32C-308 (9) BP-2022-0015
5 HENRY ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
32C-308-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2022-0015 PERMISSION IS HEREBY GRANTED TO:
Project# REPAIRS Contractor: License:
Est. Cost: 4900 PETER SADLER 104640
Const.Class: Exp.Date:05/02/2022
Use Group: Owner: SZAWLOWSKI REALTY INC
Lot Size (sq.ft.)
Zoning: URC Applicant: PETER SADLER
Applicant Address Phone: Insurance:
25 RIVER RD (413)824-0716
WHATELY, MA 01373
ISSUED ON:01/04/2022
TO PERFORM THE FOLLOWING WORK:
INSULATION/DRYWALL REPAIRS
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:
it.Tht.)L
Fees Paid: $100.00
212 Main Street, Phone(413) 587-1240,Fax:(413)587-1272
Office of the Building Commissioner
/ ti4* .\-'%.
The Commonwealth of 1% ass usetts
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Office of Public Safety and Ins7ec .2 /
j
Massachusetts State Building Code(780nf///),,,, /Building Permit Application for any Building other than a One-oror-tviiiii alily D elling
_ (This Section For Official Use Only) �-.., '= J
Building Permit Numbed 0-1-1--I Date Applied: Building Official:
SECTION 1:LOCATION
s 6 H.-Hi'.1 L 151- nok(4+ir ck:A ploy
No.and Street City/Town I 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 0 or check all that apply in the two rows below
Existing Building 0 Repair it Alteration 0 Addition 0 Demolition 0 (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? Y ❑ N�oJ0
Brief Description of Proposed Work: rVA-0 0Itril(c CA--(/'
//lSU(I�il a'/1 etAa 1 r ial
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)Sr 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❑ 1-4❑ 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 El IIB 0 IIIA ❑ IIIB ❑ 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:
A trench will not be Licensed Disposal Site 0
Public 0 Check if outside Flood Zone 0 Indicate municipal 0 required 0 or trench or specify:
Private 0 or indentify Zone: or on site system 0
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:
City of Northampton
Massachusetts
4z
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 V$�
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR COMMERCIAL &
MULTI-FAMILY NEW CONSTRUCTION/ADDITIONS/ALTERATIONS
1. Building Permit Application signed by legal owner and filled out by owner or authorized
agent.
2. One set of plans and specification of proposed work(digital and hard copy).
3. Site Plan with location of proposed structure(s)and setbacks.
4. Construction Debris Affidavit filled out and signed by applicant.
5. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
6. Contractors must supply a copy CSL and proof of Liability Insurance.
7. Energy Conservation Compliance Certificate(if applicable).
S. Note any Conservation and/or Special Permit requirements(if applicable).
9. Driveway Permit(if applicable).
10. Proof of Water and Sewer entry fees paid(if applicable).
11. Trench Permit(if applicable).
12. Initial Construction Control Documents filled out and signed by the Registered Design
Professional in responsible charge.
t
i
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
1O I ?-eCt149 1 it)C/Nc. I-ivfeti oii
Name(Print) No.and Iftreet City/Town Zip
Property Owner Contact Information:
6hel ti 5 eW/o)er - - -
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes:
// 6'e lC1
Name Street Address 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❑.
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)
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
S .Ca . CCusr-om tio►'h e
Company Name
"Pei-e( 6ROt- - C5 /O'-I {0 yfi/y->
Name of Person Responsible for Construction License No. and Type if Applicable
96 e.iuer t1c1 . (A)h/ 7 M 7
>q- 013 -3
Street Address City/Town State Zip%
i - off-,c, - - C I+Acc., 0/hit .CvrYl
Telephone No.(business) Telephone No.(cell) e-mail a..ress
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❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item I Estimated Costs:(Labor -
and Materials) Total Construction Cost(from Item 6)=$ V lj UCH
1.Building $ 2_, Coo ' Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ 1'r L 00 appropriate municipal factor)=$ .
3.Plumbing $ l i Z O 0 —
4.Mechanical (HVAC) $ Note:Minimum fee=$ / (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
I
6.Total Cost $ /coo _ (contact municipality)and write check number here 2 zicg
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 to the b st of m knowledge derstanding.
4113- 321 O?-/
Please print and sign name Title Telephone No. Date
.25 g,,,� (ohm O/C 7 3_-.$acccreaL-tA-c L, cofr
Street Address City/Town State Zip mail Address
Municipal Inspector to fill out this section upon application approval: Li"2.0Z Z
Name Date
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton
Massachusetts 's
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building wee
Northampton, MA 01060 s°t ``sue
1:.
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: nT
fbp.,id
The debris will be transported by:
Name of Hauler: LU /C ) ) 771)C/r--41)
'
Signature of Applicant: Date: 1 33 Z
The Commonwealth of Massachusetts
Department of industrial Accidents
1 Congress Street,Suite 100
Boston,AfA 02114-2017
• www.mass.govidia
tuktre Compensation Insurance Affidavit:Budders/Contraetors/ElectriciansiPlumbers.
CO HE FILED WITH THE PER:Mil-TING AUTHORITY.
