32A-140 (14) BP-2023-0620
109 MAIN ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
32A-140-001 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-2023-0620 PERMISSION IS HEREBY GRANTED TO:
Project# repair steps 2023 Contractor: License:
Est. Cost: 6500 DAVID CLAXTON 017890
Const.Class: Exp.Date: 01/19/2024
Use Group: Owner: LLC NIS BUILDING
Lot Size (sq.ft.)
Zoning: CB Applicant: PIONEER CONTRACTORS
Applicant Address Phone: Insurance:
4136267267 WCC500500957
NORTHAMPTON, MA 01061
ISSUED ON: 05/16/2023
TO PERFORM THE FOLLOWING WORK:
REPAIR TO FRONT STEPS
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: $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
cx
7 r
MAY 9 1 2023 i 1i'he Commonwealth of Massachusetts
Office of Public Safety and Inspections
OF e p� - -._� Massachusetts State Building Code(780 CMR)
(nrHAnmr ,u%tnut Application for any Building other than a One-or Two-Family Dwelling
�`— (This Section For Official Use Only)
Building Permit Number: A, (/AO- Date Applied: Building Official:
SECTION 1:LOCATION I
No.and Street City/TownVC(7.--- Zip Code Name of Building(if applicable)
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 Ve 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 tlps permit application? Yes No 0
Is an Independent Structural Engineering Peer view required? Yes 0 No Qv
Brief Description of Proposed Work: Gar' 1(G Cl(j'r,.1-VPJ S\'erg LR„tist)L.
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): t3 Proposed Use Group(s): 7j
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 4.pplicable)
A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business 0 E: Educational 0
F: Factory F-1 0 F2 0 H: High Hazard—/ H-1❑ H-2 0 H-3 0 H-4 0 H-5 0
I: Institutional I-1 0 I-2❑ I-3❑ I-4❑ M: Mercantile H 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 ❑ IIB 0 IBA El IIIB ❑ IV 0 VA 0 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:
Public' Check if outside Flood Zone`( Indicate municipal. A french will not be Licensed Disposal Site 0
oi
Private 0 or indentify Zone: or on site system CIrequired'16(or trench or specify: drZ
permit is enclosed 0 12_44,‘ytq
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable I7 Is Structure within airport aeoach area? Is their review completed?
or Consent to Build enclosed 0 Yes❑ or No Yes 0 No ❑
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 Ad ress of Pro erty Owner
�N � lea \ ) Maw. St. ,D r el , AM b/bib
Name(Print) No.and Street City/Tow Zip
Property Owner Contact Information:
P1cd1,6<A, .lIl Auo 913- —6,970 u!?-ems -- `11.40S c-w,,N.@ h\0w,Q'Z�Ln-Gw
Title Telephone No.(business) Telephone No. (cell) e-mail ddre s
If applicable,the pro ertyowner hereby authorizes:
PtI ` U.WkI.rc p( PO'2 t 14j k kaM k�- PIA o/t (
Name Street Address City/Town State Zip
to apply for and act on the property owner's behalf,in all matters relative to work atithorized 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 0.
Otherwise provide construction control forms(see section 107 i1 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 Zip Discipline Expiration Date
10.2 General Contractor
?ti•w R)P Covt-k-sa.. i
Company Name
1)iv,S( ' CAQ)6 cs— (?11 Ci,0
Name of Person Responsible for Construction License No. and Type if Applicable
e a, 13o,6 114 f -�c�,. MA t)i I.
Street Address City/To n State Zip
413- 5'Ili, - 5'4et I. yt3 -r'u - ?Z67 i ino,e-w-civ atW1-ol'-l
Telephone No.(business) 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 CI No CI
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ &Slit' Building Permit Fee Total Construction Cost x_(Insert here
2.Electrical $ appropri to municipal factor)=$ .
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minim fee=$ I (contact municipality)
5.Mechanical (Other) _$
Enclose check pays le to
6.Total Cost $ &STO•'--' (contact municipality)and write check number here ot/ 6/y
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.
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip Email Address
;cniitt Municipal Inspector to fill out this section upon application approval: v. c0 5
Name Date
,'� The Commonwealth of.11as achusetts
i (d! Department of Industrial Accidents
11.1�:2 ' ~ �1 / Congress Street, Suite 100
f: j
_ Boston. 02114-2017
4- W►s'►r.mass.got/din
lt tit lscrs' I onepensatloll InStrraitee Xffedasit: BuildersiContractnrs Electricians.Plumbers.
I(Itit Iu III 1%IIII Inn t•I.RtIIItt\(:,11 flit/tiff%.
