25C-164 (4) BP- 022-1016
18 ORCHARD ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
25C-164-001 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-2022-1016 PERMISSION IS HEREBY GRANTED TO:
Project# 2022 FIRE DAMAGE REPAIR Contractor: License:
Est. Cost: 19000 DAN HAN 101146
Const.Class: Exp.Date: 10/24/2023
Use Group: Owner: LLC MZZ LUCKY
Lot Size (sq.ft.)
Zoning: URB Applicant: DAN HAN
Applicant Address Phone: Insurance:
25 WALLASTON AVE (617)721-4620 travelers
QUINCY, MA 02170
ISSUED ON:12/05/2022
TO PERFORM THE FOLLOWING WORK:
INTERIOR RENOVATIONS, UPDATE WIRING 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 VIO' ATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
1' Q' '.� •
• s
Fees Paid: $1 33.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
We cc u_)6/5 .4-) 2PGLC1C Y
, i AUG 1 8 he Commonwealth of Massachusetts
�E,
I 2022 Office of Public Safety and Inspections
Massachusetts State Building Code(780 CNIR)
DEaT OF ppli ation for any Building other than a One-or Two-Family Dwelling
_.� ��^,O/ITFg4MPTh MA�' O N3 ( is Section For Official Use Only)
Building Permit Number dA' j Date Applied: Building Official:
r SECTION 1:LOCATIO
l
\ No.and Street ty/Town Zip Code Name of Building(if applicable)
Assessors Map# Block#and/or Lot # fr2
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[Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2)
Change of Use 0 Change of Occupancy 0 Other 0 Specify:_-
Are building plans and/or construction documents being supplied as part of this permit- ”lication? Yes 0 No 0
Is an Independent Structural Engineering Peer Review r quired? • Yes 0 No 0
Brief D ription of Propose Work: Gi
: eri or- 'e. 11ct.U4.— ► cm s_-j... tot 1°)d c)ir K:
3
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) ❑
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 0 A-3 0 A-4❑ 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❑ 1-3❑ 1-4❑ M: Mercantile 0 R Residential R-10 R-2 0 R-3 0 R-4 0
S: Storage S-1 0 S-2❑ U: Utility 0 Special Use 0 and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 0 IB ❑ IIA ❑ IIBD IIIA ❑ IIIB ❑ IV 0 VA El 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:
A trench will not be Licensed Disposal Site 0
Public 0 Check if outside Flood Zone 0 Indicate municipal❑ required 0 or trench or specify:
Private 0 or indentify Zone: or on site system❑ 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❑ 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:
City of Northampton
Massachusetts 'w �_ <�
t111,C f;
b DEPARTMENT OF BUILDING INSPECTIONS
sV �, . 212 Main Street • Municipal Building �/-
-.....4,.^,,^" Northampton, MA 01060 's'�-,� :. ��"
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR COMMERCIAL &
MULTI-FAMILY NEW CONSTRUCTION/ADDITIONS/ALTERATIONS
1. Building Permit Application signed by legal owner and filled out by owner or authorized agent.
2. One set of plans and specifications of proposed work (Digital & Hard copy).
3. Site Plan with location of proposed structure(s) and setbacks.
4. Construction Debris Affidavit filled out and signed by applicant.
5. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
6. Contractors must supply a copy of CSL and proof of Liability Insurance.
7. Energy Conservation Compliance Certificate (if applicable).
8. Note any Conservation and/or Special Permit requirements (if applicable).
9. Driveway Permit (if applicable).
10. Proof of Water and Sewer entry fees paid (if applicable).
11.Trench Permit (if applicable).
12. Initial Construction Control Documents filled out and signed by the Registered Design
Professional in responsible charge.
13. Please provide the appropriate fee in the form of a check made payable to: The City of
Northampton
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Ad• ess of Property Owner
A. M2 y LL(. 1 orchoyci S , NVjetm gtini o(o6 D.
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
si C t z.H (A 9/7 -S61)- 92-07 -__-
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes:
DAIA ) . 1f1.v 25' u/jI [&54-(1`-' Pie Qom,'•47 kN o2,7v
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 1a 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 0.
