54HillsidePermitAppThe Commonwealth of Massachusetts
Board of Building Regulations and Standards
� Massachusetts State Building Code, 780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two -Family Dwelling
FOR
MUNICIPALITY
USE
Revised Mar 2011
This Section For Official Use Only
Building Permit Number:
Date Applied:
Building Official (Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Propert Address: +
cia_.114.+C� �+-
1.2 Assessors Map & Parcel Numbers
Map Number Parcel Number
1.1a is this an accepted street`? yes no
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
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)
Public Private ❑
1.7 Flood Zone Information:
Zone: Outside Flood Zone?
Check if yes❑
1.8 Sewage Disposal System:
Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 0, weer' o ecord: ea
Name(Prirtt Ci , State, Z[P
' r G —
No. and Street —Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply)
New Construction ❑
Existing Building ❑ Owner -Occupied ❑
1 Repairs(s) ❑
Alteration(s) ❑
Addition ❑
Demolition ❑
Accessory Bldg. ❑ Number of Units
Other ❑ Specify:
Brief De ription of Proposed Work':
5 41\lI
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:
Labor and Materials}
Official Use Only
i. Building
$
1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
❑ Total Project Cost' (Item 6) x multiplier x
2. Other Fees: $
List:
2. Electrical
$
3. Plumbing
$
4, Mechanical (HVAC)
$
5. Mechanical (Fire
Suppression)
$
Total All Fees: $
Check No. Check Amount: Cash Amount:
❑ Paid in Full 0 Outstanding Balance Due:
6. Total Project Cost:
$ oil 31
M
SECTION 5: CONSTRUCTION SERVICES
5.t Construction Supervisor License (CSL)
lA
License umber xptrateon Date O
,
List CSL Type (see below) tiJ
NameoFC�t of c1rr
Type
Description
1reet No and
(Buildings s u to 35,444 cu. ft.
RestrictdUnrestricted
Restricted 1&2 Family Dwellin
Ci t yff 6wn, t ee,z rP
M
Masonry
RC
Roofing Coverin
WS
Window and Siding
�;h;J M %. 0741, r l��
SF
Solid Fuel Burning Appliances
I
Insulation
Tele hone d Ernit adde,ss
D
Demulitioii
5.2 Registered Home Im rovement Contractor (HIC)
{
HIC kegistraiion Number Wp,bon Date
Company e or HIC r t Name
N . lid St • et p
4D
m�ait address-
Cit own, State, ZIP Telephone
�7i,�` _
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. C. 152. § 25C(6))
Workers 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 .......... No ........... ❑
SECTION 7a: OWNETt AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property, hereby authorize , ^.rt ��} ca ,
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 71h: OWNER' OR AUTHORIZED AGENT DECLARATION
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 trueandaccurate to the best of my knowledge and understandin .
Print Owner's or Authorized Agent's Name (Electronic Signature) ate V
NOTES:
I. 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. og u/oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss
2. When substantial work is planned, provide the information below:
Total floor area (sq. ft.) (including garage, finished basement/attics, decks or porch)
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"
The C-'orr mottItrea th of Ahessuc•husetts
Uepariment of Industrial Accitlents
1 Congress .street, Suite 100
Boston, MA 02114-20117
,;��;�w_ ,�_,� ►►rr�'rT•s:ratasc.{���tl`rlirr
11 „r kern' Conilot rmaIion I r 4urmiscr :t ffida,, il: Builticru (. outs.�lrrr*rl':lectritdanslPlurnberx.
10 Ak. k IIA.l) MI I It I I I F PERM 111NC A U 1410RI fl .
Naltme (Husims,. Organaiwi In Individual):
Address:. ---I t C3 C.,�� ) �{
City, State'Zijl: So.Y�PI\ Phont L
Arc Neu an crnpl.utirr:' € irsrk the apprnytrinlc Ini.t:
f.� l am a intpl.rnit uIUi i U1 x:rd t•r par[ link•r'
J111 a aulc pxuprrctar 131 pxulncnflrp and hJ1 C ulr ernl,la el'.• ti. M-Li ! Sur n;l..• rn
:utv Lv}-XILAt . INLI WUI[ el., etlrnp. nLSYrJrrLV cLxlutrLd
3f0 1 am a IrL1111X IA11 -r duirty- all ,nxrrk rn}•wlf. ENO wOrl,c-M' cramp rmurrnlxt rtzlunttl.) "
4.❑ I wit a Iwrm00%m r and u ill lac hirimN cxrrrerac cur w Lrxrduct all w'urk kin rm prtgIcrq I will
L'tk4UM Itlat all 4,ortKTU0ur.1 either ha�c narkzrs- mwnp cit, vn insurance Lrr all• sole
pruprw1or., N ah no cnmplvyc ,�
S I Jill a general wtill:wtvi lad I Esa, c hxwd t[vc +ill,- unlr r. turd Iiml:d or, IN.- s1i:2 icJ -ficcl
I Ixse ,uh-.u1:lrac[nr> LtYC crrrploNc', end h�,. L „L+t ..e•r, -: ,.vul,. IZMNLtXl
tt. u,` arc a cxwtxa€r:en rota II, orks r r> hulL•cfLIWd ncWlr nght a l em emptrun per 11101_ L
152. (11141, Lindwc hao. no LinploWCh. [\o wurkc ' wiarlp. inhUMCctrcyuul•d.l
T1% pe of project ( required):
I. iVeus construction
8_ 1 Remodelmgt
9- DImlolitlon
10 B u, I Ming addition
11.0 Electrical repairs ar additions
11L] Plumbing reTairs or additions
13.L"--j Root'rspaLm
14-QOthci___
'Any apptii�;atl !hilt chwvk% bm Ill rnw,t vAly pill our dw +rc!wzi MoNk ahu% my then uarkLTc' cuntpenwatiun ptutu4y i.nfexrrlaUnm
t Ilc,rnmmiur, %Nho %uh niT thaa Oft-KLtk a Imbcaltnu dtcy arc 1TIn i all work and dwn hire twtmde i,nFra.tcr., mot subrrur a newaffvja, it tnclicalmis xwh.
