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The Commonwealth of Massachusetts. �2
Office of Public Safety and Inspections f ,//0,
Massachusetts State Building Code(780 CMR) �r
Building Permit Application for any Building other than a One-or Two-Family] W
T (This Section For Official Use Only)
Building Permit Number. .Z" 10 7 Date Applied: I Building Official:
SECTION 1:LOCATION
No. Stre City Town Zip Code Name of Building(if applicable)
Assessors ap# 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 0 Alteration 0 Addition 0 Demolition !'(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.'s'
Is an Independent Structural Engineering eer Review required? Yes CI No
Brief Descripti of Pro se Work: . -( v , G� er jy ) .
SECTION 3:COMPLE LE 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❑ A-5 0 B: Business ❑ E: Educational 0
F: Factory F-1 0 F2❑ H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0
I: Institutional I-1❑ I-2❑ I-B 0 I-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3 0 R4 0
S: Storage S-1 0 S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA III HA CI IIB ❑ IIIA ❑ VIBE IV CI VA VB ❑
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:
PublicA trench will not be Licensed Disposal Site
Check if outside Flood Zone❑ Indicate municipal required❑or trench or specify:
Private 0 or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-ways/ Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable C'Y Is Structure within airport app ch area? Is their review completed?
or Consent to Build enclosed❑ Yes CIorNo Yes 0 No �
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code Use Group(s): Type of Construction
Does the building contain an Sprinkler System?: /1JO _Special Stipulations:
Design Occupant Load per Floor and Assembly space:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Prtoperty Owner IictLivi fth 0/ /7 / fc -7 617n7z.c , ,1,✓ sfd 4/%c
Name(Print) No.and Street City/Town I Zip
Pro erty Owner Contact Information
o
Titlet Telephone No.(business) Telephone No. (cell) e-mail adc s
tr a plic?a le,the properowner hereby authorizes:
fit
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 0.
Otherwise provide construction con7ol fn-ms(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
Compran Name f
Name of Person Responsible for Construction LicenseNo. and.Type if Applicable
'---t) .._tc,t4 1-'t-e(4 e_ ,‘q..,;_s tit kli (----* -0_, C..,/7 il ill- e I 6z2-; c
Street Address City/Town State Zip
L113- s,--Sli /> L;�'// .......-7 ,
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION11: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=Total Construction Cost x i(Insert here
2.Electrical $ appropriate municipal factor)=$
3.Plumbing $ /5P 17 /)1,+CC'1%`7
�'C
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact ' /.municipality)
l
5.Mechanical (Other) $ Enclose check payable to f ,I'"� 1 �V, t,t^.
6.Total Cost $ (contact municipality)and write check Amber here
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 ac ate t6 the best of my knowledge and understanding. .
Nje(1.1,k:ten-pc- _ -__`_, C?----______ ex i, „kJ/A,4- 4/6 5-7 ris0-9/ /14...9e--,9,j
Please print and i name Title Tele hone No. ate
:7brc etc e- w e. � 'G % p19-- utA)s I-7- , c-2c,,wt ;'1_‘.-A%(,-p
Street Address 1 City/Town State Zip Email Address LOY\
Municipal Inspector to fill out this section upon application approval:
Name Date
City of Northampton
.� Massachusetts elL�` s,�I `,c
DEPARTMENT OF BUILDING INSPECTIONS iN
A "^
212 Main Street a Municipal Building `gyp'\ `-:
Northampton, MA 01060 'rs"""y�i^`r
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: 6-2C6 (-C 10 Cc ,\\_ - I ( e. 6/6 LlC_)
The debris will be transported by:
Name of Hauler: �,k) ?- I-e-r/v / (Ct c2,i c).- 'J
911
Signature of Applicant: � 1 - Date:
The Cannon wealth of Massachusetts
. ltl=�ll�
- Department of Industrial Accidents
1— 1, I Congress Street,Suite 100
::�r
• Boston,MA 02114-2017
•_="�=,:i www.mus gav/d/a
1}.o kers'Compensation Insurance Affidavit:Buiklert/ContractorsFElectriciansJPlumbers.
TO lit 111.t:11 wrfll THE PERM rtiNG AUTHOR!IN,
Appiieenttnformalion Please P
Print Lesibly
Name.(3ueanss.Organzatfon Individual): iy ) 44c Ss k �i(ij'4" / `Zi '
Address: . ' It(c c1e-f\-Os kJ
r
City/State/Zip: 11,1f, (4--;e al AA Phone#�j/, ' 3 7 ---___5—.