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)
90.v\ I) , [-EA0 . 617 7114-jzt) P16147,40 I?
Name(Registrant) Telephony,G o. ` e-mail addres,2 T' I' R gistration Number
'2-S W cell r--sfi I) ✓ (A 1vv V `7 ( +�!
Street Address City/Town State 0 Zip/70 Discipline Expira ion Date
10.2 General Contractor
•
1n • LI C�✓1 / J� `9/i?% dvr 1v 0 �
Comiany Name
Name of Person Responsible for Construc n License No. and Type if Applicable
)$ w i1ts�J ve Q�,'0c t_ d 217o
aStreet Address City/Town/ State Z
Telep72 I 2 v _ _Avt4 20� f��4 02/ 9 D �4 . '(cam
hone No.(bu iness) 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 D No D
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ 47 a tp , Building Permit Fee=Total •nstruc:.' Cost x (Insert here
2.Electrical $ ,/0 69 & appropriate I tip 1 fact .
3.Plumbing $ L•0 p' el
4.Mechanical (HVAC) $ [ Note:Minimum f . =$ co. 4 ct municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ / q, a e c7 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby :ttest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to . e best of my knowledge and understanding.
?1-- ' ��fr, 7r- / - / 772/ 16'2 c
Please • name / At/e'ativ,19/.
Title Telephone No. Date
5 k/2 1//` 6 ,4,7 ,4#1 O._217c,
Street Address City/Town State Zip Email Address / ^ 2
Municipal Inspector to fill out this section upon application approval: /12— it Z /'&Z Z
Name Date
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD _ SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton
Massachusetts
n V
DEPARTMENT OF BUILDING INSPECTIONS tT
212 Main Street • Municipal Building
Northampton, MA 01060
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( Ar y'ZI `v4— C �s
The debris will be transported by:
Name of Hauler: $ 4
Signature of Applicant: Date: _ cc 2
,.
The Commonwealth of Massachusetts
' 0 Department of Industrial Accidents
: 1 Congress Street,Suite 100
Ai
Boston, MA 02114-2017
-,- ' www.mass.gov/dia
111,1 kers'Compensation Insurance Affidavit:BuilderseContractors/ElectriciansaPlumbers.
ft)HE FILED WithI'UBE PERSII YUNG ALTHORI'l-E.
_Xonlicant Information Please Print Lodi*
Name(Business.(hganua lion Individual):
Address:
City/State/Zip: Phone#:
Are yen a employee Cheek tie appropriate hot: Type af project(required I
1.0 I Arti a employer watt_eir4p4ioyees rfull:motor part-tune f.• 7. J New construction
t am a sole proprietor or pardnership and have tki eniployer:s vs orkuts for r)k tn 8. 0 Remodeling
any,:apa4.:Ity.(Nu*Laken'comm.insurance regurnalj
9. 0 Demolition
10 1 am a hunWOW11471 doing all 4 mi.arpelf[No workers'comp.istoarance required.)'
I 0 0 Building addition
4.0 I am a homixv-rsh and will he hning s.untractort to otioduct;di*ork on my property. I will
ensure that all contractors either lute YhOrkerS'Cueruprzuation insurance tir are sole 1 1 rj Electrical repairs or additions
propnictors with nu employees.
12.0 Plumbing repairs or additions
5,0 I am a general contractor and I have hued the sub-contracturs listed on the attrwhed,t,xt
1.3.ci Roof repairs
Th.....e iob-eontractura have employer s and has e*takers'comp.eitiarance)
1 4.C:i Other
ts.[:j We are a corporation and As officers have ex.:mt.:4:d then ng hi 4,r exam :on per M(iL c.
I.1,2_..‘.,1 i-1 I.and•Ac ha.,c nu 013pieJyCiN.[NO Or uticrs',:omp U.LNUTLIZICC nolo:rd.!