lCurttra►turw tllat L11LLk flu, bo% Iuu,1 utt, pad an jddrli.Inul NhCC whlrw ink dW name ant ncc sub-,:vuttwvra and,tatc whobvc ur nor tlur:+c %imnc., leas,:
cE*11,1. ylc,. Ii d'x, _ .!>rpl,v.lxs. 1110 mu-1 piw-ith'r!`I E." Sk,ikl'F comp. pkilic, nuinhLi.
I note an emptoyrr that i,% InovjfPiir,, PvorAerti , c rronpuxr.,uimar w.vironre fiir my empioj,ers. Below i, flee luaiiq alert job .sire
ini fiw►rrution.
Insurance Comjmn} Name:_
Pulu:y # ur Sel[-Lna. E_rc. #: Expiration Dale:
Job Site Addre& �� � �T��� C irk•, 5talc'-l_ip: fr Ir ' r
Attach a Copy of the workers' com1wismitiiDn pollieh' dreiarsatiun page (shaming tht pour► number and expiration date).
Failure to -Lcurc coverage as riqulnci under M(IL e. 152. * 25.E is a criminal e iulatrun pilrtislTable by a line up to S1.5(I0A[1 i
ancl.'clr one-vi ntr imprt-;urimcni. an'I�dI FIB 0 11 I?e11,11tics ITS t11,.' i'mm ;if a STOP WORK ORDER and fine of up to S250.(Ky a
da) az,lairIA [tie 4 WhIlOr A CLIP) ul T11in ♦![,1tC1IL1j1t Ins V bl� tilrV.Aj'tled I0 the Of %77 Lit - [MS ' SUr,.ftlUn] 01'thk! DIA 1"trr insurance
Ct?%eriit',1t \t:nl-1I:itT li.+Il
-
I do herekv certifj' under lit py,(-im and
that the information provided shotrue and eorrert.
Official tyre unfv, Do not writ'e its tlri.a area. to far completed hy' vi{I' or ro M'n of ririrrt
('itv OrTmanl
Prrr mi0l'ieenile ft
Issuing Authoritit (circle one)-
I. Board of livalth 2. Building Department 3.Uilrf]4nn Clerk 4, 1,3eetrical Inspec.ttrr S. I'Iunlhing Inspector'
G. Other
C'ontlr.ct Person. Phonr P.
ACC)R"�
CERTIFICATE OF LIABILITY INSURANCE DATE(MMJDWYYYY)
02117/2022
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT., If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A Statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
rAq,,O.d,ro
ROUCER NAMECONT:
CT Ananna AgUadrO
&Associates PHONE (413)566-7373 (a13) 56a-0859
AIC Na xt : A!C Na :5S Bidge 51,. P 0 Box 357 ADOREss, arianna(_ aquadroinsurarce com
INSURER(S) AFFORDING COVERAGE NAIC #
Jortnampiun MA ;s1U51 INSURER A, Main StreetAmenca Insurance 29939
INSURED iNSURERB: Travelers Indemnity Co. 25658
MICHAELPHILLIPSING INSURERC: Chubb
PO BOX 514 INSURER D :
INSURER E :
GOSHEN IAA 01032-0514 INSURERF:
COVERAGES CERTIFICATE NUMBER: CL2221710655 REVISION NUMBER:
IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
ND;CATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSiONSAND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN
LTR
TYPE OF INSURANCE
IN D
WVQ
POLICY NUMBER
JMMIDWYYYYJ
(MMIDINYYYY1LIMITS
A
x
COMMERCIAL GENERAL LiA61LiTY
CLAIMS -MADE � OCCUR
MPT6631 G
I
12/102021
12/14/2022
EACH OCCURRENCE
S 500,000
PREMISES (Ea occurrence
$ 500,000
MED EXP (Any one person)
S 10,000
PERSONAL a ADV INJURY
$ 500,000
GEN'LAGGREGATE LIMITAPPLIES PER.
