31B-047 (6) BP-2021-2342
11 SUMMER ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
31 B-047-001 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-2021-2342 PERMISSIONIS HEREBY GRANTED TO:
Project# DEMO Contractor: License:
Est. Cost: 2000 GEORGE KICZA 084268
Const.Class: Exp.Date:06/10/2022
Use Group: - Owner: JELB PROPERTIES, LLC
Lot Size (sq.ft.)
Zoning: EB Applicant: GEORGE KICZA
Applicant Address Phone: Insurance:
33 GARAGE RD (413)218-0288 wc2-.335-b20p09-011
SUNDERLAND, MA 01375
ISSUED ON:12/29/2021
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: 1-11
>2, .Fees Paid: $50.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
/ SECThe Commonwealth of Massachusetts /
(90 Office of Public Safety and Inspections '14
/ f Massachusetts State Building Code(780 CMR) •
- r;F!-Pi/ ,Building Permit Application for any Building other than a One-or Two-Family"T lin g
J J
(This Section For Official Use Only)
Building Permit Number'"a1 .7 3`f Z Date Applied: Building Official:
SECTION 1:LOCATION
a-I1 S S�. r�a:E-��.r.�,E�.. Utob�
No.and Street City/Town Zip Code Name of Building(if applicable)
3/6- 0h
Assessors Map# Block#and/or Lot #
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below
Existing Building Repair 0 Alteration 0 Addition 0 Demolition 1L(Please fill out and submit Appendix 2)
Change of Use 0 Change of Occupancy 0 Other 0 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No 0
Is an Independent Structural Engineering Peer Review required? Yes 0 No 0
Brief Description of Proposed Work: at vAo ,btiT AOAP V 1 Cji it (5• -ftwtj
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft)
Total Area(sq.ft)and Total Height(ft)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business 0 E: Educational 0
F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0
I: Institutional I-1 0 I-2❑ I-3 0 I-4 0 M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4 0
S: Storage S-1 0 S-2 0 U: Utility 0 Special Use 0 and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 0 IB ❑ HA IIB 0 IIIA ❑ IUB ❑ IV 0 VA 0 VB 0
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:
Public 0 Check if outside Flood Zone 0 Indicate municipal 0 A trench will not be Licensed Disposal Site 0
Private 0 or indentify Zone: or on site system 0 required 0 or trench or specify:
permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable 0 Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No 0
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:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
3.U\ "..1-`1 Lt.L Ia)L b t S,.,..t.14,,,1 I('1 A• o 1VW
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information
0 Lti sevt.e `4t‘ -a- 'we`\ - l4s"►eo4,14I-((-..lkts f_ ok.M,I. ( .-^'.
Title Telephone No.(business) Telephone No. (cell) 'e-mail addresJ
If applicable,the property owner hereby authorizes:
NajL.LZA '7 ( 1-D'St 33 �cs.``z tJ. �,.,dt�l---1 V'1,v4• 0 lVV-S
me StreefAddres's City/Town State Zip
to apply for and act on the property 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 a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O.
Otherwise provide construction control forms(see section 107 in the code)as required.
10.1 Registered Professional Responsible for Construction Control (the professional coordinating document submittals)
GP ncl e k4• V\ GZ0., I113- S-P- (33,..'S `( hcd YP. 16 5 A Giw-� Gs- a. .y�1os
Name( gistrant) Telephone No. `-e-mail address
ress Registration Number
33 9 nca_l ek 3 v vvI e i-1-0L YNNc& C i 3 11 19/J D� 0
Street dress City/Town State Zip Discipline Expira 'on Date
10.2 General Contractor
0 Co rg e 1--1 . K l r_2 a.
Company Name
6(,(2e H-_ K1cza_ GS- afs zig k2 rG//6/ L
Name of Person Responsible for Construction License No. and Type if Applicable
3� 5 arr q,a Rol... sv 1..oler(o,1,d bay 0I 37S
Street Address �! City/Town State Zip
1^1[ - - 02.Z2 - - V .c rve KS/2 °Jj Ono,tZ . Cem
Telephone No.(business) Telephone No.(cell) a-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 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ Building Permit Fee=Tota . r.. ....n Cost x (Insert here
2.Electrical $ appropriate . j ipal factor=$ .
3.Plumbing $ o' pi,
4.Mechanical (HVAC) $ "2 Note:Minimum f•- =$ / (contact municipality)
5.Mechanical (Other) $ O
Enclose check payable to 6.Total Cost $ J OO.Oa (contact
(contact municipality)and write check number here I l(i2
SECTION 13: TURE OF BUILDING PERMIT APPLICANT
By entering my name below, re attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
0,.1 Lit) 410- aptb' ;1 itI,k
Please print and sign name _ Title Telephone No. Da
1n to.,...,,1 174. So. O.t.i.:.141 Mkt 0l51'z) ,,..)o..e not N.Liii-E4( ft.(9.
Street Address City/Town State Zip Email Address
1.
Municipal Inspector to fill out this section upon application approval: g ' ` is/a9/at
Name Date
City of Northampton
r-''-
rlj
S Massachusetts `,',
~ * tic
DEPARTMENT OF BUILDING INSPECTIONS ;yf t
'.' 212 Main Street • Municipal Building JJ, ��Ca,
--� Northampton, MA 01060 sfrj
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: \AtA4.-, jr'-c--\c, 1;^, a-,.A E.,- --KRi_A^ g,it. v"io yt0
The debris will be transported by:
Name of Hauler: yA.,• ,S1- I r.,.1 &s)
Signature of Applicant: Date: ; i /,,
1) 1
^a4
_ ►-' The('ol monwoollh�i of Ildf(lehlliSeilS
Department of Industrial Accidents
wow 1 Congress Street,Suite 100
a 11111 Boston,MA 0211I-2017
mill
www.mass.gov/dia -
~ Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information / Please Print Legibly
Name(Business/Organization/Individual): J tircS>� W‘1-1..J1 (�o$ a% 1 r.a C t, (.N-�k t`q1...,
Address: rcnk Ls t
City/State/Zip: 5 4,01It,,tl.... %P.m• 013-1-S Phone#: i)1- j(c)-'ci`16 h
Are you an employer?Cheek the appropriate box: Type of project(required):
I tam a employer with _ g employees(full and/or part-time).* 7. El New construction
2. I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
4. a Demolition
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10❑Building addition
4❑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 11.0 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. 13.0Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 14.El Other
152,§I(4),and we have uo 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: L'i,1::'ii L"il.A'‘
Policy#or Self-ins.Lic.#: W f,,}•-1%.S- a O?O 5- O t L Expiration Date: . -1 WI I },
Job Site Address: 't-11 S v^^Y^.t S I. City/State/Zip: IJ of N-0.o-' VI A 0 l C b 0
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 he forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
i ur k
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): .
n____a ..rI7_..lil. Ai n__!II J2_._ram____..._.__._... . r•. Pr._.. . rn.. 1 4 In .•V 1 R f 1 1•