs prior to its being impacted by renovation or �molition
activities, can result in significant penalty exposure, and higher clean-up, decontamination,
disposal and monitoring costs.
A DOS certified asbestos consultant must be contracted to determine if asbestos is present and
whether removal/repair is necessary. If the building is a state owned facility, contact DCAM and
DOS. DOS provides a list of licensed asbestos abatement contractors and consultants. You may
wish to inquire if a contractor has any history of violations. Only DoS licensed and DOS certified
asbestos abatement contractors and consultants may be hired to perform asbestos related work
in Massachusetts.
Received by: a0.lV ter W 11VkL,
Klint ame!' Title
Signature Dat
City of Northampton
Oi µ�-"±Py� '
Massachft-
usetts h ,�._ �
• .
�a 3 DEPARTMENT OF BUILDING INSPECTIONS ao 40 toe'
a
\;`'o �;. 212 Main Street • Municipal Building A
Northampton, MA 01060 . S
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 MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: Q0 0,4c,►1/40. 46t- L\•(0\tt
The debris will be transported by:
Name of Hauler: WvA
Signature of Applicant: ', Date: \\' VA'Z.\
14.
-• The CAI of Massachusetts
iy Dept:toe* 'Industrial Accidents
1-=
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. •=IS= I Congress Street,Suite 100
1111— Boston, M-1 02114-2017
wirmatass.govidia
Wu*** atiniteanalion Insurance Affidavit:Builders,ContractortifElectritioniSPhinthers.
TO BE PILED WITH Till:PERMITTINt;AtItIORITY.
Aordiestorligoriroktkuu Please Print Legibly
Name. itiasinessiOrganizatiorilodividuatli: \JJcm
1
Address: 1 z,
CitylStateqip' \KV4,46 iVA,k Phone AVS ' AV-,
Arry orintrove?Climb die appropriate tut: Type of project(required):
1.0 I imiciiiiiimptoyer with M. employee/(MI iteith'eirpreseirm3... 7. 0 New construction
2f711tafflasMie polpidtted orpitnaerstop am have rio employees wadi*Rime VS ri Remodeling
ogyitapseiry.ftSe*otters'camp.unturance textured,'
. °I)etneiliticrin
.1.E1 Iasi*hattleMinef deals an woiltnlyt.elf„pia%%miters'comp,onteirame mostect„)
0 Building addition
trj I sionahaineowisatrad will be hails enatrietais to nonduct all week on propetty. 11111
mime dun 311 cotiosetcas either base winkets-oogr000ktrion atiaritace twr!tote 11 a Eiertrical repain,or additions
pruptiettnt ith no employee:.
12.0 Plumbing repairs or additions
*Cliasnagetwisi contra-formal 1 Mite hsreti dte soft:eetort*Ant ti%ted on the wthuiteti Awe_
I Root repairs
noise sub-euatrbegatilowetraplayeoaaillowestioelress'comp,
6,0 14.0Other We and corporation and it:,officer%havenitertienid tht;it tipfie of mmtztptteet par
152,4114 NA lorm no employee,.[No wort omp.it:tanner Intim:MI
Any*Omit thin cheek%box NI mint Abu Ad thcshrt.rut II oW shoWn; Men woriontt:..tantpermattert pob ifiais**..
troraenwarts who tubmit dot ithdatt insiseafing they art doingtdl work awl then tire matt&coat:1143On MUM ubniit a new atlidaki inctietainicsuch.
tCertiraeloialbatebectthr lox most tab.:Act am old:timed sheet thawing the Pattie of the mincontrectett and mac whethet 1.1tr not titnte%mtaim htc
eirtployeet. Ifdor stAb-eatarActms 1rawettvioyCvh.they Mist ph.r.itie their workers'Matti policy nonther„
I am an emplarer that is providing workers'compensation insurance for My employee& Below is the pitt!!• ard fob site
information.
Insurance Company Name: 6 k Ws.4N44 re,"hot, -"44
Policy#orSdfin L re.it: \,,,,N(2:-KVSS‘ViSc()\Q Expiration Date: 4lattA VC.
Jon She Address: t 'Fa tt CityrStaterZip: to%
..,
Attach a copy of the worken"compensation policy declaration page(showing the policy number and exp ration date).
Failure to secure coverage as required under MGT- c. 152., §25.4 is a criminal violation punishable by a fine up to$1,500D0
araVor one-year imprisonment,as well as civil penalties in the lcomi of a STOP WORK ORDER and a fine of up to 8250.4)0 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 her eh certify under the pains and aides ofperjuri that the i4ormatiott provided above is true and correct
Suenature: 4"s"46,,t nate
Phone LIVS Sltt IS 2SLk
, .
Official use only,. Da not write in this area,to he completed'by cOr or fowl d,Orktig
City or Tow n: PermitiLicense#
Issuing Authority. (circle tine):
I. Board of Health 2.Building[)epartment 3.CityrnmaCterk, 4.Eleendoidliispeelor 5. Plum bi r inspector
6.Other
Contact Person: Phone 4:
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: \SD c ee_ c,.\ 5`
The debris will be transported by: \ 11\/ 'N(
The debris will be received by: Cr.st.c_‘, —700 v \\,. 4- .\,. d
Building permit number:
Name of Permit Applicant ` fr-'s$42,R \K\ thA)c.
II•1n• zk ..,a‘S.,..„..
Date Signature of Permit Applicant