22B-037 (6) 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 $169.00
Type of Construction: WORK SHOP ROOM UNDER REAR ADDITION
New Construction
Non Structural Renovations `,
Addition to Existing \ \l"A\
Accessory Structure �\ �' .
Building Plans Included: v
Owner/ Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION`P$�E'SINTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Penn it With Site Plan
Major Project: Site Plan AND/OR SpecialPermit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Perm its Required:
Curb Cut from DPW Water Availability Sewer Availability
ptic ApprovalBoard of Health Well Water Potability Board of Health
/se
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
/7,72 -I" ZS'Zozz —
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.
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The Commonwealth of Massachusetts/ �p �`
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Board of Building Regulations and Standards 1IUNIOIPALITY
Massachusetts State Building Code, 780, ,l
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Building Permit Application To Construct,Repair,Reno��?tl°i ��D 's a� Revisid Mar 2011
One-or Two Family Dwelling '�.A44 'ro4;
This Section For Official Use Only '�.�o:"
Building Permit Number: Q�-' ` yam/ Date Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
2,44 Got-i-A L6 1 S T 2- 2-'3 d3?
1.1a Is this an accepted street?yes `/ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
we K/4 S/""1
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 j� Private❑ Zone: _ Outside Flood Zone? Municipal%On site disposal system 0
Check if yesyl
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
1-kikl2a/6.3‘ r2v12.—NLe.- t I-A/- 0(06 2-
Name(Print) City,State,ZIP f II
C�►2r16.�E- 4 Si 043) -WLS$ 3r-cAm -Fe1'e �)sryla,:l,Will
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building' 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 Work2: ConrsTFt G c.f.-Gvci, /L .5//c /Zap,—r c/ R',en'
/Zr.ris/e i.q . 2 ,42 �dd;Ti o.--, 0ni t oc'S.L'-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ ZU God 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ' 0 Standard City/Town Application Fee
dao 0 Total Project Cost3 (Item 6)x multiplier x
3. Plumbing $ "VA 2. Other Fees: $
4. Mechanical (HVAC) $ / List:
"/A
5. Mechanical (Fire $ Total All Fees: $
Suppression) /V7,.
Check No. \'\ \Check Amount \LA Cash Amount:
6. Total Project Cost: $
Z"7 D 0 0 0 Paid in Full 0 Outstanding Balance Due:
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414,
' ''- The Commonwealth of Massachusetts
,!,4„ ., Department of Industrial-1 ccidents
"' 1 Congress Street,Suite 100
? t Boston. MA 02114-201,
'41;
,r:,�t-' wwwmass.gov/dia
%%orkrrs'('ompensation Insurance.Afmidasit: Buildersi(contractors/Ekctricians/Plumbers.
I'O HE FILED N flit Tt1E: PERMUTING At 1•HORI 1"ti.
Applicant information Please Print Leeibh
Name 1Husincss Organtxation lndrvldual):
Address:
City/StatelZip: Phone#;
Are you ar eaepMyee?Cheek the appropriate hot: Type of project(required):
I.❑1 ant a employer with enrpkiyecs i full and or port-Haack.' 7. 0 New construction
20 I am a sole proprietor or partnership and haze nu employees working for sir is S. 0 Remodeling
:env capacity.[Nu workers'coerce.insurance n'qurrasl.] Ky
301 am a hostrolowner doing all work myself.(Too workers'comp.imurance myuraL ' 9. ❑Demolition
l0 D Building addition
4.0 I am a homcwwner and will be hiring contractors to conduct all work on my property. 1 will
ensure that all conCraiors either have workers'compensation ursuranix or are sole 1 I.Q Electrical repairs or additions
proprietors with no employees,
12.0 Plumbing repairs or additions
5.0I am a general contractor and I have hied the wb-eontracters Wed on the attached sheet. t 30 f repairs
these subti or cmtraets have employees and have workers'comp.ielarancer
h.Z1 Vic are a corporation and its officers have exercised then nght of exemption per Wit_e 14.0Other -
1+2.§1I41,and we base no esrrpkiyees.(No workers'comp.insurance required.)
`s ns applicant that checks Eva a I must also,till out the sectnin below show in►their worker,'compensation voile!, infsrmatto n
'bknneow'ners who submit tins atdidai it tndic'ating they are doing all work and then hire outside contractors muss salrrut a new atfidas it inlieatine such.
:C omtra.tor that cheek this box must attached an additional abed,how mg the name of the sub-contractor,and sate whether or not those enhit1C,has.
employees If the sub-contractors base employees.they mere pu,'.tic shift ,s i•rlsen'eoznp pot s numb s
l am an employer that is prodding workers'compensation insurance for mt,employees. Below is the policy and job site
information.
insurance Company Name: —
Policy#or Self ins.Lie. : Expiration Date:
lob Site Address: City/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 impnsonm nt.as well as civil penalies in the form of a STOP WORK ORDER and a fine of up to S250.00 a
dad against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Siunature: �-J "I R.1'1't/ A•es Dal, y/e y/zz
Phone 4:
Official use only. Do not write in this area,to be completed by city or town ofcial ,
City or Town: Pernut/License#
Issuing Authority(circle one):
1.Board of Health L Building Department 3.('ity/Town Clerk 4.Ekctricai Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone#: __ _ __
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
O /.? V 7/ ///is�z
Go z_s ,j /IrQ ,y- c/ License Number Expiration Date
Name of CSL Holder
I ,2 Oct Coal,!, , /7 / List CSL Type(see below)
No.and Street �/ Type Description
G✓! ll!%�.�tr !�✓`c y Aid
Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
z G f Zvyi I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
rill�S J' �?dr.fosvr� l? e s"/ 07/23
y HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
p J2/7;co,t,i.',/7, "
No.and Street Email address
!s-!11 e.,4 z r /��.ac "I/! "/ fG
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 .❑
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-Oc- t S ► 1 ON TCaOaAE IZY
It to act on my behalf,in all matters relative to work authorized by this building permit application.
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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. It) 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
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>"1 .� Massachusetts
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' I q. DEPARTMENT OF BUILDING INSPECTIONS - �,
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� � 212 Main Street • Municipal Building ,�,, q
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,>.' Northampton, MA 01060 'rs{iY•^.:j.`b
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: Z/4 /( fi`z_<�;c. 4 CL,T/ S r N /1-1-Lr.P T"^'
The debris will be transported by:
Name of Hauler: Sir-1.«</ ou,K, i-16,c- sei2 TGr-)P..74,,,, ez,z
Signature of Applicant: '0 Date: yA j2
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