25C-084 (14) 644E1,Dos) nal rJ BP-2023-0611
0 BRIDGE ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
25C-084-001 CITY OF NORTHAMPTON
Permit: Acc Structure
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2023-0611 PERMISSION IS HEREBY GRANTED TO:
Project# SHED 2023 Contractor: ll License:
CITY OF NORTHAMPTON CENTRAL
Est. Cost: 3205 SERVICES 103548
Const.Class: Exp.Date: 10/01/2023 11
NORTHAMPTON RECREATION DEPT SHELDON
Use Group: Owner: FIELD
Lot Size (sq.ft.)
Zoning: SC Applicant: CITY 0 NORTHAMPTON CENTRAL SERVICES
Applicant Address Phone: Insurance:
Memorial Hall (413)587-1260
NORTHAMPTON, MA 01060
ISSUED ON: 05/10/2023
TO PERFORM THE FOLLOWING WORK:
STORAGE SHED
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: TAIT
• ! , Q .
•
Fees Paid: $
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Buildinc Commissioner
C`IN ' '
MAY 9 2023 € The Commonwealth of Massachusetts
Office of Public Safety and Inspections
7-D� j Massachusetts State Building Code(780 CMR)
"'OR ,v
THmDrot� ietTermit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number:44,13- (/// Date Applied: Building Official:
SECTION 1:LOCATION
_5(A,t_(do ela( /2-4 i a1ateo
No.and Street City/Town Zip Code Name of Building(if applicable)
0? -
Assessors Map# Block#and/or Lot #
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here or check all that apply in the two rows below
Existing Building 0 Repair 0 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 application? Yes 0 No 0
Is an Independent Structural Engineering Peer Review required? Yes 0 No 0
Brief Description of Prf!e1o
sed Work:
ram'"!`sue 0 oLS� a
se
tdt r
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 ANti AREA
Existing Proposed
•
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 4Total Area(sq.ft.)and Total Height(ft.) /22, 5 ' /D /Z ' 4L-
SECTION 5.USE GRIre'
�
UP(Check as applicable)
A: Assembly A-1 0 A-2❑ Nightclub 0 A-3 ❑ A-4 0 A-5 0 B: Business 0 E: Educational 0
F: Factory F-1❑ 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❑ I-3 0 I-4❑ M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4 0
i
S: Storage S-1 er 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 ❑ VB ❑
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 wil,14tot be Licensed Disposal Site 0
Public 0 Check if outside Flood Zone 0 Indicate municipal❑
Private 0 or indentify Zone: or on site system 0 euired or trench or specify:
;eqrmit is endosed❑ re, y ./lt?
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 01
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 Property Owner
1o.c �a� . (.t.(d G GA 44410444/10 01 a(Q 0
Name((*rurt) No.and Street City/Town V Zip
Property C Information:tact - - t v a f e a`-,�S 1 Ctune� -c_s Are. PQr-5 1 ( t,
,e.Y 1� �
Title /v Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes:
Name Street Address Ciy/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 D. •
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 Zi Discipline Expiration Date
10.2 General Contractor
M^l V Q'C__01--- n->.-A„\
Company Name ,/
Name of Person Responsible for CTbnstru�ction License No. and Type if Applicable
✓� //k O AVM AJdrk •�,(r�,, MA a'OGC
Street Address City/Town State Zip
° 'i- ' ' /�llll' 98:VI - cfL�4 �- I' 24- 0 5,14(�f4 fcc ,
Telephone No.(business) Telephone No.(cell) e-maYi 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 Es ' ated Costs: r 2
(nd Ma • ) Total Construction Cost(from Item 6)=$ 7f 2 ^
1.Building $\ Z) Building Permit Fee 4 Total Construction Cost x (Insert here
2.Electrical $ 'L s appropriate municipal factor)=$ .
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ 1/4
Enclose check payable to I v
6.Total Cost $ 3/ ZO 5- (contact municipality)and write check number here
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.
� la01ac(iep f l 0.54-r t.t.c. S'0g - 2 Z( Wed 7
Please pr' t and sign name Title Telephone No. Date
b L.ec-Ks 4 Aw k-wl /K.f Q(r�a(�.. c� . cc«.. a'.. w�c�L� �; r�
Street Address City/Town State Zip Email Addres
Municipal Inspector to fill out this section upon application approval: / 57010
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
,art re(P-r— _
Massachusetts ?, cf
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I
DEPARTMENT OF BUILDING INSPECTIONS
F 212 Main Street ID Municipal Building
-^ Northampton, MA 01060 v }'
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. 'I?
