10B-004 (5) BP-2022-1161
94 AUDUBON RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
10B-004-001 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-2022-1161 PERMISSION IS HEREBY GRAN TO:
Project# REPAIRS Contractor: License:
Est.Cost: 179000 THOMAS DOLAN 039281
Const.Class: Exp.Date: 12/08/2023
Use Group: Owner: H LASHWAY WILLIAM J&LEE
Lot Size (sq.ft.)
Zoning: RR Applicant: THOMAS DOLAN
Applicant Address Phone: Insurance:
P O BOX 297 (413)297-5164 SOLE PROPRIETOR
CHESTERFIELD, MA 01012
ISSUED ON:09/19/2022
TO PERFORM THE FOLLOWING WORK:
REPAIRS DUE TO FIRE
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 VIOL TION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
i r
Fees Paid: $1,163.50
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
•
RFc
The Commonwealth of Massachus s SFio 4 .
W Board of Building Regulations and St dar j
Massachusetts State Building Code, 7 0 C 6 �Q� US ITY
4, oP
Building Permit Application To Construct,Repair,Renova tlft ' a R ised ar 2011
One-or Two-Family Dwelling '70A iNsp• F
This Section For Official Use Only Mq o'0so Ns
Building Permit Number: 617"A A 'fla l Date Applied:
I I Yao,
'Ib �� ieiIABuilding Official(Print Name) Signature
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
9L/ 40afo6vit Rn ABeds ttjp.. l
Q60 O1.1a Is this an accepted street?yes V no Map Numeer 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:
Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
x 2.1 Owner'of Record:
als/haa. Aar A)02f4 w 4 y 4 weds Ma.. O l 053
Name(Print) City,State,ZIP
?Y 'ludo boa RD Y13-S811- y/7/ —
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) V Alteration(s) 0 Addition 0
Demolition ( Accessory Bldg. 0 Number of Units Other 0 Specify: f e14,v. ,S1sao.Ee
Brief Description of Proposed Work2: De,w+a.,e 6,4a41,0.dt'l 6444t r Atom aura// Dirt e
DeMo 4paciA4t.# v 6a4.a4,e aA.ywwli, A// Nets elgtegizat Phas441»d, fdtuL4M i
Z4y wale bI ii✓0ow11 .tss1. ?.r.i.w, istillt aw.s , he/f 44PI, �Lap,r,,.a�/ 74,al1-mL
aId 7b !a alone on eals-iiaid. 8a,himi._ . jonal Aii•Amtw R eiomms To
A100 . 4 ward — SECTION 4:ESTIMATED CONSTRUCTION COSTS a`x 9 Q.atitti
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building s 1. Building Permit Fee: $ Indicate how fee is determined:
1 s"b,'17a' .4 0 Standard City/Town Application Fee
2.Electrical $ sv
b,Od p, 0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ %Bog e° 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire I
d
Suppression) $ Total All Fees: $ It 143.E
C ck No.j OWO Check Amount: Cash Amount:
6.Total Project Cost: $4 pi 900 0 IIPaid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) LSD DNaJ'l /ate 8' J029-3
>° 4 7 jt/ License Number Expiration Date
Nameo "Ck Hoder "" ��
?
Nu.and Street List CSL Type(see below) a447 7 /e u Type Description
n gOI e /114.. D a / U Unrestricted(Buildings up to 35,000 Cu.ft.)
City/Town,State, iP / (/ R Restricted l&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
Lii3-g?�' /�/ _ SF Solid Fuel Burning Appliances
G �D q17) LAp/ &4 014o1.< . I Insulation
Telephone Email address .D Demolition
5.2 Registered Home Improvement Contractor(HIC)
L o47oa 9-e2t�.2y
`�l om as 4 boi-imi HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
64) Dili y SY.- G*odr low, oa6
f c 1101,gcukt,
No.and Street Finail address
, l Oj M 4 0 WO 40—a97--Sr6N
City/Towr1; 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 l' No 0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize 7 n 7 „Da kw
to act on my behalf,in all matters relative to work authorized by this building permit application.
A4J L I—r ttk Sei f /s a OsE t
Print Owner's Name(Electronic i to ) 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.