.Antillean( Information Please Print IxBihls
Name(Business tgantzatton;tndtvedual►: _ k)l CCry , Q i1M€P/r Goy,-E- tom
Address: Q.D. 3 c_,It-,'
City:State'Zip: ft - "t IAA Ph,,ii 13- :3-16-5- l
Are yeti r*plotrr?Check an:appnlpria 'thus:
Type of project(required):
1. 1 am 4 employer with 3 employers(fill amine pare-lrnr I• 7. 0 New construction
2.0I am a sole proprietor ur putnership and have nu employees wurknis fur me m S. El Remodeling
any capacity (No workers'comp.uuurancx myuuetl-j
9. ❑Demolition
30 I am a homeowner dmng all wort myself.[No workers`comp insurance mtturatt l'
4.0 I am a humeouner and will be hiring sum-actors to conduct all work on my property- I will 10 El Building addition
m
ensure that all c.mtr-.cturs either hose workers'compensation uburance ur ate sole 11.0 Electrical repairs or additions
proprietors is nth no employees.
12.0 Plumbing repairs or additions
<f1 I am a amoral e.lntraeon and 1 base hired the sub-contractors listed.In the anartt sheet. 13.❑Roof repair tJ These sub-contractors hose employees and hase workers'comp newt-met.
014. other Sid r
h Y.e an:a cutpaotali.on and its oaken base uercmoeol tors right of eaemplwn pet Mt c.
I I .i II 41.and w e has a no employees.INiu workers'comp insuanec reyuered
•Any applicant that checks hos a I must also till out the section below show mg then workers'sumps-risottos policy information
'Romero.nets who submit this attlelas tt uttlae'ating they are doing all work and then hue outsuk eontraetnrs must subnut a new aliedas it indleahig,.mils
:l untractors that cheek this hos must attacked an additional sheet show ing the name of the sure-:mittacte s and sate whether of not those entities hase
employers It the sub-cuntraeays hase employers.they must pms ride them worker'ss>nip }idle}number
I am an employer that is providing wormers'compensation insurance for tiny employees. Below is the policy and job site
information. .
Insurance Company Name: (s56c la S �^5 Co
Policy#orSelf-ins.Lie.tt: I.JCC.S6ps- siso0 .A Expiration Date. �l`3o``7
Job Site Address: ,Oq t "t • s t*D(``V. fits State lip: Dicks) _
Attach a coPy of the workers'compensation policy declarat a page(showing the policy number and expiration date).
Failure to secure coserage as required under MGL c. 152.*25A is a criminal siolation punishable by a tine up to S1,500.00
arts or one-year imprisonment,as well as cisil penalties in the form of a STOP M1ORK ORDER and a fine of up to S250.00 a
day against the suot.itor.A copy of this statement may be forwarded to the Ofli4e of Ins estigations of the DiA fair insurance
cos ernes serilication.
I do hereby certiji'u der the pai s Ities of perjury'that the information!provided above is true rent!correct.
r
Signature �,, J'A ` I)::, S-,,/2',�
Phone z. ZI/.3 ' S 6e -- G'j
Ofcial use mill. Do not write in this area.to he o unlpieted by city or town official.
('its or lossn: Permit.License a
Issuing.authority (circle ones:
I. Board of health 2. Buildin;;Department 3.( its I own Clerk 4.D'aeectrkal Inspector 5. I'lunibint Inspector
6.Other
Contact Person: Phone N:
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800) 876-2765 NCCI NO 40959
POLICY NO. WCC-500-5005957-2022A
PRIOR NO. WCC-500-5005957-2021A
ITEM
1. The Insured: Pi Con Inc
DBA: Pioneer Contractors
Mailing address: P 0 Box 1145 FEIN:**-***1984
Northampton, MA 01061
Legal Entity Type: Corporation
Other workplaces not shown above: See Location
2. The policy period is from 06/30/2022 to 06/30/2023 12:01 a.m.standard time at the insured's mailing address.
3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the
states listed here: MA
B. Employers'Liability Insurance:Part Two of the policy applies to work in each state listed in item 3.A.
The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 500,000 each employee
C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTRA 000063757
INTER SEE CLASS CODE SCHEDU_E
Minimum Premium $393 Total Estimated Annual Premium
GOV GOV Deposit Premium
STATE CLASS
MA 5437 State Assessments/Surcharges
$1,739.00 x 4.1800%
This policy, including all endorsements,is hereby countersigned by 7 ' 06/02/2022
Authorized Signature Date
Service Office: King &Cushman Inc
54 Third Avenue P 0 Box 447
Burlington MA 01803 Northampton, MA 01060
WC 00 00 01 A(7-11)
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.
City of Northampton
.• / Massachusetts �,,, ,
t �, y
DEPARTMENT OF BUILDING INSPECTIONS v �x
212 Main Street • Municipal Building ,� 1)
`�
Northampton, MA 01060 slat, x�t^
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: �fCJ1le- t?ar(/� � f N 0 r;�p
1 �, 1
The debris will be transported by:
Name of Hauler: USA-.
TC4 i A____,
Signature of Applicant: Date: 5-ir/23
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