09-011 BP-2023-0296
325 KENNEDY RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
09-011-001 CITY OF NORTHAMPTON
Permit: Demo
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2023-0296 PERMISSION IS HEREBY GRANTED TO:
Project# FIRE DEMO 2023 Contractor: License:
J BURNISKE LANDSCAPING &
Est. Cost: 2000 EXCAVATION
Const.Class: Exp.Date:
Use Group: Owner: S ADAMS STARR S&SHERID
Lot Size (sq.ft.)
Zoning: WSP Applicant: J BURNISKE LANDSCAPING &EXCAVATION
Applicant Address Phone: Insurance:
5 MATTHEWS RD (413)378-8868
SOUTH DEERFIELD, MA 01373
ISSUED ON: 03/10/2023
TO PERFORM THE FOLLOWING WORK:
REMOVE AND DISPOSAL OF BURNED PROPERTY
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:
Fees Paid: $75.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
w
The Commonwealth of M sac seli. T
k.,1° Board of Building Regulatio s an. Stan3 s, Iv FOR
CIPAT,IT'Y
Massachusetts State Buildit g C 4. 80 CMR 9 USE
. !
Building Permit Application To Construct,Repait isp e.. Or Delis a Revised Mar 2011
One-or Two-Family Dti'ellirigtiQ^z� n�,,y,
This Section For Official Use_Oniy`'-/ 4 o, ,2'/
F / --
Building Permit Number: a �•�' Q 1 Date Applied: ___ ��_i • _
. ' - �J3o 3
Building Official(Print Name) Signature 1 I D. e
SECTION 1:SITE INFORMATION _
1.1 Property Address:
G d y PS / 1.2 Assessors Map&Parcel Numbers
1.1a Is this an accepted street?yes G[ no Map Number 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 CI Municipal Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP1
2.1 Owners of.Reco d.
S?'R/ A+diotm S LE L)S /14 14 c7 i o 53
Name(Print) City,State,ZIP
�2 c J 'cA/ve d y a., w_54 4.Sy/,3 51AP,?L +e/r)iv o L>n,
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) 0 Alteration(s) 0 Addition 0
Demolition Accessory Bldg. 0 Number of Units Other 0 Specify:_ ____ _ -__
Brief Description of Proposed Work2:
°A,Df t-L_ S- V!5 ibSol L C. f= 4,2e d A,ez ? ----
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Official Costs: Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee: S _ Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical $ 0 Total Project Cost'(Item 6)x multiplier— _x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ �( —
Suppression) Total All F if
Check No,7_Check Amount: ` Cash Amount:
6.Total Project Cost: $ ❑Paid in Full 0 Outstanding Balance Due:
ASBESTOS REMOVAL
All residential, commercial and institutional buildings are subject to Massachusetts Department of
Environmental Protection (MassDEP) asbestos regulations at 310 CMR 7.15. Therefore, owners
and/or operators (e.g. building owners, renovation and demolition contractors, plumbing and heating
contractors, flooring contractors, etc.) need to determine al asbestos containing materials (AGMs),
both friable and non-friable, that are present at the site, and whether or not those materials will be
impacted by the proposed work, prior to conducting any renovation or demolition activity.
Examples of commonly found ACMs include, but are not limited to, heating system insulation, floor
tile and vinyl sheet flooring, mastics, wallboard, joint compound, decorative plasters, window glazing,
asbestos containing siding and roofing materials and fireproofing materials.
Failure to identify and remove all AGMs prior to its being impacted by renovation or demolition
activities, can result in significant penalty exposure, and higher clean-up, decontamination, disposal
and monitoring costs.
A DOS certified asbestos consultant must be contracted to determine if asbestos is present and
whether removal/repair is necessary. If the building is a state owned facility, contact DCAM and DOS.
DOS provides a list of licensed asbestos abatement contractors and consultants. You may wish to
inquire if a contractor has any history of violations. Only DoS licensed and DOS certified asbestos
abatement contractors and consultants may be hired to perform asbestos related work in
Massachusetts.
Received by:
Print Name Title
Signature Date
BUILDING DEPARTMENT
DEMOLITION PERMIT SIGN-OFF SHEET
Date:
Address: Building Use:
Owner: Phone:
Owner's Address:
UTILITY CUT OFF
(Signature of Authorized Representative of Utility Department required)
As required by the Massachusetts State Building Code (780 CMR), a permit to demolish shall not
be issued until a release from the utilities is obtained, stating that their respective service
connections and appurtenant equipment have been removed or sealed and plugged in a safe
manner.
