24B-086 (5) BPJ2022-0953
26 CARLON DR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
24B-086-001 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-2022-0953 PERMISSION IS HEREBYGRANTEi TO:
Project# WALL Contractor: License:
CITY OF NORTHAMPTON CENTRAL
Est. Cost: SERVICES 057642
Const.Class: Exp. Date: 12/25/2023
Use Group: Owner: NORTHAMPTON CITY OF NEW FIR STATION
Lot Size (sq.ft.)
Zoning: HB Applicant: CITY OF NORTHAMPTON CENTRAL ERVICES
Applicant Address Phone: Insurance:
Memorial Hall (413)587-1260
NORTHAMPTON, MA 01060
ISSUED ON:08/12/2022
TO PERFORM THE FOLLOWING WORK:
BUILD WALL
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: a 326i5,
e, „
Fees Paid: $
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
\---TIECEIVET51.
; AUG 1 0 2022 Th Commonwealth of Massachusetts
Office of Public Safety and Inspections
.s pFaT.of uu - ¶NSPFC1IONS Massachusetts State Building Code(780 CMR)
"-oliptlistiotingrPellititt Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number:#7.1• 4963 Date Applied: _ Building Official:
SECTION 1:LOCATION
No.and Street City/Town + , A� Zip Code Name of Building(if applicable)
Assessors Map# Block#and/ornd Lot�j#
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 Repair 0 Alteration Addition 0 Demolition 0 (Please fill out and submit Appendix 2)
Change of Use ❑ Change of Occupancy 0 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ..
Is an Independent Structural Engineering Peer Review required? Yes 0 No igt
Brief Description of Proposed Work:
hi:
�� S er�rr Ices l.,z,,,�c t �chN.h=os Ass? at
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SECTION 3:COMPLETE 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) 0
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 ❑ A-3 0 A-4 0 A-5 0 B: Business 0 E: Educational 0
F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0
I: Institutional I-1 0 I-2 0 I-3 0 I-4 0 M: Mercantile 0 R: Residential R-ID R-2 0 R-3 0 R-4 0
S: Storage S-1 0 S-2 0 U: Utility 0 Special Use 0 and please describe below:
Special Use Description
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 0 IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV CI VA 0 VB 0
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:
Public 0 Check if outside Flood Zone 0 Indicate municipal 0
A trench will not be Licensed Disposal Site 0
Private❑ or indentify Zone: or on site system 0 required 0 or trench or specify:
permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable 0 Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No 0
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction:
Does the building contain an Sprinkler System?: Special Stipulations:
Design Occupant Load per Floor and Assembly space:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Pro erty Owner
a 1 St ri Jl rt. 7. /r-t '
Name(Print) No.a d Street City/Town Zip
Pro erty Owner Contact Information:
cti- /-n u-,Lvq-h Lf13 riti$7- /306 L'�3 = 2129
Title Telephone No.(business) Telephone No. (cell) es �
e-mail . `
If applicable,the property owner hereby authorizes: Ov
Name Street Address City/Town State Zip
to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1)
If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑.
Otherwise provide construction control forms(see section 107 in the code)as required.
10.1 Registered Professional Responsible for Construction Control (the professional coordinating document submittals)
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
_____14/2 r 4- CP I c, is '{fit.-
Compa ame (
Haft m6 h CS - o6-7CP4.: .
Name of Person Responsible for Constriction License No. and Type if Applicable
2LtQ mua` Si-- SC) - 3 id ii". -`-t __--
Street Address 'City/Town State Zip
4r - 1 1ado LII-2, 63► aZ2 �h‘rtel k.-t( to hor+inPau -fir -- -1,66
Telephone No. (business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT (M.G.L.c.152.§ 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes 0 No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) =$
1.Building $
Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)=$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ 6157) (contact municipality)and write check number here
J
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 accurate to the best of my knowledge and understanding.
Oa_.-t-- nt r =c/ 41(3 �81.- 130‘ 8 , ." zz-
Please print and sign nam r Title Telephone No. Date
SF- rte. 3 7lfo�-��r.�a,._ rn- }-
Street Address City/Town State Zip Email A ess —/bJ
Municipal Inspector to fill out this section upon application approval: r ' •
' "
Name I ° D to
The Commonwealth of Massachusetts
f v*., .411101M fl. Department of Industrial Accidents
C _ idl= 1 Congress Street,Suite 100
E_= Boston,MA 02114-2017
v� ,...,—, www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name (Business/Organization/individual):
Address: 4 fi l.c.,._ si- S�
City/State/Zip: N, t:l= .. Phone#: lfi i" - tom, g-1 - I e, 'I,
Are you an employer?Check the appropriate box: Type of project(required):
I am a employer with 307 4-employees(full and/or part-time).* 7. 0 New construction
2 1 am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]r
9. Demolition
4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will
10 Q Building addition
ensure that all contractors either have workers'compensation insurance or arc sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0 I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13.0 p
ROOF repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.0 We arc a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,*I(4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Mt l j
Policy#or Self-ins. Lic.#: Expiration Date:
Job Site Address: a .1Cod to,,,,,,,., i'- e City/State/Zip: ki
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expirati date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$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
coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: ._a Date: t
Phor)e#T l'1 1 c "I- I O C.
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):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work: Oa ft,v. tie L, L\tEN r .
The debris will be transported by: &C -
The debris will be received by: l'
Building permit number:
/73
Name of Permit Applicant r �
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Date Signature of Permit Applicant
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