20-012 Muntuf''J 'en. rr- f34'-Zozl —Is1.c
592 SYLVESTER RD BP-2022-0021
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:20-012 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ADDITION BUILDING PERMIT
Permit# BP-2022-0021
Project# JS-2022-000036
Est.Cost: $56000.00
Fee: $392.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DANIEL PEDERSEN 106194
Lot Size(sq. ft.): Owner: GODARD LAURENCE
Zoning: Applicant: DANIEL PEDERSEN
AT: 592 SYLVESTER RD
Applicant Address: Phone: Insurance:
64 VILLAGE HILL RD (413) 531-9026
WILLIAMSBURGMA01096 ISSUED ON:8/9/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:EXTEND COVERED &ADD RESTROOMS
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:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy signature:
FeeType: Date Paid: Amount:
Building 8/9/20210:00:00 $392.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
. /-fl Z -°K
File# BP-2022-0021
APPLICANT/CONTACT PERSON DANIEL PEDERSEN
ADDRESS/PHONE 64 VILLAGE HILL RD WILLIAMSBURG (413)531-9026
PROPERTY LOCATION 592 SYLVESTER RD
MAP 20 PARCEL 012 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHE 1ST
E OSED REQUIRED DATE
ZONING FORM FILLED OUT Fee Paid of 3 t
/�►
Building Permit Filled out _,
Fee Paid
Typeof Construction: EXTEND COVERED&ADD RESTROOMS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 106194
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
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
i •
Sig ':ture of Building Official p1 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.
• (lam 1�d
eiam 9)"
,c' - i 1,
The Commonwealth of Mas ac . set / 'O
C \`i I Office of Public Safety and In ecti /�
Massachusetts State Building Code(78 Op 6 �0c, /
Building Permit Application for any Building other than a One- A -: ' ily Dwe ing '
(This Section For Official Use Only) J4r�yq,%.
o, b
Building Permit Number:b i4P 'al I Date Applied: Building Official: 060 s
SECTION 1:LOCATION
Set 2 Syl uesbr r (II . At,r,,ue 0/062. /L4,, e/ Mils &,
No.and Street City/Town, /� Zip Code Name of Building(if applidble)
Assessors Map# Block#and/or Lot #
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below
Existing Building'Dr'Repair 0 Alteration 0 Addition B" Demolition ❑ (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 O --No 0
Is an Independent Structural Engineering Peer Review required? Yes 0 No III.--
Brief Description of Proposed Work:
Mew n 54rac.N-s -r c %al rd ,,ef 0...•-e.
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): Proposed Use Group(s):
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 applicable)
A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business lir E: Educational 0
F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4❑ H-5 0
I: Institutional I-1 0 I-2❑ I-3❑ I-4❑ 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:
J SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 0 IBC IIA ❑ IIB 0 IIIA ❑ IIIB ❑ IV 0 VA CI VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item)
Trench Permit Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: /
Public 0 Check i outside Flood Z e 0 Indicate municipal❑ A trench will not be Licensed Doi posal Site 1B/
required❑or trench ors ify 14I G
Private EY or indentify Zone: tV/P or on site system �p ertnit is n���s�ed
Railroad right-of-way: Hazards to Air Navigation: W' fA f1 ri Commission'Re iew Process:
�S ORt
Not Applicable 0 Is Structure within airport approach area? Atln,,j f Is their review completed?
or Consent to Build enclosed❑ Yes 0 or No❑ Yes 0 No 0
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
V Name and Address of
Property Owner
4ggyp - tnOd ✓.5��SSA - 0106 X
Name(Print) — No. Street City/Town _ Zip
Property Owner Contact Info ation: r
W.3 -, '7.0 _- 24 - - 0,,to @cdncstsj tij
Title Telephone No.(business) Telephone No. (cell) lJ e-mail address
If applicable,the property ow hereby authorizes:
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)
—30
�r- (017 - - Sq �p°7�-J.4,4e� ,/
Name(Re trant) Telephone No. a-mail address Registration Number
3 Fo 2 i tq/(� , 5/— A /Y)/4- 0/06,2
Street Address Ci rn State Zip Discipline Expiration Date
10.2 General Contractor
rnb ' A ' A
Company N e
1 .n i e I Pe CS—IO6/�' (
Name of Person Responsible fo Construction License No. and Type if Applicable
G(( Vi /(Ag.e d • +1i;...".sbt..r-, r-,A rY/OCt6
Street Address City/Town State Zip
l3 _ 531 9024) d6&.gl -o h q@ roc ke1MA,I. Co
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? YesCNo O
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 Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)=$ .