A
of/ Vir ‘\°: ‘ (,,t°'‘'
1-€,X ,kil
' el° - 1) k(,:-
lit' \<v\,
Cc
OX
The debris wi I be disposed o in: ` _ VVVV
y \
Location of Facility:
The debris will be transported by:
Name of Hauler:
Signature of Applicant: Q'6() - Date: ,5-74Z_C) 2-
.,.
The Commonwealth of Massachusetts
VIIMMO, .MEM
Department of Industrial.4ceidents
1 Congress Street,Suite 100
MM. Boston,AL-102114-2017
www.mass.govidia
1101 kers'Compensation Insurance Affidavit:Builders/ContritctorsfEkctricianstPlurribers.
ID HI:FILED Twirl,IlIE PERM'ITINC:AVIIIORI'l'i.
Applicant Information Please Print Ixeihis
Name(BUSHICSS,'Organization I ndsviduat}: ..
Address:
City/State/Zip: Phone ir--":
Are yart wn employer?I'heck ihr approprintr bolt Ty pe of project(required)
1.0 I am a employer with employees(fall andtor part-timei..• 7_ E21N-e w constrtiction
2.0 I ant a.....de prop-setur in imalacadnp and have nu ertmloyees working tor am m S.. 0 Ref:OA/tiding
any cap:tory.[Na*Rattal.'ctanp.inmaranm required.)
9. 0 Demolition
30 I an a luitmarw Bet doing all work myself[No worktzs'camp imardalm fc'srautd.r
10 0 Building addition
itj i ant a hurnorwmn and will he hiring omit-actors to...wawa all work on my irroperty. I will
Lmaure that all k-ontradors either Itakc workers'emameirsation insurance or am sole ' I 1.0 Electrical repairs or addition
pupnetem with no calpluyees.
12.0 Plumbing repairs or additions
30 I am a ecneral contractor and I have hued the sub-contnietors iiittd an the anachod sheet.
I 3.1:1Roof repairs
These sub-contractors haw tiriplayern.arid has e*arkers'conap.insurance.:
14.00tIlet
n.E3 We are a corporation and ar.,off-wets have exercised then right of ea.cirmaron pet h461.-c.
'SI..t,I i 4 i.and we have nt tamplayeca.1--No workers comp,insurance teHlitiCli I
'Any applicant that ch,+.26,box at mint aim.)1111 out the section teluw showing their workers'compensation polo.),intermation
t 14011110MtICTS Ur hil salmon this affidavit indreming they are doing all work.and then hue outside vantirmbas*mat i4u1an.11.a new alfatak it msticalleig such.
%Contractors that check this box must attached an ailthuonal short shins trig the name ol the talb-4:1311(11/14404,and date w hearer or nut those eitlitiet,have
employees, If the stab-contractors have emple!,res.they must pi-avid.:aerie winiers'i..-anir...policy number.
. - - -
1 am an employer that iA providing ft:tinkers'compensation insurance for or employees. Below i+ the policy and fob site
information.
Insurance Company Name: _
Policy#or Self-iris.Lic.4. Expiration Date:
Job Site Address: Cityt'State,Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date.
Failure to secure coverage as required under MGL c. 152.;,;.25A is a criminal violation punishable by a tine up to S1,500D0
an&or one-year imprisonment_as well as civil penalties in the form of a STOP WORK ORDER and a line 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.
1 do hereby certify carder the pain%. and penaltie.N of perptty that the informatian provided abate is true and earreet.
Sienature Date:
Phone 4:
Official arse only. Do nut write iii ibis,ureic, in he completed by city or tots:1 allicial.
City or Town: PermiteLicense#
Issuing Authority(circle one):
1, I.Board of Health 2.Building Department 3.(:ity'Tossu Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
• . kt;421N.: The Commonwealth of Massachusetts
=Ai• - •
NiMir I V=Q Department of Ind:Istria!Accidents
l'El;;: 1 Congress Street,Suite /00
...... .
lam ;z1s! . Boston, MA02114-2017
116176 t^.i.,
•
„.....„ wwwsmass.govidia
- _ -
IS 0)kers' t'onipens 14 I inn Insurance Affidavit: Ruilders/ContractorldElectricians/Plumhers.