'1`IO.r7if 12) " i ‘5.e p it i°/ ?aft
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"maybe substituted for"Total Project Cost"
City of Northampton
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' I. Massachusetts A,?` <<
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(c A ,. DEPARTMENT OF BUILDING INSPECTIONS � j�-
212 Main Street • Municipal Building v'tia�
Northampton, MA 01060 rsl:W .3,O°
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: /A//ey Recyt L hip ti4w44"...41441
The debris will be transported by:
Name of Hauler: /1)rw 7)06L#11 1 r old l/ isA Sea vie,cs
Signature of Applicant: Date: ?' ly - Zz
The Commonwealth of Massachusetts
► :: Department of Industrial Accidents
' M
1.. ♦�W��, _..,...,, ,� / Congress Street.Suite 100
"• a"l: . ' Boston, MA 02114-2017
t 1 l3 www mass.g ot�/dia
VIuwkers'Compensation Insurance A111davit:Builders/Cont seton/}kctrichins Plumbers.
t'O BE FILED WITH I HE PERVIEFT NG At1THO1tlT .
Annlicant Information Please Print Legibly
Name 113ustnessOrganization,Individual I: 7 °Nati / , 04/ /. I
Address: 6, K.,( e _5 _.____----__.___(_..
City/State/Zip: V 1,bl m,ieg __-_Mb- Phone#:_____/le-A 77..- 76 . __._....._.
Ate yem an rntpkn,r?. (.'beck the appropriate hot:
Ty pe of project(required)
I-®I am a employer wath c:niployeek(lull and or pact-these!-' 7. Q New construction
: lam a aasie pnrprtetur or p rtncr leap and hate no emptasycrs VI.or'a ma for nne an X. gR4arriodcltng
any lapse sty [No worker,'comp.insurance mowed I
9. IrDerno ition
10 I am a homookknet doing all or tut-vell.[No workcas'cutup nkuraasce rttwto,l 3
10❑ Building addition
4 El I ant a homeowner and wilt be hard contnc4ort to eondurt all work on my mop:It} I a al
mane that all vault-actors either hake worker:'comfit-motion utsurance or are vole I I.O E.leetncal repairi or additions
prupnetors with no crnploycet
12.0 Plumbing repair*or additions
50 t i am a patcral contractor and l have bed the sub-cr'xntreetorr listed on the attached Jibed
ed
Mo.:sub-ctmtrscet.ro hart.employe...-.and iu e*otters'ctnnp.wurance I �Roof repairs
14.EJ Other
6-a We arc a coryaotadttn and aU oaken tusk excreted then ralthi ot exemption pet M( L c --
152 It4t.and we hake no rittpiuyees.[No workers'comp analstanc'c required-]
"Nast apptacant that clsocka box+t i mast also fell out the section below sin,*ins that atttitcrs'conspcna iiun policy uttetntattton
a Htstracwtwtacrs who submit h us attatiattt uaiacaunat tltt- are doing all work and then hire outside contractors moist submit a new affidavit iodating such
:(unuacturs that check this brit must attached an ash auunai sheet abow tug;the name of the sins-ctmtrat turn and agate V.hotter tat not Hesse rttti',ies have
t alp ivwcc, II tie,aih-contracttm h.a employ duck rrlusa pnnadc their wurittrr'tt,anp puhck nutnbet
I am an cntplol'rr that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ___,___--
Policy#or Silt=ms. Etc.#: Expiration Date.
lob Site Address: Ctty.Statt'Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and date).
I-allure to secure coverage as required under M L c. 152. §25A is a criminal violation punishable by a tine up to SI.5(It).00
artd or one-year imprisonment.as well as civil penalties in the fot»t of a STOP WORK ORDER and a tine of up S250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA f ,insurance
coverage veriticatican
t do hereby certify under the pains and penal ' cif ierjury that the information provided above is tree and correct
Stbtnature. Date , . O1 /Y ..1Oo7,Z,
Phone t 4'/3- a 9 7- 5// !i
1
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 S. Plumbing Inspector
b.Other
Contact Person: Phone*: __