17A-215 GBS
Ground Breakers Services
116 Mountain Road - Hampden, MA 01 036- Phone: (413) 566- 2250
July 10, 2013
Vis Taraz RE. ,E-1 7 .
/46 North Maple Street 3
Florence, MA ,U1-
Vis.taraz .gmai1.com
DEFT o' ' ON iJ∎P010'0 RE: Shed Demo
• Obtain Demolition Permit
• Demolish building
• Take debris to a Recycling Facility $ 1600.00
• Break up and remove concrete floor/foundation $ 400.00
• Truck in loam
• Spread and rake out loam
• Spread grass seed $ 600.00
Total: $ 2,600.00
i Thank you,
7/ 2 `i'/2o/
Scott Rurnplik
CITY OF NORTHAMPTON
Construction 1..ebris Affidavit
in accordance with the provisions of MG.L. c. 40 § 54, all debris resulting from any work
covered by a Building Permit shall be disposed of in a properly licensed disposal facility,
as defined by M.G.L. c. 111 § 150A.
Address of Work: I IVO r 444 41 a /are e
_____—The-debris will be transported by:_ --
The debris will be received at: VP,lie ,e6 c vv.
- Signatur of Pe it Applicant
'Date 7 TT (3
Building Permit Number:
_ _
Rightfax C2-1 7/24/2013 5 : 00 : 15 AM PAGE 2/002 Fax Server
CERTIFICATE OF LIABILITY INSURANCE [DATE(MM/DD/YYYY)
07/24/2013
T TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to
the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
P L KRYNICKI INS AGCY PHONE FAX
459 MAIN STREET (A/C,No,Ext): (A/C,No):
E-MAIL
INDIAN ORCHARD,MA 01151 ADDRESS:
28RL S INSURER(S)AFFORDING COVERAGE NAIC#
INSURED INSURER A: AMERICAN ZURICH INSURANCE COMPANY I
GROUND BREAKERS SERVICES INC.DBA GBS INSURER B:
INSURER C:
INSURER D:
116 MOUNTAIN ROAD INSURER E:
HAMPDEN,MA 01036 INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY
PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY
HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD SUB POLICY EFF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (MM\DDIYYYY) (MMIDDIYYYY) LINTS
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY ~—
CLAIMS MADE OCCUR_ DAMAGE TO RENTED
I $
PREMISES(Ea occurrence)
MED EXP(Any one person) $
PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $
EI POLICY E PROJECT 0 LOC PRODUCTS-COMP/OP AGO $
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANY AUTO LIMIT(Ea accident)
ALL OWNED AUTOS BODILY INJURY $
•
SCHEDULE AUTOS (Per person)
•
HIRED AUTOS BODILY INJURY $
(Per accident)
NON-OWNED AUTOS PROPERTY DAMAGE $
(Per accident)
• UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _
— EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $ _
- RETENTION $ $
A W• ORKER'S COMPENSATION AND x WC STATUTORY OTHER
EMPLOYER'S LIABILITY Y/N UB-0542N313-13 05/26/2013 05/26/2014 LIMITS
ANY PROPER TOR/PARTNER/EXECUTIVE ® N/A E.L EACH AH ACCIDENT $ 100,000
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000
If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE
CERTIFICATE HOLDER CANCELLATION
CITY OF NORTHAMPTON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
ATTN CHUCK MILLER BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
212 MAIN ST
AUTHORIZED REPR 7.7
NORTHAMPTON,MA 01060 4
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved.
07/23/2013 15:25 413-543-9134
PL KRYNICKI INS PAGE 01101
e ACORD CERTIFICATE OF LIABILITY INSURANCE °AT D/YYYY,
07//23/23/2013
_
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCED,AND THE CERTIFICATE HOLDER. ■
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(Ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the
terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement s. _
PRODUCER ( ) CONTACT Bonnie Turntrerg
Pl.KRYNICKI INSURANCE AGENCY PRONE FAx
413-543-9119 413.543-9134
Atc,No, Aic,No]:
- -MAIL
ADDRESS
459 Main Street CUSTOMER ID;
Indian Orchard MA 01161 INSURERS)AFFORDING COVERAGE NAM i)
INSURED INSURER A: First Financial insurance
GROUND BREAKERS SERVICES, INC DBA GB$ INSURER B: Safety Insurance
INSURER C: Westchester Surplus Lines Insurance Inc.
115 Mountain Road INSURER D;
Hampden MA 01036 INSURER E:
_ INSURER F: _
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD —
INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY SE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR -ADDL.SUBRr
.a TYPE OF tNBURANC`E INSR WVD PDI Y NUMBER (MMIDDJxYYY)IIM/DDIYYyY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000.000.
