22D-067 (4) BP-2022-0342
121 FLORENCE RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
22D-067-001 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-2022-0342 PERMISSION IS HEREBY GRANTED TO:
Project# STRUCTURAL REPAIR Contractor: License:
Est. Cost: 3330 DALE HAWLEY 055048
Const.Class: Exp.Date:08/29/2022
Use Group: Owner: MORIN MARLENE A
Lot Size (sq.ft.)
Zoning: WSP Applicant: DALES STRUCTURAL & CARPENTRY
Applicant Address Phone: Insurance:
P O BOX 273 (413)667-3149 WCC-500-5008253
HUNTINGTON, MA 01050
ISSUED ON:04/06/2022
TO PERFORM THE FOLLOWING WORK:
STRUCTURAL REPAIR
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:
Gas: Final: Final: Rough Frame:
Rough: Fire Department Driveway Final: Fireplace/Chimney:
Final: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
• • T,
'1 •
II
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
SZ., The Commonwealth of Massachusetts ot , FOR
Board of Building Regulations and.StanJardhPR - 5 2022 MUNICIPALITY
Massachusetts State Building Code, 780 CMR USE
Building Permit Application To Construct,Repair,Rent-F4t i) i0:szRevised Mar 2011
One-or Two-Family Dwelling_ ;�nTI a,,, 0r, r.,n o,oho
This Section For Official Use Only
Building Permit Number: 113(2'r ) 3 (-12 Date Applied:
c-v1/..) (Z55 y-6-zozz
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessor4lap& Parcel Numb s
1R1 It1a�.tic e ,AD - as--v 6 7
1.1a Is this an accepted street?yes X no Map Number Parcel Number
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:
Zone: Outside Fl.•• -one?
Public Private 0 Municipals On site disposal system Cl/ Check if yes
SECTION 2: PROPERTY 1 ERSHIP'
2.1 Owner'of Record:
119AR1eAie n1 iizt .ne)ArNce I in - 0/06g
Name(Print) City,State,ZIP ,c
`
1!2.1 f/e Ike A)ce '/3- 3,96 - /61/ 1YiA4/,t),�oA%ems " 6;3/4f/, c. o �
No.and Street Telephone Email Addr
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building Owner-Occupied 0 Repairs(s) Jd Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other p' Specify: 5Tps,.( i,c4/ t
Brief Description of Proposed Work' `f Pt p!d E -r C A)e C i f e Al- yy/a�� -
i c4 C c-, je %/ I ut>s it t vA-. �,,vci2ofP 'e ��i� q I.�¢Fe
f. ),y/( X ,,(,� ../c /bl Peed ) 1j3)4fc12 st-P t i� t
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building $ 3,3se . e'-0 I. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ 1�
Suppression) Total All FeeNti #
06
6.Total Project Cost: $ ,-3 . -, O .cry Check No. Check Amount: Cash Amount:
f 3 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES O
5.1 Construction Supervisor License(CSL) G S � SD y�! r '
D W A /I4 t,J 1e{' A017.,t .57-R, ..4„e,' $ License Number Expi 'on D e
Name o CSL Holder ,� C ht ieP e- ? List CSL Type(see below)
No.and .1gStre ZI X 17 3' T Description
G°� Unrestricted(Buildings up to 35,000 Cu.ft.)
//t/Aie*Pdv..91 -c,,) r 41 A eve 5 O R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
1f 2 SF Solid Fuel Burning Appliances
4/3-le6 - 3/- C> Apt Clap p P.ti 14 `q 6n4A;/ 1 Insulation
Telephone Email .•dr' L' •C aft D Demolition
5.2 Registered Home I provement Contractor(HIC)
e c lit y D a 9aa 3
HIC Registration Number Expirati Date
HIC Company Nag o Registrant Name
6t B o X 0e3 ill rA Aso eAth 6 41, -i I, c c 0-1No.and Street Email address
�No,✓ ,.� 4,,) ,. pi" • oie sd 4/3 9 9-3/y 0
City/Towntate,ZIP Telephone
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:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES`/ FORJ BUILDING PERMIT
_
I, Owner f the subject property,hereby authorize Pa'le g /�4yf/ J /k vl/'tvi /to act on my behalf;in all matters ruit application. V
I') 1 .5—• ZZ
Print Owner's Name(Electronic Signa Date
SECTION 7b: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 true and accurate to the best of my knowledge and understanding.
r) 11 -5 - 2z
Print Owner's or horized en lectr 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.) (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"maybe substituted for"Total Project Cost"
The Commonwealth of Massachusetts
n Department of Industrial Accidents
• s"s`....