•.kr.s applicant that..ito,.-1..,.box,s I must also fill out ilic secturn bd..'N stowing their workers'compensation policy informatbrat
'Horns:owners whir submit this affidnv it indieating thev arc doing all work and then tare ouktiiie etintractors room tobritit a new affidav it iralicaling itch
*,Contractor:that check din but must altathed an 3t1ilillnald ibet I:how inn the name of the.itt,-...eaitr.betari and Attie'whether Of nut those entities have
cmplory cc:. If the sub-contracturs bzurc emplo:.cc:.at..!. ilium prw.idc their is orkers',-,--Inp,rti lir:.number
...
I UM an employer that Ls providing ovorAerN'i umpenNution insurance for my employees. Below is the policy and Job site
infOrmation.
Insurance Company Name: _
Policy*or Self-ins.Lie.4: Expiration Date:
Job Site Address: CityStateiZip:
Attach a copy of the workers'compensation polky deciaradon page(shouing the policy number sad expiration date).
Failure to secure coverage as required under NIGL c. 152. §25A is a criminal violation punishable by a fine up to S1,500.00
andor 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
average verification.
I do hereby certify under the pains and penalties Iti fr c'rimy dtot the information provided above is true and correct.
Signature: Date'
Phone#:
Official use only. Do not write in this area.to be completed by city or town official
("its or Tow n: Permit/License a
Issuing Autheirit!, (circle one):
I. Board of Health 2. [kidding Department 3.City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone 4:
Initial Construction Control Document •
i!ry To be submitted with the building permit application by a
CRegistered Design Professional
v for work per the ninth edition ofthe
' h ' Massachusetts State Building Code, 780 CMR, Section 107
Project Title: Date:
Property Address:
Project: Check(x)one or both as applicable: New construction F d iting Construction
Project description:
I MA Registration Number: Expiration date: ,am a registered design professional, and I have
prepared or directly supervised the preparation of all design plans,computations and specification concerning''-:
Architectural Structural Mechanical
Fire Protection Electrical Other
for the above named project and that to the best of my knowledge, information, and belie such plans,
computations and specifications meet the applicable provisions of the Massachusetts State Buil - Code, (780
CAR), and accepted engineering practices for the proposed project. I understand and agree t I (or my
designee)shall perform the necessary professional services and be present on the construction sit on a regular
and periodic basis to:
1. Review, for conformance to this code and the design concept, shop drawings, samp s and other
submittals by the contractor in accordance w ith the requirements of the construction d ents.
2_ Perform the duties for registered design professionatc in 780 CMR Chapter 17, as applicab _
3. Be present at intervals appropriate to the stage of construction to become generally f - `ar with the
progress and quality of the work and to determine if the work is being performed in a m er consistent
with the approved construction documents and this code_
Nothing in this document relieves the contractor of its responsibility regarding the provisions of ` CMR 107.
When required by the building official,I shall submit field/progress reports(see item 3.)together 'th pertinent
comments,in a form acceptable to the building official.
Upon completion of the work,I shall submit to the building official a'Final Construction Control Document'.
Enter in the space to the right a"wet" or
electronic signature and seal:
Phone number: Email:
Buthizng Officthl Use Only
Building Official Name: Permit No.: Date:
Note 1.Indicate with an'x'project design plans,computatons ardi speoficatons that y ou prepared or directly ..,,. '- • If'other'is
chosen.provide a description.
Version O1 01 2018
Appendix 1
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required. The applicant shall fill out
the checklist and provide the contact information of the registered professionals responsible for the
documents. This appendix is to be submitted with the building permit application.
Checklist for Construction Documents*
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing(include local connections)
9 Gas(Natural,Propane,Medical or other)
10 Surveyed Site Plan(Utilities,Wetland,etc.)
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investigation
16 Energy Conservation Report
17 Architectural Access Review(521 CMR)
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified
must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the
authority having jurisdiction.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address
Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address
Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Please follow this link for construction control forms to be used by Registered Design Professionals.