7 COMMERCIAL GENERAL LIABILITY GE-TO RENT D 100,000.
_ _ , PREMISES{Ea oocunenzel $
CLAIMS-MADE V OCCUR MED exP(My one person) $ 5,000
A 553FW22570 08410/2012 08/10/13 PERSONALaAOVINJURY $ 1,000,000.
_ _ — GENERAL AGGREGATE $ 2,000,000.
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG ,$ 2,000,000.
7 1 POLICY EGOJ 7 Loc
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
. (Eeaoordent) $ 300,000.
ANY AUTO
—
ALL OWNED AUTOS ALL INJURY(Per person)�$
B J SCHEDULED AUTOS 6209644- 5/20/13 5/20114 BODILY'INJURY(Derr eCOde $
J PROPERTY DAMAGE $
HIRED AUTOS (Per accident)
NON-OWNED AUTOS $
3
. -+ —
UMBRELLA LIAR OCCUR _ EACH OCCURRENCE $ I
EXCESS LIAB CLAIMS-MADE AGGREGATE $
_ DEDUCTIBLE — - — $
RETENTION $ _ _ y f 3—
WORKERS COMPENSATION AND �OFRY AAT tS T I DER
EMPLOYERS'LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE f E.L.EACH ACCIDENT S
OFFICER/MEMBER EXCLUDED? I N/A See Remarks"
IMandelory in NH) £.LDISEAIiE-EAEMPLOYEE S _^
If yes,deecilbe under
DESCRI�TIDN OE OPERATIONS below E.L.DISEASE POLICY LIMIT 9;
C `Environmental Liability (324309368001 08/10(2012 08/10/2013 $1,000,000.OGC./$2,000,000.Agg.
'DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES!Attach ACORD 101.Additional Remarks Schedule,IT more space is required)
Grading of Land;Debris Removal-Construction Site;Excavation;Carpentry;Wrecking-Building or Structures NOG;Landscape Gardening;Tree Pruning,Dusting,
Trimming;Tank Const-Not Pressurized HOC. "Vehicle Schedule:'03 KW,VIA#2NKMHZ7X33M707925,Plate APN56247;'08 KW,Vin#2NKMHN7XX8M21$227,
Plate APN70935.'00 International,Vin.#1HTSCAAM1YH2707O3,Plate#GB63. "`Workers Compensation certificate being faxed directly from company.
+ _
CERTIFICATE HOLDER �__ CANCELLATION �
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TN
CITY OF NORTHAMPTON EXPIRATION DATE THEREOF,NOTICE WILL BE DEUVEREB IN ACCORDANCE
WITH THE POLICY PROVISIONS.
21 MAIN STREET
ATTN:CHUCK MILLER AUTHORIZED REPRESENTATIVE
NORTHAMPTON MA 01060 + -
{ �1I,A...I. . . �J� '•���
ID 1980-2009 ACORD CO' , ION.All rights reserved.
ACORD 25(2009/08) The ACORD name and logo are registered marks of ACORD
.
• City of Northampton - .
' Massachusetts �$ -4.
,4�; .' DEPARTMENT OF BUILDING INSPECTI ONS w '; f 1! x
ar
' 212 Main Street • Municipal BuildingJb a ''`
r � _' Northampton, MA 01060 &p ,.-`i.
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which
he/she resides or intends 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."
The building department for the City of Northampton wants any person(s)who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages, which include
foundation/footings (before backfill), sonotube holes (before pour), a rough building inspection
(before work is concealed), insulation inspection (if required) and a final building inspection.
The building department requires these inspections before the work is concealed, failure to secure
these inspections can result in failure to obtain a certificate of occupancy until the work can be
inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas)the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspections are made
I, understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
a. The Commonwealth of Massachusetts
�--= Department of Industrial Accidents
, « r Office of Investigations
600 Washington Street
rf Boston, MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le•i 51
Name (Business/Organization/Individual): G I Gd J ge.a.A-05 Sewt es "..6 co -F ? 4)-
Address: 1 ! 10 Al o.J/v 'Al g
City/State/Zip: (4 ,til..A A) D(o3& Phone#: 13 3-6 as
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. I❑ New construction
listed on the attached sheet. 7. �11 Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8.)6-Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance ; comp. insurance.$
5. We are a corporation and its 10.0 Electrical repairs or additions
required.]
3.n I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job 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 coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 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. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby certify th ains 1112 lties of perjury that the information provided Bove is true and correct.
