23A-031 (4) I BP-2023-0568
67 PARK ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
23A-031-001 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-2023-0568 PERMISSION IS HEREBY GRANTED TO:
Project# INT DEMO 2023 Contractor: License:
Est. Cost: 40000 MAX HEBERT 110574
Const.Class: Exp.Date: 02/10/2024
Use Group: Owner: MAX HEBERT
Lot Size (sq.ft.)
Zoning: GB Applicant: MAX HEBERT
Applicant Address Phone: Insurance:
173 MADISON AVE 4138963019
HOLYOKE, MA 01040
ISSUED ON: 05/05/2023
TO PERFORM THE FOLLOWING WORK:
INTERIOR DEMO WORK
POST THIS CARD SO IT IS VISIBLE FROM THE STREET 1
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: I Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
o/ 1 '/.
I ' I
Fees Paid: $260.00
212 Main Street,Phone(413)587-1240,Fax (413)587-1272
Office of the Building Commiss' ner
The Commonwealth of Mass chus s �AY 1•
r Board of Building Regulations and St rds 3 - FOR
MLyf�TI
�3 Massachusetts State Building C6de, 'It s ��� USE
Building Permit Application To Construct,Repair,Reno tent-f Revised Mar 2011
One-or Two-Family Dwelling "1-1 o,06 pores
This S on For Official Use Only
Building Permit Number: y- .6-0 Date Applied:
K "s� 5-5-Zoz3
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
67 Park Street,Florence,MA 01062 23A 23A-031-001
1.1 a Is this an accepted street?yes X no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Florence Village General Same 17,284 +/-80'
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
0 >0 0 >0 6' >6'
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public i Private El _Zone: Outside Flood Zone? Municipal® On site disposal system 0
Check if yes®
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Max C Hebert Holyoke,MA 01040
Name(Print) City,State,ZIP
173 Madison Ave 413.896.3019 maxchebert@gmail.com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building® Owner-Occupied 0 Repairs(s) ® Alteration(s) ❑ I Addition 0
Demolition 6d Accessory Bldg. 0 Number of Units 2 Other ❑ Specify:
Brief Description of Proposed Work': Demolition and removal of plaster,flooring,millwork,doors,etc.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 40,000 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 0 ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 0 2. Other Fees: $
4. Mechanical (HVAC) $ o List:
5.Mechanical (Fire $ 0 Total All Fe s: $
Suppression)
Check No.[uik Check Amoun . j -
6.Total Project Cost: $ 40,000 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS-110574 02/10/2024
CS-110574 License I4umber Expiration Date
Name of CSL Holder Unrestricted Construction
List CSL Type(see below) Supervisor
Max Hebert
No.and Street Type Description
173 Madison Ave U Unrestricted(Buildings up to 35,000 cu.ft.)
City/Town,State,ZIP R Restricted 1&2 Family Dwelling
M Masonry
Holyoke,MA 01040 RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
413.896.3019 maxchebert@gmail.com I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
Text foe? Text 5/3/2-6-
Text HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
Text Text
No.and Street Email address
Text Text
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 . l 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 - -r4v
to act on my behalf,in all matters relative to work authorized by this building permit application.
- f �1 -Text-�� �J5,
Print Owner's a(Electronic azure) Date
SEC ION 7b:OWNER'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.
.-Text-- • e.
Print Owner's a uthorized Age ame(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 infohnation 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"may be substituted for"Total Project Cost"
IX The Commonwealth of Afassachusetts
c_
• "'` I-„_,�l Department of Industrial Accidents
1 I Congress Street. Suite 100
`�"= Boston, MA 02114-2017
' t0.4. wls'w.mass.gov/dfa
Wotk+en'Compensation Insurance Aif►dai it:Builders:('ontractorsJElectricians/Plumhers.
7O BE 111.E11)N ITN I HE PE:RM11"itl\t:At"lHOR1l l.
.‘onlicant Information Please Print Lel;ihh+
Name IBustncssOrgantration,'lndntidualI: Max Hebert
Address: 46 Round Hill Rd,3rd Floor
C1tylStatefZtp:_ Northampton,MA 01060 pion l :`413.896.3019
Are yea Y employer?I hick the appropriate but: Type Of project(required):
I ET am a employer w ith cn>t►tuyecs(lull and or part-lime I• 7. El New construction
IL^J I ant a sole pruprietuz or taistnership and have no employees workmg for me in 8. (3 Remodeling
s mowed.]
any capacity [No workers'comp.insurance m rd.] tJJ
9. Q Demolition
CI1 am a horneow then doing all work myself.{No wolf 'comp.insurance minced.]'
l O 0 Building addition
4.Q I am a homeowner and will be luring contractors to conduct all work on my property. I will
ensure that all contractors either huge workers'compensation insurance ur are sole l 143 Electrical repairs or additions
proprietors w ith no employeesc 12.13 Plumbing repairs or additions
SC)1 am a general contractor and I have hired the sub-contractors listed un the attached sheetl ❑Roof repairs
These sub-eunuuiurs have employers and have workers'comp_usurance.•
6.0 We are a cpuratrun and its officers have exercised then nest of exemption pet MGL e. l4. Other
ur
152,i 1(4 J.and we has c nu employees.[Nu worker**comp.inaitrance requited.)
'Any applicant that checks box vI must also fill out the section below showing their workers'coenpensaaun polity mfesinatnra.
t Hunncowrrers who subaint this at rda%it mdicating they aredwng all work and then hue outside contractors must submit a new affidasit indicating such.
%Contractors that check this box must attached an additional shun show mg the name of the sub-crmlractors and state whether ur not those entities hase
employers. If the sub-cuntractors has.:einplu.e`cs.they must provide then worker, ...,trip.policy number.
i am an engrin t er that is providing workers'compensation insurance for eery employees. Below is the policy and job site
inforrrrettiutt.
Insurance Company Name:
Policy rr or Selz'-ins. Lie. #: Expiration Date:
Job Site Address: City:StateZip:___
Attach a copy of the ..orkers'compensation polity declaration page(showing the policy number and ettplration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal v tolattcin punishable by a fine up to Si,50O.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 insurance
co.erage verification.
I do hereby c ifny under the pains and penalties of/er%url'tutu the in formulron provided shunt•is true and correct
Signature: . i t...,._ 05.01.2023
Phone 05.01.20 3
r Official use only. Do not write in this area.to be completed by city or lawn°HJit idte
t it. ur I own: Permit/License#
Issuing:Authority (circle one):
I. Board of Health 2. Building Department 3.City/Town C'_ierk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
t (intact Person: Phone#:
City of Northampton
fatHAM pp. �S ,sir
L' Massachusetts ���. <•,
* c.
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 sNyY
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: 740 Belchertown Rd.,Amherst,MA 01002
The debris will be transported by:
Name of Hauler: Amherst Trucking
Signature of Applicant: ' Date: 05.01.2023