From: 1-7n. Y1
a I 5't7/ P 0 2 / 7 v
/ - 7 z / --- 4- 6 z �
To:
Jonathan Flagg
Building Commissioner
City of Northampton
212 Main Street
Northampton, MA 01060
The Massachusetts Building Code, section 107.1 allows for an exclusion from requirements for
construction control in certain situations. In accordance with code section 104.10, I request that you
grant a modification to waive the requirement for construction control of the project at
because the work is of a minor nature, will not affect structural elements, health, accessibility, life or fire
safety, and will be done in accordance with the prescriptive requirements of the code.
Thank you for your consideration.
Respectfully,
f � ^
AcG CERTIFICATE OF LIABILITY INSURANCE D'l'EINMrDOTYYTYI
....� 0 „7 4E2022
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HI{OLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER CONTACT
NAME: _..........
PHONE
Alatttiews i"s irarce AgenC!' (A/C,No.EMI: (781)32?-8786 tN4 N41 (7, 1)324.5215
160 Pleasant Street ADDRESS
Mal0tr.MA 02 idfl INSURERS)AFFORDING COVERAGE
... INSURER A Travelers Insurance
INSURED ................_ __..._.................._ .......... ... ...._...... __.
INSURER • `
Dan Her Construction INSURER C
25 Wollaston Ave
INSURER D
Ou ncy,MA 02170 INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
'Hs IS TO CERTI+°Y THAT THE.POLICIES OF INSURANCE LISTED HFLCIN HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE FiOLICY PERIOD
INDICATED NOTWITHSTANDING ANY RFOUIREMI_NI TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE: ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXC,,USIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSF._......._.. ... ..._._. ADM SOON'.___ __. .._ ..._ POLICY EFF'.POLICY E7CP __ ....._.______.._..._ .....
Ll R TYPE OF INSURANCE INSR YiMQ POUCY NUMBER IMN/DDryYYYI IMMIDOlFYYYi: LIMITS
GENERAL.t/ABNITY EACH OCCURRENCE (S
GAM DE TO RENTES�
r�r+tr.?EaGw.GFNERfL;.Ind}ILLY~ ,E3.CNSES SEa occ ae?tftl S_.___.�..._.._._
.... C.A1x'S•stoDE. ........OCCUR MEED EXP(My ore person` $
t''ERSONAL A AOV INJURY
$
_ - GENERA.AGGREGATE 'S
GE' Ar•6F2E:zx.'E OW-AP$'L cS ITER, '"nODUCTS-COMPKkw AGG 3 ...............
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AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
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ANY aU'U BODILY INJURY IPor portant S
A.I.OYiNEC • SCItEOJLEED BODILY INJURY(Par accidonl) $
_.... AUTO$ AUTOS..NON WNED PROPERTY DAMAGE
: _ I S
.Net AL,OIL, A. 1> (pot'ercatonfl
...._... _.._
UMBRELLA-LAE EACIt uc.CURRENCE
EXCESSUAB .1 AWLS-MADE AGGREGATE
GILD -R 7eU` .ONt S .
-'•'- tVC STATLA ,011+.
WORKERS COMPENSATION IORY.LIMITS:_...„_._ ER
AND EMPLOYERS'LABILITY Y f N _
rw+aROPRIE7C)R, RTNEWEXEcAnidE (_ _.I 6HUB-6Btf}709-922 0711212022 07112/2023_ELEACHActyDExT $ 1DO,OOD
A (Mandatory
6EA61ERcxwJLF!D% (NIA E.LD( EASE-EAEMPLOYEi 1 ........_ it10,000
(Mandatory`in NH} _..
ae dctcnEa sib - _ 500,000
SE RI PT ION OF OPERATIONS!:,oL:wr _ .....�.
EL DISEASE-POLICY UMRt
DESCRIPTION OF OPERATIONS:LOCATIONS VEHICLES(Attach ACORD 101.Additional Remarks$chWVle.If more spact is nquiradt
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
AUTHORIZED REPRESENT/LT
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ACORD 25(2010?05) 198 AC 8-2010 ORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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