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$340t (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ 51,000 (contact municipality)and write check number here a CteA
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 y knowledge and understanding.
:bewld {7e ae,—. — CoKtru4or 913 -$3/- 9°24 7-2-Z1
Please pricit and sigrt‘natrui, i Title Telephone No. Date
Street Address City/Town State Zip Email Address
f r
`
Municipal Inspector to fill out this section upon application approval: �(�,"..�-j'I _8-
,, Name Date
•
•
City of Northampton
Massachusetts ... 'r`
! rtt
K # DEPARTMENT OF BUILDING INSPECTIONS I. 4
212 Main Street • Municipal Building b
Northampton, MA 01060 �J1 11: :,gyp
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: Vq l<<'`1 121-4/4//el J2-34'. /0 E43-d
The debris will be transported by:
Name of Hauler: Mark /A';k'L_
Signature of Applicant: Date: i
r2 -2
The Commonwealth of Massachusetts
)C.=: • "NOMINEE(/ Deportment of Industrial Accidents
a I Congress Street,Suite 100
'71• Boston,MA 02114-2017
,.; wwtumass.gov/dia
- 1Yorirers'Compensation Insurance Afdaxit:Builders/ContractorstElectrician,'i'lunrbers.
ID BE FII.ED Wit 11 l IiI:PEK%IlIT11G Al fllO1(l t Y.
.X.pplicant informtat- Please Print Leeihls
Name(Business`C)rganiretion'tndividual): 6600_0,A4 e e P
•
Address: 64y Utt//ye Rived
CityiState/Zip._...j/`rilt..a/hs6 f MA. 61og6 Phone #: /l3 531-�024_
Are you an engrloyrr"c hark the appropriate hose Type of project(required):
1. lam a employer w nth employees(full and'ot part-time).*0 7. New construction
20 I am a soh:proprietor or partnership anti haw no employees Nuri.ing for nu:in
any capacity.[No tkoilier;comp.imutanee required.] 8. a Remodeling
9. ❑ Denwlition
Z r�lam a IwnmvNtes dung all myself.No wvni cis'comp.msuranc required
]"
10[3-Wilding addition
4.0 I am a humet.w sum and%%ill be huMg contractors to candela all work on my property. t will
emote that all contractors either have workers'compensation insurance or an:wit 111:1 Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
50 I arts a general contractor and 1 has c hired the sub-contractors listed on the attached sheet.
Thew sub-contra ltm have ample\tic's and lice workers'comp.insurance. 13.EiRoof repairs
b. a are a cotporatio n and its officers hate exercised their nyht of exemption per htGL c_ 14. Other
152. 14 4 i.and vie lea t c no employees.(No workers'conttp.insurance required.)
`Any applicant that checks beret El must also till out the section below showing their workers'cornpersaatlon policy infoematiwn_
lions:ow ices t'hu submit this afttd a'it indicating they are doing all work and then hire outside contractors must subunit a new atfrdas it indicating such.
:Contractors that cheek this box mast attached an additional sheet show ing the name of the sub-contractors and state whether on not those entities ha%t
employees. if the sub-contractors base en 'k.vice..they stud prof idc their workers'cont{1.policy number.
am an employer that is providing workers'compensation insurance for m) employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.P: Expiration Date:
lob Site Address: City/State,Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure a cos crave as required under MGL c. 152,§25A is a criminal violation 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$250.00 a
day against the violator. A copy of this statement may he forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby c and the pains and penalties of perjury that the information provided above is true and correct.
Si.merlon d
: Dale: !r Z-Z
Phone: in 3 53(%024
Official use only. Do not write in this area.to be completed hi city or town official
City or Town: l'ermitil.icense t+
Issuing:Authoritn (circle one):
I. Board of Health 2.Building Department 3.( its(Tow a Clerk 4. Electrical inspector S. Plumbing Inspector
6.Other
Contact Person: Phone#:
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