POLICY JE° LOC
OTI;ER
GENERAL AGGREGATE
S 1,000,000
f'ROOUCTS-COMPlOPAGG
S 1,ODO,D00
lodividual Risk Mod Prom
5
B
AUTOMOBILE UASIOTY
t.); AU'p
OWNED X SCHEDULE)
AUTOS ONLY AUTOS
vv HIRED NON -OWNED
AU'f05 ONLY /� AUTOS ONLY
BA8123W809
12/23/2021
1212312C22
COMBINED SINGLE LIMI
Ea acddenl)
S
BODILY INJURY (Perpersoni
E 100,000
BODILY IgJURY(P« ac�donl;
s 300.000
—
ROPERTY DAMAGE
er acrlderl
S 100.000
ninsured motorist BI
F'.-
E 100,000
UMBRELLALIAH
EXCESS LIAR
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
S
AGGREGATE
S
DEv I RETENTION S
-•
WORKERS COMPENSATION
AND EMPLOYERS' 41ABaITY y f N
ANY PROPRIETOWPARTNERIFXECUTIVE ❑
1FFICER/MEMBER EXCLUOED7
(Mandatory in NH)
li yes, describe under
DESCRIPT{ON OF OPERATIONS bale%
NIA
6582UB-4N43852-5-21
08)2412021
0512412022
FR PER
57ATUTE FR
E,L.EACH ACCIDENT
s
E.L. DISEASE - E4 EMPLOYEE
$ ,
E.L DISEASE POLICY LIMIT
S
FSCRIPTION OF OPERATIONS 1 LOCATiONS t VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more apace Is required)
FRTIFICATE HOLDER
CELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of Northampton
210 Main SI
AUTHORIZED REPRESENTATIVE
Northampton MA 01060
,ORD 25 (2016103)
9 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORO name and logo are registered marks of ACORD
Commonwealth of Massachusetts
Divtston of Professional Ltcensure
Board of Building Regulations and Standards
ConstFij&iOn Supervisor
CS-082683
Expires 1;' 1�1 2022
MICHAEL J PHILLIPS
PO BOX 514
GOSHEN MA 01032
Commissioner
Office pt Consumer Affairs & Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE: C-C*ratjcn
f +�tration Ir 1 n
171266 03r04 2022
MICHAEL PHILLIPS, INC.
MICHAEL PHILLIPS
31 MAIN ST
P,O BOX 514 r'^
GOSHEN. MA 01032 Undersecretary
�,U ��C--it-
NGb Le
..aQCS-rt
�t
-NOTE -
THIS PLAT IS COMPILED FROM DEEDS, PLANS AND OTHER SOURCES AND IS NOT
TO BE CONSTRUED AS AN ACCURATE SURVEY AND IS NOT TO BE RECORDED.
BUILDING LOCATION ACCURACY IS NOT GUARANTEED
HILLSIDE ROAD
TO. EASTHAMPTON SAVINGS BANK &
FIRST AMERICAN TITLE INSURANCE COMPANY
TO THE BEST OF MY INFORMATION, KNOWLEDGE AND BELIEF
I HEREBY REPORT THAT ! HAVE EXAMINED THE PREMISES AND BASED ON EXISTING
MONUMENTATION ALL VISIBLE EASEMENTS, ENCROACHMENTS AND BUILDINGS ARE LOCATED ON
THE GROUND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY WITHIN THE LOT LINES,
EXCEPT AS NOTED. I FURTHER REPORT THAT THE PROPERTY IS NOT LOCATED WITHIN
A FLOOD PRONE AREA AS SHOWN ON FEDERAL FLOOD INSURANCE MAPS FOR
COMMUNITY #250167
SURVEYOR: ���, =m •
OF �ass4 ti
RANDALL GN
E.
IZER H
#35032
{951�
Np SURYE��
c
-NOTE--
THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY
AND DOES NOT CONSTITUTE A PROPERTY SURVEY
-MORTGAGE LOAN INSPECTION PLAT-
NORTHAMPTON, MASSACHUSETTS
PREPARED FOR
ROBERT C. BUSCHER & ELIZABETH B. MARCH
SCALE: 1 "=30' MAY 9, 2011
HAROLD L. EATON AND ASSOCIATES, INC.
REGISTERED PROFESSIONAL LAND SURVEYORS
235 RUSSELL STREET - HADLEY - MASSACHUSETTS
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street + Municipal Building
Northampton, MA 01060
W
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:
The debris will be transported by:
Name of Hauler:
Signature of Applicant:
Date: 0 ,
ia.
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