1 Congress Street,Suite 100
:�W?t= Boston,MA 02114-2017
.^ r'!' wwwmass.gov/dia
11 utkers' Compensation Insurance Affidavit: Builders/Contrsetors Electricians;Plumber,.
TU HI. IYLED%1 I I II I IIE PERs1I rrIN(:Al'111O141 1 1.
Applicant Information ���� f / Please Print- I.c ibly
Name iBusiness Organtiauon Individual). >tie /� #4' Lc%; t"c'.' A.f S a 7„„...,i,,`/,.r,,1 ,;,, '��24�,f
N
Address: i. e ,
ige A- -Al'>..7) _...._
City/State/Zip:_/f ,,)4f ffJ c;%,J r,Q$/$ 0f 0 3d Phone#: At/:3 Le ie'2- 3 VI,
Art yen tin employer?(beck the appropriate hits:
IV pe of project(required):
I.EI I am a.mploycr with employees(lull and or part-time,• 7. D New construction
MI am a wile prupretur or lurtncrship and hase no employers working for teem 8. O Remodeling
any capacity (Nu winters'comp.insurance requar l.)
30 I am a homeowner doing all work myself.(No*otter;corm.rnwrur.requital]'
9. El Demolition
10 0 Building addition
4.Q I am a hornouwner and w dl he hiring contractors to conduct all work on my property I v.1111
en+urc that all csmtr-acturs either hase worker'cunihensalson insurance or arc wile 11a Electrical repairs or additions
proprietors w ith no employees
12.0 Plumbing repairs or additions
50 I am a general contractor and I has a hired the subcontractors listed tin the attached sheet_
130 Roof repairs
i h.se sub-contractor,.has a employees and has a workers'.imp.insurance. /
6.0 We an:a corporation and its officers hase exercised their nght of e.xemptiun per M6L c.
14. Other ST rc.c-1 1
15_.►1141.and we tease no employees.(No worker,'comp.insurance required.( r r
C'rs! /- rCO-/- ;44
*Any applicant that sheiks box a 1 must also till out the section below show mg their workers'compensation poly.} infurmatiun.
Homeowners who submit this at1-idasit indicating they an:doing all work and then hue outside contra.tors must submit a new affidasit indicating suck
:Cunt:actor.that check this but must attached an additional sheet show mg the nano of the sub-contractors and state w hciher or not those entities hase
employees If the sub-contractors Kase employer...they must pruside their worker'comp policy number
I am an employer that is providing workers'compensation insurance for ter) employees. Below is the policy and job site
information. )
Insurance Company Name: : p 0 11— d S 50ci.4��Qj £' ](ff la viz< 7-N_S u e.AAkc e C 11
Policy#or Self=ins.Lie.#: W CC —re �S— ,� S3 anA I J ,Expiration/ Date: S/M/ ;,20
Job Site Address: f, V r/Da e4t/C 2 C City:State.'Zip:. __Flo Flo/Qe41C-P; i7JJq O j4 o ;l
Attach a copy of the workers compensation polky dfJeclaration page(showing the policy number sad expiration date).
Failure to secure coverage as required under MGL r. 152. §25A is a criminal violation punishable by a tine up to S1.500.00
and or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage seriticatii,n
I do hereby certifj'under the pains and penaWes efperjury that the information provided above is true and correct.
Stgnaturi : Z 0 L. k. 17dt. Date ist - 5 1 .-
Phone -- [p: /f'3eg? ' 3/'
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):
I. Board of Health 2.Building Department 3.City Joss n Clerk 4. Electrical Inspector 5. Plumbing Inspector
. 6.Other
Contact Person: Phone*:
City of Northampton
O <MAMf-- �5....- . Si
• - Massachusetts �4, k_ '<<
Cr.
d 1 ' • �G DEPARTMENT OF BUILDING INSPECTIONS ?'
>.�. -�• ' 212 Main Street • Municipal Building v`, CV
\N ='"� 6 Northampton, MA 01060 J.. i 46°
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: t) J(e yP P 9 r/;A) 123Iq 9$//v.,1,7 ,J O2
AJOteti<tiq -k9,-C f /27 g, )113 - 5n - -4/;RE2
The debris will be transported by:
Name of Hauler: 4 ( /e y
Signature of Applicant: i 'c44 ) Date: ' - r` z