Eversource(Gas)
Signature Title
National Grid (Electric)
Signature Title
DPW(Water)
Signature Title
DPW(Sewer)
Signature Title
DPW(Storm water)
Signature Title
DPW(Tree Warden)
Signature Title
DPW Director
Signature Title
Historic Comm. Review _
Signature Title
Health Department
Signature Title
City of Northampton
Massachusetts .
�
f
4 DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building ;
Northampton, MA 01060 '44W.
') ;°`y�y
APPLICATION FOR DEMOLITION PERMIT
Attached are the forms required for a Demolition permit. Please fill out all of the attached forms and
submit them to the Building Department with the appropriate fee. Please make checks out to the City
of Northampton. (Cash not accepted)
Please be advised that disconnect signatures from the following departments must be submitted with
the application:
1. Eversource (Gas division)
2. National Grid (Electric division)
3. Northampton Department of Public Works Water
4. Northampton Department of Public Works - Sewer
5. Northampton Department of Public Works - Storm water Management
6. Northampton Department of Public Works -.Tree Warden
7. Northampton Historical Commission Review (if built prior to 1945)
*Proof of extermination is required to be submitted to the Health Department for all Commercial
demolitions and all abandoned residential properties. (Extermination may be required at the Health
Inspector's discretion if evidence of rodents exists).
Other required documents:
• Massachusetts Construction Supervisors License
• Copy of Workers Comp Affidavit
• Asbestos abatement report
A Demolition Permit will not be issued, and no demolition is to commence until ALL required
documents are submitted to the Building Department.
For further questions or information, please contact this department @ (413) 587-1240
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
_.-_- -----,-. List CSl.'I'vpe.(sec below)
No.and Street Type Description
_.U 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
_ I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 141 L /g5535f
HIC Company ame or HIC Registrant Name — — HIC Registration Number Expiration Date
5 /4?fritiaS i •
No. d Street /
S.-PEED 41 - o 1; �I/?j' 1 b0 Email address
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
to act on my behalf,in all matters relative to work authorized by this building permit application.
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 1,icense 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 he substituted for"Total Project Cost"
City of Northampton
sic
Massachusetts 't{
1 ' = ' DEPARTMENT. OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
- Northampton, MA 01060Ty {%;
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: '\101-fie/ Rc )i/R
The debris will be transported by:
Name of Hauler: Y-1 V f S 10s Att
Signature of Applicant: Date: 3- 6 - Z3
&N, The Commonwealth of Massachusetts
.......=
Department of Industrial.Accidents I
Vailtsgrg ' .1 Congress Street,Suite 100
....-.7.:7" .,
444" Boston,MA 02114-2017
wwortmass.govfifirr
Eaters t7rirripensation Insurance Affidavit:BuildertsiCipiirattorsitlectriciansitlumbers.
ti)BE FILED'wan THY PERM irriN(.; .riM)Rill'N.
aui licant Infortriation Please Print Lenibli
__,
Name(Bus iness:Or.i.c titration'Incl i vidittai t: -J.."Aep-p/ oPe::::;.,sect---L e...___4„es-cr4V.A--3-754A)
Address: 5 n44-F i-t /S )"Zd.
cityistatc..:zi)- 5 SA DI515
Are yob an eniptirt er?Ciotti the approprtsic bac Type of project(required):
am.i vt111)641./Viien. ,.,40.5. ert00,1,13(AM aild'Or port•time I.* 7 0 New com.truction
z.iD i 4111 4 sok puma:tot Of Iltirtnotskap and tome no employees working for tree in $. C3 Remodeling
any esrutiry.Pio woviers'etiolp.inseinnee requited"
9. 1, 6 Initilitson
30 141M a homeowner doing all walk myself.llt10 livosters°curry,insurdner retooled"'
le[3 Building addition
40 i am a honsixositet and will be;taring contrsesarsto condoti all week on my property. I Will
cosine date all ionitinclots either hate otniers'comperoation itwutunte us Ws:$1063 II a Electrical repairs or additions
proplicient with no employeiet
I 2.0 Plumbing repairs Or additions
NO 1 am a mentnitermanietor 4,11+,i I home toted the stili-etIntriactont limed ini the widened sheet
I 3.0 Roof repairs
These tols-eurittactort how employee.and lust workers'comp.inxilitlitli:C.,
14.0 Othei
6.0 we art 4 Corporation and its officers htsVe exercised their right of exemption per WA_c.