It)lik. 1.!LED NN till TIM PERMITITSC AUTIR)RITI.
Applicant Information Please Print Levi bh
Name fthisinetitOrganizationiinclividuall: '1'"I'l 6 \-\f‘
Address: 80 L.o c..-ti,s .-.- -1--
City/State/Zip: ‘\ 0..-44-vo."4.0-tyl MA/ Oa 4c1)hone#: CL1/ 3.1 '''-'8 7 - /
i
Are yen an rinployer,Check the appropriate hot: T:rpe of project(required):
I.C1 I 312t a ti171116y1X Yr lth _, , _,.,employees OA aric.Vin part-tirnel.• 7. Ell:Jew construction
24:01 ant a wit:proprietor or partni.-rship and have no ens/drip-es working for me in K. 0 Remodeling
any capacity.[No*cetera'emirs.If/MAMMY required.)
9_ eDemolition
I am a hornoattnet doing.all work myself.[No**Acts'comp.UW111111011 Millitell 1
I 0 0 Building addition
4.0 LAM a honksaana and will be hiring ianstracturs to conduct all work on my property. 1 will
noun that all contractors either hate worlooni"conipensanon Utterano.or are wile i i a Electrical repairs or additions
proprietors tt ith no employees.
1 12.0 Plumbing repairs or additions
.sC3 I am a general contractor and I kite hired the sub-cora:whin,initial on the attached sheet 1
i I 3.0Roof repairs
These sulseontrsetors hate employees and!save emitters'camp.insairarice..:
01itet
6.0 We an:a corporation and its officers have ca.c.reised their right of eicenipinin per WIL C.
l:S.,... 114k and we has,.rio=picot:ca.[No*utters'etenp.insurance required"
'Any applicant that checks boa al must also fill out the section below show Mg their tvorto-s*cumpernation policy information.
*liornimwrien.so.tso submit this affidatit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicaang suck
I.Curitractori that check this boa must atta.:Ised an additional sheet showing the curiae of the tub-cOntrtseters and state whether Or not thou:aitlitit.-4,hates
employees. Itch..sub-contractors hate ottploytxh,they mum pros ide their sc otters*comp.policy number.
I am an employer that is providing workers twmpenstition insurance fOr my emphlees. Below is the Indio,and job site
information.
Insurance Company Nan : _
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State:Zip:
Attach a copy of the workers'compensation polky declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under NMI-c. 152. USA is a criminal violation punishable by a fine up to$1500.00
and,Or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine 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 herehj certify under the pains and penalties of perjury that the inform anon provided abate is true and correct.
Signature: Clitkrii- - rA eer' Date: 11// S."- 20 Z/
Phone : SC)6 Z Z-( - Li
, .
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
6.Other
Contact Person: Phone#:
Initial Construction Control Document
,, l,f
' To be submitted with the building permit application by a
t
� Registered Design Professional
, -` for work per the ninth edition of the
' Massachusetts State Building Code, 780 CMR, Section 107
Project Title: Date:
Property Address:
Project: Check(x)one or both as applicable: New construction Existing 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 specifications concerning2:
Architectural Structural Mechanical
Fire Protection Electrical Other:
for the above named project and that to the best of my knowledge, information, and belief such plans,
computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780
CMR), and accepted engineering practices for the proposed project. I understand and agree that I (or m`
designee)shall perform the necessary professional services and be present on the construction site on a regular
and periodic basis to:
1. Review, for conformance to this code and the design concept, shop drawings, samples and other
submittals by the contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3_ Be present at intervals appropriate to the stage of construction to become generally familiar with the
progress and quality of the work and to determine if the work is being performed in a manner consistent
with the approved construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official,I shall submit field/progress reports(see item 3.)together with 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: Finail:
Building Official Use Only
Building Official Name: Permit No.: Date:
1
Note 1.Indicate with an'x'project desist plans,computations and spedfications Etat you prepared or directly supervised If'other'is
chosen,provide a description
Version 01 01 018
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.