10-019 BP-2023-1331
170 AUDUBON RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
10-019-001 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-2023-1331 PERMISSION IS HEREBY GRANTED TO:
Project# DEMO BARN 2023 Contractor: License:
Est. Cost: 1000
Const.Class: Exp.Date:
Use Group: Owner: M BORAWSKI ROBERT A&ANN
Lot Size (sq.ft.)
Zoning: RR/WSP Applicant: M BORAWSKI ROBERT A&ANN
Applicant Address Phone: Insurance:
P.O. BOX 301
LEEDS, MA 01053
ISSUED ON: 10/05/2023
TO PERFORM THE FOLLOWING WORK:
DEMO BARN
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:
‘2 I
I/
Fees Paid: $30.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
Z
File #BP-2023-1331
APPLICANT/CONTACT PERSON:BORAWSKI ROBERT A&ANN M
P.O. BOX 301 LEEDS, MA 01053
PROPERTY LOCATION 170 AUDUBON RD
MAP:LOT 10-019-001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Building Permit Filled out
Fee Paid $30.00
Type of Construction: DEMO BARN
New Construction
Non Structural Renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans/Plot Plan
Driveway Grade%
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
X( Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
q/ag/gs
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
F
sF /1i
°FAT `'S ��
ti <2,The Commonwealth of Massachusetts TtigG,°
Board of Building Regulations and Standards fro cti R
W
Massachusetts State Building Code, 780 CMR ��oAF2y US
Building Permit Application To Construct, Repair,Renovate Or Demolish a �01e8ised ar 2011
One-ol• Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: &O`e.3- 1,33 Date Applied:
i ` ir ,
ttlfitA
Building Official(Print Name) t Signature li D to
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
/ 7D Av,,-,`,V. l2p 4.�k_ r s
1.1 a Is this an accepted street?yes 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 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 ne 'of Record:
O101, FAt_►A-: T30,t.4WSk 4eA6 $ Or063
Name(Print) City,State,ZIP
17 a 4 p, 6 0 v / -t O o.. JX. 301 .1—vr— 3 aq
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) ❑ Addition 0
Demolition Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2:
bp-44vii 3 /7' 11;4-seai , -,ex`70
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials) _
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:,$Q
Suppression) I;'( —� �`1
Check No.i1 V Check Arnow't: U
6.Total Project Cost: $ I�1 C 0 Paid in Full CI Outstanding Balance Due:
Y
City of Northampton 4 �`
J�'t,y
�oq ' 'tI'2. Massachusetts ti3
04*
DEPARTMENT OF BUILDI G i
• Muniicipa 4�,� �"%
212 Main Street MA O1 60 �
Northampton,
SEP 252023
DFPT.OF BUILDING INSPFCTTIQN
PROCEDURE FOR OBTAINING A"
T71 i�4iVIIT�I�WINDOWS,
DOORS,ROOFS,RENOVATIONS,ROOF MOUNTED SOLAR,ETC.
,.
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 and hard copy).
3. Construction Debris Affidavit filled out and signed by applicant.
4. Worker's Compen
sation Insurance Affidavit filled out and signed by applicant.
5. Contractors must supply a copy CSL,HIC, and proof of Liability Insurance.
6.Energy Conservation Compliance Certificate(new /replacement windows).
7.Home owner's License Exemption Form (if applicable).
8.Note any Sp
ecial Permit requirements(if applicable). ,
9. Energy Code—all new construction (Gut/Rehab)requires a HERS Rater
Affidavit
he City of
10. Please provide the appropriate fee in the form of a check made payable
tNorthampton.
f
I •
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
City/Town,State,ZIP R Restricted 1&2 Family Dwelling
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)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street 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 0 No 0
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: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.
Re hien/ ,4 13.A w5-1,A 9/a.q.._ 3
Print Owner's or Authorized Agent's Name(Electronic Signature) r ate,
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 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"
...
., , The Cornmonweahh of Massachusetts
-, Department of Industrial Accidents
1 Congress Street,Suite /00
. - 1 Boston, MA 02114-2017
wooentass.goildia
'11,at kers' Compensation Insurance Affidas it:BuildersiContractorstElectricians/Plumhers.
to Bk. FILED WITH THE PERNIITTING AtiTHOR111%
Annlicant Information Please Print 1.egibls
Name(a us incs,s;Organimittomlndividual):
Address:
C'ity'State!Zip: Phone
.trr you an employ er?Cheek thr apprupriate bot.: Type of project(required):
1.0 I am a employer with employees(fa auvorpart.tinwv. 7. 0 New construction
2:01zar1...1 wic proprietor or pormerslup and have no employees working for me ui IC Ell Remodeling
anv capacity[No workers'cuinp.Exeniranix requrred,)
9_ 0 Demolition
;I:j i am u honseownet doing all work myself.flio ssorims'comp.insurance requiting'
IC 0 Building addition
s 1-R1e-am a homeowner and will be hiring cordractors to I.-undue'ult work on lay property.. I will
motor that al/corns-actors tither ItiNe workers'cumpensation insurance or are sole 11.c3 Electrical repairs or addition:.
pmprsetors IA ids no employees,
12.E1 Plumbing repairs or additions
:q0 I am a c-eneral Lora:what and I love hired the sub-contraeturs listed on the attached Arco.
13EDRoof repairs
Theme sub-contractors have employees and bast:woriters'eornp.insurance)
14.00th-er
e arc a corporation and its officers have esenased their right of esa-roption per MCA,L.
15'4§I(1).and we have iso employees.[No*oilers'comp.inslarance toquirctil
'An).applii.ant; :,..1i,vkai boot#1 must also till uLF the section bolo*hiroi4 low thclr•iciarlia.r.5:compensation palie!,inforinahal
' ttotneu%ner,4 iltf:51.4i1111i1 Thui.afficta.,it indarating they are&nog all kirk arid theta hoc mashie otitilraotric-,nitti4 siihnnt a new affidav it indicating such
',Ciantractur%that chcoic this box most au-sched:In Addstiunal allizet kii...8 thy the hairic of the sub-eormactors and state whether or not those
emplo)ce., 11'the sal-LuttiracEur),lur.c ortrlo:.cos,tli.i..) rou,t ri.o.ide their ,.....rkezi,',t.ortip.p.,114:).Mather
I am an employer that Is providing workers compensation insurance for my employees. Below is the policy and jab%at,
information_
Insurance Company.Name: ____
Policy#or Self-ins.Lie. tl: Expiration Date:
Job Site Address: City Staie/Zip:
Attach a copy of the workers' compensation polic, declaration page(showing the polies number and expiration date).
Failure to secure coverage a rNioreti under MCiL c. 152,*25A is is Criminal violation punishable by a fine up to$1,500.00
andlor one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a fine 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
co‘,......1:2,2 verification.
/dr) hereby certifit under the pains and penalties of perjury that the information provided above is true and correct.
Sronaturc-- (/) ,-4..i,/1/4. Date: 9/)-I/c-7
Phone#:
Official use only. Do nut write in this area,to be completed by city or town official
City or Town: PermitiLicense#
Issuing Authority (circle one):
1. Board of Health 2.Building Department 3.City/Town Ckrk 4.Electrical Inspector 5. Plumbing lope:vim
6.Other
tOillACI Person: Phone#:
City of Northampton
dial-,,j
S r.
�' I` ' Massachusetts 4,7
a, v
n f) DEPARTMENT OF BUILDING INSPECTIONS
W ,-
212 Main Street • Municipal Building aj
Northampton, MA 01060 J�yyy �1�\
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: /-2 v pl-vn t, /, oti lt,, )-(z�()-
S
The debris will be transported by:
Name of Hauler: 4 A ?" 12,2 c I rR u ....1.s.I c
Signature of Applicant: , ,9 i Date: C/25/c:)- 3
City of Northampton
f
A Massachusetts , .
r7 'AO
i; DEPARTMENT OF BUILDING INSPECTIONS
e►
fsE 212 Main Street • Municipal Building �_,
Northampton, MA 01060
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, R / e/? , 11 er
e 4 ,,h 1— _ 13o f' /3 W c It 1 (insert full legal name), born_(insert
month, day, year), hereby depose and state the following:
1. I am seeking a building permit pursuant to the homeowners'exemption to the permit requirements of the
Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or
work on a parcel of land to which I hold legal title.
2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'
exemption, does not involve the field erection of manufactured buildings constructed in accordance with
780 CMR 110.R3.
3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2:
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
there is, or is intended to be, a one-or two-family dwelling, attached or detached structures
accessory to such use and/or farm structures. A person who constructs more than one home in
a two-year period shall not be considered a home owner.
4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I
qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of
the project or work on my parcel, I am not engaged in construction supervision in connection with any
project or work involving construction, reconstruction, alteration, repair, removal or demolition
involving any activity regulated by any provision of the Massachusetts State Building Code.
5. If I engage any other person or persons for hire in connection with the aforementioned project or work on
my parcel, I acknowledge that I am required to and will act as the supervisor for said project or work.
Signed under the pains and penalties of perjury on this et S day of r ,— , 20?-3
(Signature)
0,,
Q1HAp,, CITY of NORTHAMPTON .. -.<.
DEPARTMENT of HEALTH & HUMAN SERVICES pL.
.1
w.,
Commissioner-Merridith O'Leary, RS Y
"�'„jp _lb Municipal Building-212 Main Street-Northampton,MA 0106O
' 110 Phone(413)587-1214-Fax(413)587-1221 ,,,.t4�.http://www.northamptonma.gov/245/Health Public Health
Prevent.Promote. Protect.
WITNESS OF EXTERMINATION
Date //41(/' J I Time
Property Owner: R a Coe ri- bo r a,W S k
Property Address: l7 e 1i/d‘ d-v /2A to z if / W 4
Exterminator: Ain v~1- -Af 7'J/ (eh' az 1 -�,L
Company: a reei Jerfre 7 4e ti L o(/ C-
Company Address: 90 ( ' c z Sr . ,/p7%22.0 t 54-a)V i 4411- D 10e 0
Rodenticide/Chemicals Applied ;.1.A--C. ''tee)k
Reason for Extermination: pi.„ 3..€1.4-t /-e cr''V C71 44-1-z/1u
Comments: 7)(..., 2 //t.9 leehet C., / et tr Sik-4 Gu S.
.3 I time r s /de✓ r.-t`' a N /) v n2 7t
. -D�J vcf e ln o( � vl 2 , egi, 61 1-
I hereby certify,under the pains and penalties of perjury,that Ito the best of my knowledge
and belief,have applied the above noted pesticide in accordance with M.G.L. Chapter 132B
and any other applicable law or regulation.
El City Water ❑ Well f 'Septic System
If appli641,
le ❑YeslI ❑ N����o__ ���� / , ��tLtixW���(2�1 z3 �I l�l�Board of HRepresentative Si a re of Ext rminator
*Demolition best practices relating to fugitive dust and debris must be adhered to in accordance
with MGL Chapter 111, Section 122.
6Ll-1, 20 1.73 - K.1 0 cgtGcnl.S vc,1-1 n5 ()nil I I014,1).#