Xmilicatit InfOrtlitttittti Pkone Print Lettiblii
Name BUSIII,CNS.I)r_ lion,Individual)"
COSkNIA,
Address: ,95 itjf .
city/state/zip: A- Phone 1j13
Are yaw esektyer?Cheek tbe a ppro late boa: pe of project(required):
1.0 I arn a employer with empiuyees(full tentor part-tuirey.' 7. New construction
21:3 I am a sole proprteior Or pannerthip wad have no trapbuyoct working fur roe ns 8 J Remodeling
an Lapiteiry.(No workers'•zoittp./noir:wet required.]
9. El Demolition
31:3I am a bOrriettectler deans all work myself.[No aorkers'conga.iseituaixe wcpsnoll
i Ej Building addition
4.0I am a liorneowtter and will be hiring contractors to conduct all week on my property.. I Will
ensure that all...-imaraelits%Onion-hose Yonkers'europennation insurance or MC sole 11..0 Electrical repairs or additions
prupneton with no ehiphoyeits..
12.0 Plumbing repairs or additions
I am a eeneral coutnickir nd Ileo*:heed the sutheontroetors hated On the anadicti nieet.
lb BO/tool repairs
sois-cooirsciots base employees and Nave 4,orierS:comp.insitranec.:
Other
6.0 We are a corporation and its officers have exercised then right of exerrsption per NiCit 14.
4 and We it.Vot no eittpiOyees.[No*mien'comp.insUnime requan.d.!
*Am,aprin.au mai...acciss boa 41 most also fill out the senior ca:10 5.1ov. scrs'compensation pubs:),uit,:emalion.
r.Homeowners who submit this affidak it indicating they are doing all work and then hire outside ceintraetors MUM submit a new officio iv/ilk-zing such.
Contractors that check this hoc!MINI attached an odilitional elseet showing the name of the sabb-costractor,and.srale whether or rii.)r thaareunites hase
anpluyeta_ If the sub-contractors kr,e employ.ecs_they must pros irk their viorkers"comp.policy noint,er
•
1 am an employer that is providing workers'compensation insurance far my employee:N. Belo Pi."1.4 the polio.and jab site
information.
Insurance Company Name:
Policy#or Self-ins.Lie. Expiration Date.
Job Site Address: CityStateiZip:
Attach a copy of the workers'compeusation policy declaration page(showing the policy number aid expiration date).
Failure to secure coverage as required under NIGL c. 152. §25A is a eruninal violation punishable by a fine up to$1,500.00
andror one-year imprisoninent,as well as civil penalties in the form olj 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.
1 do hereby cert'.„ ander the pains and penalties of perJurr that the information provided above is true and correct.
Signature: / Dat : ) 13 ZZ
Phone#:
Official use only. Do not write its this4L1411t.to be completed by city or town official
City,or Town: PermitiLicen,se
Issuing Authority(circle one):
I.Board of llealth 2. Building Department 3.City/Town Clerk 4,Eleetrical Inspector 5. Plumbing Insnecik)r
6.Other
Contact Person: P hunt:
...
,
.., ..\ Initial Construction Control Document
To be submitted with the building permit application by a
ti
1111 Registered Design Professional
*
,... : ... for work per the ninth edition of the
5117--\
rts slay Massachusetts State Building Code, 780 CMR, Section 107
Project Title: Date:
Property Address:
Project: Check(x)one or both as applicable: New construction Existing Construction
Project description:
I MA Registration Number: Expiration date: ,am a registered design professional,and I have
prepared or directly supervised the preparation of all design plans,computations and specifications concerningl:
Architectural Structural Mechanical
Fire Protection Electrical Other:
for the above named project and that to the best of my knowledge, inform.ation, and belief such plans,
computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780
CMR), and accepted engineering practices for the proposed project. I understand and agree that I (or my
designee)shall perform the necessary professional services and be present on the construction site on a regular
and periodic basis to:
1. Review, for conformance to this code and the design concept, shop drawings, samples and other
submittals by the contractor in accordance with the requirements of the construction documents.
2.. Perform the duties for registered design professionals in 780 CMR.Chapter 17,as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the
progress and qiialitv of the work and to determine if the work is being performed in a manner consistent
with the approved construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent
comments,in a form acceptable to the building official
Upon completion of the work,I shall submit to the building official a'Final Construction Control Document'.
Enter in the space to the right a"wet" or
electronic signature and seal:
Phone number: Email:
....
Building Official Use Only
Building Official Name: Permit Na: Date:
Note 1.Indicate with an'x."project delideain plans,computahons ar....1-..-. ns that you prepared or directly supervised.If'other'is
chosen,provide a description
Version 01_01_2018
Appendix 1
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required. The applicant shall fill out
the checklist and provide the contact information of the registered professionals responsible for the
documents. This appendix is to be submitted with the building permit application.
Checklist for Construction Documents*
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing(include local connections)
9 Gas(Natural,Propane,Medical or other)
10 Surveyed Site Plan(Utilities,Wetland,etc.)
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investigation
16 Energy Conservation Report
17 Architectural Access Review(521 CMR)
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified
must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the
authority having jurisdiction.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Please follow this link for construction control forms to be used by Registered Design Professionals.