Signature: - f Date: 1 ')3 1/3
Phone#: 1 ( 3 56
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 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
de
SECTION 8-CONSTRUCTION-SERVICES-
8.1 Licensed Construction Supervisor: J Not Applicable ❑
Name of License Holder: . C U� 1 D. WV i p2it
A License Number
12,5 mvA ,� j Id w fr1 A Q 16 30
Add Expiration Date
( `1(3 5 aas�
Signature Telephone
9alRegistered Home Improvement Contractor i7- Not Applicable ❑
Company Name Registration Number
— Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MG 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 ❑ No ❑
11 :Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner:Person(s)who own 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 homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
•
IF-
J
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) - ,, .
--
New House ❑ Addition ❑ Replacement Windows Alteration(s) EJ Roofing n
'''....Or Doors D
Accessory Bldg. ❑ Demolition New Signs [D] Decks [(] Siding[D] Other[D]
Brief Description of Proposed �P/�d ,f'`/s �'/ _ /
Work: �—i-'< <'!�°p(
Alteration of existing bedroom Yes Adding new bedroom Yes --�No
Attached Narrative Renovating unfinished basement Yes
Plans Attached Roll -Sheet
sa If New h-use and or addition to existing housing, complete the following:
a. Use of builds One Family Two Family Other
b. Number of room 'n each family unit: Number of Bathrooms
c. Is there a garage aft. hed?
d. Proposed Square foota.- of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves _Number of each '
g. Energy Conservation Complianc- Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetland? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below fi • hed grade
k. Will building conform to the Building and Zon g regulations? Yes No.
I. Septic Tank City Sewer P ate well City water Supply
SECTION,7a'OWNER AUTHORIZATION-TO BE COMPLETED WHEN - - - ,
OWNERS 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.
Signature of Owner Date
I, Di ,as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
oiK
and belief.
Signed_under.the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
•
r
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Inf motion
Existing Proposed Required by'Lo g'""
This column to be filled in by
Building Depart iient
Lot Size
Frontage
Setbacks Front i 3 1 I
Side L: ` R: L:' . R:` ` _ `
Rear
Building Height 1 i
Bldg. Square Footage I I % i a 1
--._ Open Space Footage
(Lot area minus bldg&paved .� i ► I
parking) .
1 1 1 s
#of Parking Spaces
Fill: i
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES Q •
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO (3 DON'T KNOW 0 YES 0
IF YES: enter Book ! I Page; I and/or Document#1 1
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES i NO l
IF YES, describe size, type and location: j
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
RECEIVED Department use;only
City of Northampton Status of Permit
JUL Z 3 Building Department Curb Cut/Dnveway Permlt r.
212 Main Street Sewer/Septic Ayailablllty'•
Room 100 Water/Well Availability
CtNOHrHA69PTON MAoloso Northampton, MA 01060 Two Sets of Structu��il Plans
p one 413-587-1240 Fax 413-587-1272 PIotSIte.Plans. F`
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION"•
1.1 Property Address:
This section to be completed by office
'1/4j/ /1) 0 5/-� G(19 71- Unit
" V Zone Overlay District
FJ (NC: R
Elm Sf District _,CB District
-SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED.AGENT
2.1 Owner of Record:
V
's ara z
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Auth ri e A ent:
v k-
0,
i M �r
Name( rint) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Offirial Use Onfy
completed by permit applicant _ __:
1. Building (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of '
_ Coristruction from (6). _
3. Plumbing Building Permit Fee
•
4. Mechanical (HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5)
Tlr:. This Section For=Official Use Only
Date
Building Permit Number ' = Issued:•Signature.. _
Building Commissioner/Inspector of Buildings Date s•
File#BP-2014-0080 etc
APPLICANT/CONTACT PERSON SCOTT RUMPLIK
ADDRESS/PHONE 125 MOUNTAIN RD HAMPDEN (413)566-2250
PROPERTY LOCATION 146 NORTH MAPLE ST
MAP 17A PARCEL 215 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT A
Paid 4 Fee / 72 tc■l(
Building Permit Filled out
Fee Paid
Typeof Construction: DEMOLISH 15 X 15 SHED
New Construction —
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 102465
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN.F94 MATION 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
7/-zt
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.
146 NORTH MAPLE ST BP-2014-0080
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-215 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: demolition BUILDING PERMIT
Permit# BP-2014-0080
Project# JS-2014-000164
Est. Cost: $2600.00
Fee: $20.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: SCOTT RUMPLIK 102465
Lot Size(sq.ft.): 28575.36 Owner: TARAZ VIS
Zoning:URB(100)/ Applicant: SCOTT RUMPLIK
AT: 146 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
125 MOUNTAIN RD (413) 566-2250 WC
HAMPDENMA01036 ISSUED ON:7/26/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:DEMOLISH 15 X 15 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:
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 7/26/2013 0:00:00 $20.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner