32C-318 BP-2023-1543
47 HENRY ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
32C-318-001 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-2023-1543 PERMISSION IS HEREBY GRANTED TO:
Project# 2021 WIRE YURT Contractor: License:
Est. Cost: WRIGHT BUILDERS 115196
Const.Class: Exp.Date: 05/31/2024
Use Group: Owner: KOKORO BENSONOFF DANIEL &
Lot Size (sq.ft.)
Zoning: URC Applicant: WRIGHT BUILDERS
Applicant Address Phone: Insurance:
48 Bates St 413586-8287 MCC20020005342023A
NORTHAMPTON, MA 01060
ISSUED ON: 11/08/2023
TO PERFORM THE FOLLOWING WORK:
EXISTING YURT AND PLATFORM TO BE ASSESSED AND BROUGHT UP TO CODE
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:
I (VAR
I
Fees Paid: $126.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
RECEIVE[.)
The Commonwealth of Massachusetts
13 Nov - 1 2023 Office of Public Safety and Inspections
Massachusetts State Building Code(780 CMR)
Building Pe it P pplication for any Building other than a One-or Two-Family Dwelling
DEPT OF DUII DING INSPECTIONS (This Section For Official Use Only)
NQR 1HA'iPTOt'.MA 0+060
Buil 'ng Permit-Number' 3- /. Date Applied: Building Official:
SECTION 1:LOCATION
47 Henry Street Northampton, MA 01060
No.and Street City/Town Zip Code Name of Building(if applicable)
32C 318-001
Assessors Map# Block#and/or Lot #
SECTION 2:PROPOSED WORK
Edition of MA State Code used 780 CMR If New Construction check here 0 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 ❑ 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 Proposed Work:Existing yurt,needs to be accessed by inspector to bring structure up to code.Filing application to start the process.
20'Diameter,315 SF yurt,2 raised stairs that need to be brought up to code,4 egress doors,structure is raised platform,wood frame on CMU piers.
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) ❑
Existing Use Group(s): Group E-Daycare Proposed Use Group(s):Group E-Daycare
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 1 315 SF 1 315SF
Total Area(sq.ft.)and Total Height(ft.) 315 SF 9' 315SF 9'
SECTION 5:USE GROUP(Check as applicable)
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 0 H-2 0 H-3 0 H-4 0 H-5 0
I: Institutional I-1 0 1-2 0 I-3 0 I-4 0 M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4 0
S: Storage S-1 0 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 0 IIIA ❑ IIIB ❑ IV 0 VA CI VB0
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 0 Check if outside Flood Zone 0 Indicate municipal 0 A trench will not be Licensed Disposal Site 0
Private 0 or indentify Zone: or on site system 0 required 0 or trench or specify:
permit is enclosed 0
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❑ or No 0 Yes 0 No 0
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: 780 CMR Use Group(s): E Type of Construction: VB
Does the building contain an Sprinkler System?: No Special Stipulations: n/a
Design Occupant Load per Floor and Assembly space: Code Driven
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Daniel Bensonoff 47 Henry Street Northampton, MA 01060
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Daniel Bensonoff 860 716 5122 _ - _ dbensonoff@gmail.com
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes:
Wright Builders Inc 48 Bates street Northampton MA 01060
Name Street Address City/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 O.
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 Zip Discipline Expiration Date
10.2 General Contractor
Wright Builders Inc
Company Name
Ryan Crandall CS-115196
Name of Person Responsible for Construction License No. and Type if Applicable
492 State Street Belchertown MA 01007
Street Address City/Town State Zip
41.3 586 8287 rrandall@wright-builders.com
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 12 No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ Building Permit Fee=Total Constructio 'ost x •rt here
2.Electrical $ appropriate municipal facto 1pfal
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (con.: .1 i cipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here_45,2_4520
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.
Nicholas Wright Sales/Estimating 413 586 8287 10/25/2023
Please print and sign name Title Telephone No. Date
48 Bates Street Northampton MA 01060 nwright@wright-builders.com
Street Address City/Town State Zip Email Address
Municipal Inspector to fill out this section upon application approval: Name
�N� . . i 3
� U Date
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
No changes to footprint
FRONT SETBACK
FRONTAGE
City of Northampton
r .,, Massachusetts w _ f�
f
A'40 DEPARTMENT OF BUILDING INSPECTIONS 1, .
212 Main Street • Municipal Building u, `4,
-- or Northampton, MA 01060 sti';,�5 +�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: 234 Easthampton Road, Northampton MA 01060
The debris will be transported by:
Name of Hauler: J&J Trucking LLC
Signature of Applicant: /124 61..24.4 Date: 10/25/2023
The Commonwealth of Massachusetts
..z.. 1.._. .._. _,
Department of Industria1.4ccidents
1 Congress Street.Suite 100
Boston,MA 02114-2017
l
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..... www.mass.govidiu
,. , ..-.,:-.,....,,
SI,orkers'Conipensation Insurance AMdavit:BuiklersiContriictoridElectricians/Plumbers.
TO BE 111.E1)"SS It'll THE PERMITI'ING At rl'Ilt)RITY.
Annlicant I nfornuition Please Print Legibly
Name musines., ,,,. nation:Invidual : Wright Builders Inc
Address. 48 Bates Street
City/State/Zip: Northampton,MA 01060 Phone#: 413-586-8287
. ,
ATV!•[HI an empto3er?( Incl.the A ppruprutle bovs -1-:,pe of project(required):
am a employer'Atm 23 neiuyeets(full aniOir part-timet.* 7, El NON construelauri
20 I am a sole proprietor DI partronship end 112%41 nu empkrytx4.tvorking tur taw in it r-,A. Remodeling
any capacity.[No workers comp,unurance requital]
9. :._j Demolition
30 I am a homeowner doing all work myself.[No welkin-1'comp,nuontnee reepored.)'
i 0 1-1 Building addition
4.C]I am a hittrinnkner and will Ise hiring morli-actors to conduct all work on my prtmert:t. I will
ensure that all LIngraelurs either ha%c workers•compensation insuranot or arc sole I I a Electrical repairs or additions
piuvrieruis with nu erriployet..
12.0 Plumbing repairs or additions
30 I am a general contractor and I haw heed the ctors listed un the attinted,beet.
13,01Roof repairs
These sub-cuntractora hew employee&and}SM.41 u urker'comp,mslailunce...:
14.El Other Bringing up to code
6.E]We ate a corpuratiun and as officers have cxerriacti their right of Oumpl.n.nl per lOGL c..
I.2.t,lit41.,and we base no employees.[N eartkers•comp.iniitnunce required.]
I
Arty appli=ra that check&ban el morn 360 fill uut thc section below show Mg their workers'comp:maim]p.iiwy information,
'Homeownent who nahmit this affuktvit indicating they are doing all work and then hue outtalk emu:actor&morn submit a new affulun Ii inks midi.
:Contractors that check this box mint atin:hed an additional sheet show mg the name of the suh-cmuractoes anti slake wheiset e.T not those smtitie-*haoe
onpluyeL-k. If the sub-contractor&ha)e entiplq',retx.file,, InuN1 NO%Ink IiICIE 'A t)TkerS-i:01:11, 150:is.'? ntiltil,:r
„. ', . ... . •... .. .. . .
I am an employer that is providing workers'compensation insurance for an employees. Below is the policy and job We
informatitm.
Insurance Company Name: Massachusetts Employers Insurance Company/Phillips lnusrance Agency Inc.
Polley#or Self-ins.L . MCC-200-2000534-2023A Expiration Date: 3/1/2024
Job Site Address: 47 Henry Street City stateizip:Northampton MA 01060
Attach a copy of the workers'compensation policydeclaration page(showing the policy number and esti iration date).
Failure to secure coverage as required under MGL c. [52, §25A is a criminal violation punishable by a fine up to$1,500.00
antror one-year imprisonment,as well as civil penalties in the&am 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
coverage verification.
I do hereby certify under the pains and penalties o f perjury that site information provided above is true and coma
Siiniature: /tle:C.1-e-Ed.:7-- 0.224. e- Date: 10/25/2023
Phone r:413-586-8287
Official use only. Do not write in this area.to be completed by city or town officiaL
( its or'Town: PermitiLicense#
Issuing Authorit) (circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
. . ...... ... _ ,
0
t.:
• ;The Commonwealth of Massachusetts
N 1 202 Board of Building Regulations and Standards FOR
MUNICIPALITY
Massachusetts Massachusetts State Building Code, 780 CMR USE
�.
,-St'I
'II`�:tiui' tnit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: 413 A 3../j 1...) Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
do Property Ldr Sr NOari1ctm
pq N/ 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes 17no � t 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 P vi Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Inf ma - n: 1.8 Sewage Disposal System:
Zone: utside ood one?
Public 0 Private 0 f s❑ Municipal 0 On site disposal system 0
SON PRERTY OWNERSHIP'
.1 Owner' Reco d:
AN ��fsom oF_F \_ NOr ( prv1fj l�l�I- al 08 o
ame(Print) City,State,ZIP
4'% EA1RY ST l 96o-116 -yin- dhensono ffe� 9Ma'/.
No.and Street /� Telephone Email A dres V COM
SECT N 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Cons' ion Ex in uilding 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 A sory Bldg.IV. Number of Units Other 0 Specify: t
B�ef Des - tion '
Proposed Work': 'a J C,N1 ,y a P a n O
-S 1 1 rs 1 S.l4 �_J, /de G!�s -
SECTION 4:ESTIMATED CONSTRUCTION COSTS
1 Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 35-019 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 $ 156
Suppression) Total All Fees: $
Check No. Check Amount:
6.Total Project Cost: $ 3 so(2 0 Paid in Full 0 Outstanding Balance Due:
The Commonwealth of Massachusetts
Department ofIndustrial Accidents
-
.. ►= 1 Congress Street,Suite 100
Wiz: Boston, MA 0?114-2017
.",, ,,,c- www mass.gov/dia
11 uakers' (compensation Insurance Aflidasit:Builders/'('ontractorv't:lectririans Plumbers.
IO BE:FILL')WITH THE rimmurCIM:Al I Hertel 11.
Applicant Information n Plea. ' I I-riibls
Name(d{urin�s�(k an[ntwa Individual): Ili a►�AA �,; /�� poet� l.Jc- c
Address: Li 3-- Hehr y S-f-ree,1-
, J A _ Z Z_.
City/State/Zip: M r`f 1'l gm(J� � � D��b D Phone#: �6 0 -� � �o_ � �Are you se empinyer?Cheek Ibe appropriate bat_ Type of project(required):l l sal a employer with __ crtrpk.)ccs(full and or pat e-tione't.• 7. 00""5 construction
2.0 I am a sole proprietor or punnershrp and lease no emplus ecs working tut one in S. 0 Remodeling
any eapaLAy.[No workers'comp.Insurance required"
9. 0 Demolition
Ink a homduw[rerduin6 all work myself.(Nu%eske s'comp.insurance n-goured.l'
a hammiwoer and w ill I,hump uaniraetun to conduct all wool on my p.upeerty_ l willIF.
un 10 Q Building additionemote that all rrrorrr:lct.,n caller has c vilifiers'corn �rs:tlrtwt l[rancr ix art Electrical repairs or addition,
pruptietaan with n1,cenphoyces.
12.0 Plumbing repairs or additions
5C:11 l ant a general cuntraeilrr and 1 has c hard the suts-initencton Weil on the attached Ilbeet 13.EI Roof repairs
These suib-enntraellors homy cinpluRears and lease sAenlees'comp.ut uran.e
6.0 a c an:a cuipuratton And it,officers base exercised then nieht of exemption per Wit c.
14.0()thin
1 `w Is 4).and we hase no%.inplu5ees.[No woe►cn'comp.insurance teyulred.i
'Any applicant that chocks!sox.0 must also till out the scettoet he loss show Ina then wtnlers'compensation policy udortnation.
Iknner,Ktiers who submit this attld lsIt indr.atenc they.ore doing all+oil and then hue outside c.ertrators roust submit a mess ate alas it mdxrting Brach.
:('untra.lors that chests this boy roust attained an additional sheet shx.w Ins the mute of the soh-conteactors and state whether or not those aiiitie^.s hasc
employees. It the sub-contractors ruse cenployms,they must prosidc then %oilcn sour.policy rnanb ei.
I am an employer that is providing workers'compensation insurance for an employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#:_ Expiration Date:
lob Site Address: City Stale Zip:
Attach a copy of the workers'compensation policy deebratimt page(showing the policy number sod espiratioa date).
Failure to secure coseraie as required under MGL c. 152,*25A is a criminal s iolation punishable by a fine up to S1,500.00
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
coverage vtnticaI ion.
I do hereby certify un r t e pains a erjurr that the information provided above is true and correct
i 7117 3
Phone=:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit:License#
Issuing.tuthorits 1circle one):
I. Board of Ilealth 2. Building Department 3.('its'Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
b.Other
Contact Person: Phone#:
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.)
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)
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 .❑
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 AU'I IORIZED 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 applicati is true ate to the best of my knowledge and understanding.
Print Owner's or Authori gen ' ame(Electronic Signature) 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"
City of Northampton
.m Mr�
O1 SAS s/C
? Massachusetts ��? --- '<<
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.t DEPARTMENT OF BUILDING INSPECTIONS y
` r �` 212 Main Street • Municipal Building J6 QD
,.,.� Northampton, MA 01060 sf� �^J
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.
V
The debris will be disposed of in: a 'Ie icGL G ( n�
Location of Facility: Z3 -I - S ' .A, R ' jtior4a1410-4,/k
Y i
The debris will be transported by:
Name of Hauler: Pilot &i.4,17 - ( o5 /Z
Signature of Applicant: Date: ( 1 Z 3
oat aM:a•
City of Northampton
Massachusetts
I ( ;;i 4r/ DEPARTMENT OF BUILDING INSPECTIONS
7 212 Main Street • Municipal Building
Northampton, MA 01060
PTION ELIGIBILITY A4 '
I, o,r\ e. � e nso (insert full legal name), born (insert
month,day, year), hereby depose and state the following: lit t ti ifs(
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 re day of j 6 P o. ( , 20Z3.
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City of Northampton
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c % DEPARTMENT OF BUILDING INSPECTIONS sv 1 'f `
!!�� 212 Main Street•Municipal Building ^o
r Northampton,MA 01060 dW 3'-3�
PERIODIC INSPECTIONS
LiCSC;r��
APPLICATION FOR REQUIRED INSPECTION
L, 5C/'7PREMISE NAME: NEW VILLAGE CARE
PREMISE ADDRESS: OWNER(S) OF RECORD: c rl /U / I 1= l
OWNERS: pi ST O -
ADDRESS: ST: 47 HENRY ST
TELEPHONE NO: ( 3
C
NAME ON CERTIFICATE: Wi Vi l a
TYPE OF BUSINESS G N I c.D c/ t2-J.
USE GROUP:
INSPECTION FEE $100
Please complete and return this application to the Department of Building Inspections, 212 Main Street,
Northampton, MA 01060. We will contact you to arrange a time to inspect your property. If this information is
not correct, or if you no longer own this property, please note any changes at the bottom or on the back of this
form and return it to the building department. Feel free to contact us if you have any questions. We can be
reached at (413) 587-1240. Thank you.
Applicant name: ALIA STOF��� - t o SZ •7 C
i
Applicant Title: T) G
Telephone _ b /
� I /0.30-1(: go
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Preferred inspection time/date ' f N I N �— D
Comments:
Basic Periodic Inspection Checklist
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D D , An interor lotrs aid crffir.r. ;r,r gable a ad am -e•,, ,••.,,,'^d th a erm rn-i m
D D =.d bie ri, are zso g 7M.7 Led�d mid
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D O 3.aguTed esl=7:3c/:esone oprrines=c
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D D Regt±ed izrg�y ereSs iio}rTv gv7.id-d an;-.rmrr1 in good 0.tha iir,,,
DD B qn redna-e doors" ,,,,.,,rt..,,,.-ds closes andse.11-1=r}rin
D D at t- eS a sat and-r n.d mood arr,ri=rirri, •
D❑ B.eg cd,oess+bL p-A- games and Aoessinlc auu=s are clew and ma n0.d good n
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D O No I i�^ rds:�.u.at ayCr�D "r o pool Crmr:Frri ,tiL, , �Uw r f'
D❑ Fames tclo#T�•. are m=:. ,,,Pei as T-Ifal.o ed.No l oved r?rh-nkirm oords,rrmlt--lnn,ct Zd �
D O Pbrrtii- SysL,ut Cs sL±?- pa•piz° rr^;-r affe li iQ&e ism mad " ten.> ± good s—in'±t r ocark,r
D O Gas E up=ly stned s&y„a T-infd.
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D O IE-earrng chi d CDD g-•m.w.w is µ!up 1 d Cady m.:n t mi„ed .
DO i\A- in "roans and cltcr cal sere rooms ri A+117:nt?rl free of mcms Cot hnsti)t storage.Three feet de e
sn. n Pd a c�1 of eler602i pmtls c'Tld disnor
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Fire Safety
o D AL fire ertingoiskodg and all rgitTay fre proi✓etioa -•.fl. a 7-c pery d and mid in good •
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D D Smoke alannc are installed as pea-ri•=rri _5 ins-oct D-,c as repined by Codes in coffin m-cas, each floor level
w:thath.der i a allbedrooths and haslays 1Pari:s,to belrormF •
D 0 Fully c —gel t u Qaiy nspect✓d 2_A_-10BC size)±ex aocessLelooththas,as izo i-ed
by'{ueblandag ad iJe aod-s-
D R"eceired an>Tnal FIRE ALARM TEST.22,TD W.7NTENANCE fawn inn st be sabiaai'---d to Fire Dein:L-1 +^+t for review.
CID • A„"rr„a1 spr;r,3 r test ad r,a;,r•aaace forte mast be sobthri'*edl to arc Deper+T,.,.,r for review trim:Man is se
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