152,f WO.and a c lave no eniployeti, NO worker.'cower.Mail:ranee moored"
*Any applimi that cheekt box v 1 mutt also fill not the section below shooing their WiltierS'Compousuon porky ifOWIttlik41 ' ' ''
+HuttltuWilep,viho manna dn affidatit indscatany they ate doing all work:mil tIsen hire otositie mintraeteea nwed tubitut a ne14 itlid,v,tt soli...4.41'V such.
1Comnictort that Jacek thi.but roux Attic IteA'I an....0datiOnal skeet flitAteing tlivt 11.144111:+41'the toh....•ontrockies and...ittrr,i,6.411,3 or noi til....,e,. slit,loot
employcie., If Ow it,b-einitisetor.kr,e cu4loyct."4.Ihary rilos1 prt).,'Idt.:1110r Wottcr,'....v,..11., -,,,,I, ik,urtNcr
Jam an emploper that is providing worhers'compensation iThiltailet,far my employees. Below is the policy and job sire
information.
Insurance Company Name: - --- -
Policy#or Stlf-ms.Lic.t:
Job Site Address: _City/StateiZip:_
_______
Attach a cups of the 4orkers' compensation polity declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,*25A is a etitnittel N natation punishable by a line up to$1,5tX),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 inAarance
coverage verification.
I do hereby r •und the As ond penalties of perjury that me information provided above Is tale and correct
Signature, Date. -L, _-__ 2 S
Phone#: i 7 ....5,51 '
..._,....-
Official use only. Do not write in this area,to be completed by city or town official
,
.
City or Town: __ _ Petilicense#
Issuing Authority (circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing In tor
4,Other
(ontact Person: Phone#:
. .:LareviT2121011111111111S MINATEMBSIff rillf MSIZIMP-V-ITSMIIIMIIIMEINIMMITEME2KMtEVIVIIPIE 1W-T21221F2S-
4C a CERTIFICATE OF LIABILITY INSURANCE j DATE(» . -n
�.- I 10/2612022
THIS CERTIFICATE IS ISSUET!AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
•CERTIICATE 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 'IVSURER{S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
OWORTANT: if the certificate holder is an ADDITIONAL INSURED,the policy{ies)must have ADDITIONAL INSURED ;covisions'or be endorsird.
If SUBROGATION IS WAVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on
this cetficate does not confer rights to the certificate holder in lieu of such endorsement(sl.
CONTAE
IPPF�!!SHC`
PATRICK
DBA fUt1RlCK IPPEANCE AGENCY �;+OVE FAX
MEC No.E:tl• cA'C Net
28 BRIDGE STREET E-HAR
SHELBURNE FALLS. MA 01370 -ss:
tHSU ctEMS1;AFFORDING COVERAGE MUG If
INSuR RA: Liberty Mutual Fire Insurance .—__-- I
23035
MUM USURER 13:
J BURNJSKE LANDSCAPING &EXCAVATION Ll_G ,
DBA JRB DISPOSAL INSURER C_ I —._
5 MATTHEWS ROAD INSURER_ _ _ Y._-__._._.._
SOUTH DEERFIELD MA 01373 _NsvWa E-
COVERAGES CERTIFICATE NUMBER:7 5T'313 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABC E FOR THE POLICY PERIOD
INDICATED.. NOTWITHSTANDING ANY R£DUIREMF.NT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RCSPECT TO WHICH TI-ItS
CERTIFICATE MAY BE ISSUE!) OR MAY PERTAIN,WE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SL`S.IECT TO AU. THE.TERMS:
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
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beim I I El.DISEASE-POLICY LIMIT_5500000
OESC SIPUO Foe OPERATIONS/IOCAY IiS t VEHICLES(AGM°101,AGNOlosvuR Schedule,may beat echea s move epee*is:edePet t
WDR(ERSCOMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE O' MA.
Ibis Germ cancels and supersedes ail previously issued certificates,only as they relate to workers compensation coverage.
ATE HOLDER V._ _CANCELLAI1ON
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE , PEI I Fl}BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL t DELIVERED IN
ACCORDANCE MTH THE POLICY PROVISIONS- I
At/xHOM:DREDRESEI(TAUIVE —--~ .s.• 1
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