___ _c��
An
A yea as estpiayv!Cheek fate xpproprFate tin: / Type of project iregaired):.
l. am a employer with if,) employees!full easat'aar pert-time n.• 7..a New construction
201 am a stile proprietor or pautneralup and have rw employers socking for me us $, Remodeling
any easpaesty.No w inters'camp.uuuran.e requital]
::9. Demolition
301 tun a homeowner doing all wort myself.[Nu winker'curry.auturancaw c ruuud.l'
l0 0 Building addition
4.0 l am a humcVK'aa acid will be hints t_aararadurs to atauludd ail work uh my prop ref. 1 will
ensure that all rauara iura either brit workers'runipensation iraaurancu tie ant sole 1:1 a Electrical repairs or additions
proprietors with nu etapluye s. 12.0 Plumbing repairs or additions
50 lint i general cuntrartur mad 1 lime hired the sub-contracture listeJ us the anajicti sheet 1 0Rlwfrepatr]
These sub-euntractens haw employees tail tease workers'comp.tmuaanec.•
6.0 we c a ctatpuraliva aul its officers bus a alert Lied their'Iglu
of a raptiest pa MGL e. 14.❑Other
arc
IS!.¢I)4),anti t..t have MO employee.[?Jo wurkent'comp.thsacu cr required.]
rAtty applcaatt that cheeks box*Lassa also fill out the sonars orlon showing their wurL ts'eumpenutiun polity infurmatie n.
t kbn,wwaen who simatlitilattidssit in lecatnsit they are doing all work and then hue uutxialc contracwrs must submit a sew affidavit uadiexitiag each.
:Curitraeturs that dheek this hux must:duetted an ad.litiotal sheet show tag the name of the su -wars:tors and seat Whetha Of nut dose entities have
eanpliayees. lithe at -eurrlra'kilt have c-u>rio}use.they muss provide their nurkers'imr.p p.,I,sli bier'sr.
tam an employer'r that is providing winters'compensation insurance for nfy employees. Below is the policy and job site
information. � `'p _
Insurance Company Name: 6.A IVt t2 e .c,<'I -t ct-"- CC. CLl " —
Policy at or Self-ins,Lic.#: WC-f 02C3S-b 3 h1 Expiration Date: ��i2//42-ed-c).
Job Site Address: - HV V I`-C4 CitylstuteizipMai pirn
• ) /1//7�
copy Attach a of the workers'compensation po tc, declaration page(showing the policy number and e tlon date)I/'
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a rule up to$1;500.00
anit 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 be forwarded to the Office of Investigations of the DIA for insurance
covera1Le verification
t do h . certify der the pains and penalties of petjury that the information provided above is true and correct.
7)
Signature ` �_ J� --- Date:
aidy/9-4?- -
Phone.e: 4/3 _. --- •7 /
! Official are only. Do not write in this area.to be completed by city or town official
' City or Town: Permit/License it
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.City/Toan Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:_
-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.
CURRENT SNOW COVER NEGATES THE ABILITY TO ASCERTAIN
ENCROACHMENTS UNDER SAID SNOW.
NOTE:
PROPERTY LINES SHOWN ARE APPROXIMATE, A
FULL FIELD SURVEY IS REQUIRED TO
ACCURATELY DETERMINE THEIR LOCATION.
90.7'±
approximate location
of abutter's shed
") BOOK 12652,
,A
PAGE 219
IRON PIPE
53'±
FOUND
HOOKER AVENUE
TO:
CONNECTICUT ATTORNEYS TITLE INSURANCE COMPANY
TO THE BEST OF MY INFORMATION, KNOWLEDGE AND BELIEF
I HEREBY REPORT THAT I 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
—NOTE—
SURVEYOR: arn.Lt.SQ THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY
AND DOES NOT CONSTITUTE A PROPERTY SURVEY
tH of;�. —MORTGAGE LOAN INSPECTION PLAT—
z� S9°ti NORTHAMPTON, MASSACHUSETTS
RANDALL In
8 IZEPREPARED FOR
IZER t/ ADAM & PRISCILLA NOVITT
/ SCALE: 1"=30' MARCH 5, 2021
(^ItiO suRvj ! HAROLD L. EATON AND ASSOCIATES, INC.
REGISTERED PROFESSIONAL LAND SURVEYORS
235 RUSSELL STREET HADLEY — MASSACHUSETTS
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 demolition
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: '''D`�"'M kk0,S\?� C)J'✓A\�� ---
Print Name Title
,..i,\.
,Z-`� 21 Z Z ) zZ_
Signature Date
BUILDING DEPARTMENT
DEMOLITION PERMIT SIGN-OFF SHEET
Date: 011)t,'
Address: •,•g 1+6 G 74 Building Use: L;;v‹.-t,4
Owner: /L'( l:'l Phone: 4/ —:270/7,2. —
Owner's Address: I / ) r �
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)
Signature Title
National Grid (Electric)
Signature Title
DPW (Water)
Signature Title
DPW (Sewer)
Signature Title
DPW (Storm water)
Signature Title
DPW (Tree Warden)
Signature Title
DPW Director
Signature Title
Historic Comm. Review
Signature Title