22B-037 File #BP-2022-0441
APPLICANT/CONTACT PERSON:LOUIS MONTGOMERY
PO BOX 951 WILLIAMSBURG, MA 01096413-268-2028
PROPERTY LOCATION 24 CORTICELLI ST
MAP:LOT 22B-037-001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Building Permit Filled out
Fee Paid $169.00
Type of Construction: WORK SHOP ROOM UNDER REAR ADDITION
New Construction
Non Structural Renovations
Addition to Existing
Accessory Stricture &
Building Plans Included:
Owner/ Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PB�ES'�NTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:*
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Spec ialPernit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
pticApprovalBoardofHealth Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
/77Z W- 28•2ozz
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
The Commonwealth of Massachusetts 1 O - �
„ •w Board of Building Regulations and Standards " `/ FOR
!{i Massachusetts State Building Code, 780;tcM 6 20 IY'UNICIPALITY
t or- Ai USE
Building Permit Application To Construct,Repair,Renov'a'Ce1a{"�D , ash a Reviskd Mar 2011
One-or Two-Family Dwelling !,;o. ,;C .
This Section For Official Use Only �' a�-
Building Permit Number: QAa� ' y ci/ Date Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
ZI-( GOR-11 L l S 3 03 7
1.1a Is this an accepted street?yes `" no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
..vc:2/4 S L/,./
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:
Public jar Private 0 Zone: _ Outside Flood Zone? Municipal%On site disposal system 0
Check if yesj0
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
6�
��>C i rC �2of2.P.4NG� ti ri1.A- C7l 06 2-
Name(Print) City,State,ZIP /
7-'{ Gbrz-T C- i $'r 043)SIN(-Can 9rakv ( etiK0.544Q'1t,cool
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ Existing Building g Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work': Con's/,A o�T wcv,,_/C SAi0,3 /2v0, -r v"e.0'-ew
/Xr/S/ei'`9 ./2 ,a/L .A¢CI' '''i;ar-, ON "-lows/2--
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 2a 00.0 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ CI Standard City/Town Application Fee
6 , oaa 0 Total Project Costa (Item 6)x multiplier x
3.Plumbing $ ,y/j1 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire Total All Fees: $
Suppression) $ /�I/,
Check No. 6)- Check Amount Wit Cash Amount:
6.Total Project Cost: $
Z�i/0 0 0 0 Paid in Full 0 Outstanding Balance Due:
The Commonwealth of.11nssachusttt.s
Pi- • -r1I 'a/ Department o/industrial.-lecirlent.s
16 r rr w �i, 1 J
Tsi
ems.
s I Congress Street,Suite 100
d irlt r 3 Boston, MA 02114-2017
:, . . wIvw.mass.gov/diu
Nu kcrs' ( omprn+atiutt Insurance .s Hide*it:Builders/Contractors/Electricians/Plumbers.
It)HE.FILk.()%%I I H I lIE PER'11T1'lNG AtTn(114.111l.
Antillean(furor Million Please Print L,eeibis
Name(Husiness-dhgantzzationtndividual):
Address:
•
City!State/Zip: Phone#:
Are yea as rtgttmer?Om the appropriate toes: Type of project(required):
LID t am a employer with euzlv„ycc s(full molar part-time! t)n
' 7. 0 Nest cmtrUCtton
�i am a mile proprietor or partnership and hate no employers working forme m $• (a Remodeling
any capacity.[tio workers'comp.insurance requital
30 i am a homoow t,e7 doing all work myself.1Alo workers'comp.rrieuran a requwcd.l'
9. Demolition
i 0❑Building addition
4. I am a h/a tsctiwand v.ner ill he hums txmU tin actors to conduct all work my property. t wilt
u ensure that all contra tors either lute*others'hire►imurance ur mr sole 110 Electrical repairs or additions
piurnetors v.nth no ertapluyces.
12.0 Plumbing repairs or additions
5.0 I am a geatral contractor and I have hard the sub-contractor,listed on the attached sheet.These sub-contractor.have employe...-.and have workers'comp.insurance. 130 Roof repairs
14.0Other
h.E]10,a are a erimoratiun and its officers hate exercised then nght of exemption per MCA.c.
152.SItai.and we hate no employees.[%o worker'comp.insurance required.)
*Any applicant that chocks box nI mint also till out the section below showing their workers'compensation policy information.
t Homeowners who submit this aluriketit indicating they an:idling all work and then hue outside contractors mint submit a new at'fidasit indicating such.
:Contractors that check this box must attached an additional sheet show mg the name of the sub-:oatractors and state whether or not those entities hate
employee, lithe sub-contractors hate en>lrlot oes.they most protide their workers'sump.polies number
ant on employer that is providing workers'compensation insurance for my employees. Below is the polity one!joh site
information.
insurance Company Name: —
Policy#or Sell-ins.Lic.#: Expiration Date:
Job Site Address: tits State Zip: _
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 S1.500.00
and'or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 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 verification.
/do hereby certify under the pains and penalties of perjury that the in/armation provided above is true anti correct.
St'nature: ter—' /'7/' f l t/ Pc-r_r 1 Z Z
Phone?:
Ofcial use only. Do not write in this area. to be completed by rill or town official
( its or Town: I'crntit License a
Issuing Authorih (circle one):
I. Board of Health 2.Building Department 3.( ity Tossn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
t uatae t Person; Phone*:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
O /lY7/ /i�is Ar
L�O�/!'l ✓ l�D.�t6o License Number Expiration Date
Name of CSL Holder
31 , f �,4-777, `/ / List CSL Type(see below)
No.and Street Type Description
l U Unrestricted(Buildings up to 35,000 cu.R.)
G✓! ll�,.zr 4" i t y "id 2/D%�r R Restricted 1&2 Family Dwelling
City/Town,State,ZIP `J M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
V/3 Z G zaza/ I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
/73 / 3 7 Z3
S J' d HIC Registration Number iration Date
HIC Company Name or HIC Registrant Name
A/7:c4- P/,/,/724
No.and Street Email address
e,.-/l/e.4-•ter /4cac/ Glof .
City/Town,State,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 0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize I-0%J t S tl 0/3 Tr.OW IE PY
to act on my behalf,in all matters relative to work authorized by this building permit application.
P L—tc 1A-kiev kt j a I Zri2Z
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER1 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.
Print Owner's or Authorized Agent's Name(Electronic 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"may be substituted for"Total Project Cost"
City of Northampton
Pf,.A Mp i
�C.— Ory SAS Sif'.,
"�• Massachusetts ��? x- e
H Y �.
". W.1 '''', 1 DEPARTMENT OF BUILDING INSPECTIONS ti a
'te' k 't"'a '^ 212 Main Street • Municipal Building •Jti D
l Northampton, MA 01060 �sPhi a/9x'S`
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: Ua /f.r /C,,,c .", , .S'ua7r1i S T A/ //4 ,rW
The debris will be transported by:
Name of Hauler: s//4 4 z/ a1,•t/ f s1 vc-/t i'*'I /Z TT It.) / -z z
i
Signature of Applicant: Date: y Z/2L
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