31D-192 (8) 60 CLARK AVE BP-2020-1059
GIS#: COMMONWEALTH OF MASSACHUSETTS
MV.Block: 3 1 D- 192 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-2020-1059
Proiect# JS-2020-001794
Est.Cost: $21500.00
Fee:$75.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: WESTERN MASS DEMOLITION CORP 106022
Lot Size(sq.ft.): 17119.08 Owner: VAN KOTEN BRIAN
toning. URC(100)/ Applicant: WESTERN MASS DEMOLITION CORP
AT: 60 CLARK AVE
Applicant Address: Phone: Insurance:
30 SUNSET DR (413) 574-5254 WC
WESTFIELDMA01085 ISSUED ON.5/12/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.-ASBESTOS ABATEMENT & SELECTIVE
INTERIOR DEMO
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 Isignature:
FeeTyim Date Paid: Amount:
Building 5/12/2020 0:00:00 $75.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
Cit of Northampton `
City p .� ;�Status of Permit:
Building DepartmentQ� Curb•CuUDrivewayPermit
212 Main StrE4
A. 9\ SewerlSeptic Availability
* w —
Room 100 °�� W' terNVell Availability
Two meets of Structural Plans
Northampton, MA 01
Y phone 413-587-1240 Fax 413-5$7111.372 PleU;ite Plans
x
father Specify
i APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOMEbR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: — This section to be completed by office
Map Lot Unit _
60 Clark Ave . Zone Overlay District
Elm St.District CB District I
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2_1 Owner of Record:
Brian Van Koten Jillian DeCoursey
Name(P n5 Current Mating Address:
60 Clark Ave. Northampton MA 01060
Telephone 503-729-0079
S ig na re
2.2 Authorized Agent:
-��d'�`iRl-�(,
Name( t} Current Wiling Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS _
Item Estimated Cost (Dollars)to be Official Use Only —�
completed.by pwmit applicant
1. Building 215500-00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6) _
3. Plumbing Building Permit Fee
5
4. Mechanical (HVAC)
5. Fire Protection _
g. Total =(1 +2+3 +4 +5) 21,500 Check Number
nn This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature: — J
Building Commissionerilnspector of Buildings Date
sales c wmdemocorp.com
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition [1 Replacement Windows Alterations) D Roofing ❑
Or Doors Cl
Accessory Bldg. ❑ Demolition 0 New Signs [01 Decks [[] Siding [01 Other[pJ
Brief Description of Proposed Asbestos Abatement and Selective Interior Demolition
Work:
Alteration of existing bedroom Yes XX No Adding new bedroom Yes XX No
Attached Narrative Renovating unfinished basement Yes XX No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family X Two Family Other
b. Number of rooms in each fartvly unit: Number of Bathrooms_2
c. Is there a garage attached? NO
d. Proposed Square footage of new construction. Same as Existing Dimensions
e. Number of stories? 2
f. Method of heating? Oil Fireplaces or Woodstoves O Number of each
g. Energy Conservation Compliance. N/A Masscheck Energy Compliance form attached?
h. Type of construction Wood Framed v
1. Is construction within 100 ft.of wetlands? Yes X No. Is construction WbNn 100 yr. floodplain Yes No
J. Depth of basement or cellar floor below finished grade -6 FEl:T
k. Will building conform to the Building and Zoning regulations? _X Yes No .
I. Septic Tank City Sewer X Private well City water Supply X
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, y► 1t�a� a2�ur�,�e e„ $r1atN VA I4'e h as Owner of the subject
property 'A' I'}� �
hereby authorize Yv� h MASS
SASS lkw4k m eoy � oy�
to act my b f,fn all matters re v w rize by this building permit application. ��/�,6
(}
' f=
5 tura of Owner Date
as Own er/Au th ori zed
Agent hereby declare that the statements and Information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains nd penalties of perjury.
V-
rint Nama
Signature of OwnertAgent Dale
SECTION 8 -CONSTRUCTION SERVICES_7
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Dale U n s d e rf e r
License Number
48 Sunset Drive Westfield MA 01085 106022
Address Expiration Date
05/11 /2020
Signatur Telephone 413-579-5254
1
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Western Mass Demolition Corporation 178435
Address Expiration Date
30 Sunset Drive Westfield MA 01085 Telephone 413-579-5254 04/16/2020
SECTION 10-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....... EX No...... ❑
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
re^^ Northampton, MA 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L. Chapter 142A requires that the "reconstruction, alteration, renovation, repair, modernization, conversion,
improvement removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note.If the homeowner has contracted with a corporation or LLC, that entity must be registered.
Type of Work: Asbestos Abatement and Interior Demolition Est. Cost: 21,500
Address of Work: 60 Clark Ave, Northampton MA 01060
Date of Permit Application: 4/8/2020
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under$1,000.00
Owner obtaining own permit(explain):
Building not owner-occupied
_Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PACE FOR MORE INFORMATION.
Signed under the penalties of perjury:
1 hereby apply for a building permit as the agent of the owner:
4/8/2020 Western Mass Demolition Corp. 178435
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,l hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
' Massachusetts
- �A DEPARTMENT OF BUILDING INSPECTIONS z'
212 Main Street •Municipal Building �5
Northampton, MA 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
60 Clark Avenue
(Please print house number and street name)
Is to be disposed of at:
K+W Materials and Recycling, LLC 128 Palmer Ave West Springfield MA
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
Western Mass Demolition Corporation -64 Medeiros Way Westfield MA
(Company Name and Address)
Signa ure of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):Western Mass Demolition Corp.
Address: 64 Medeiros Way
City/State/Zip:Westfield MA 01085 Phone #:413-579-5254
Are you an employer?Check the appropriate box: Type of project(required):
1.Q I am a employer with 8 employees(full and/or part-time).* 7. ❑New construction
2.F I am a sole proprietor or partnership and have no employees working for me in
8. Remodeling
any capacity.[No workers'comp.insurance required.]
9. Q Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 Q Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole l LE]Electrical repairs or additions
proprietors with no employees. 12.E]Plumbing repairs or additions
I am a general contractor and i have hired the sub-contractors listed on the attached sheet. 13.❑ p
Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.F1 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E]Other
152,§1(4),and we have no employees.[No workers'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: Liberty Mutual Fire Insurance
Policy#or Self-ins.Lic.#:WC231 S391455019 Expiration Date:821/2020
Job Site Address:60 Clark Ave. City/State/Zip:Northampton MA 01060
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify der t ains and penalties of perjury that the information provided above is true and correct.
Signature: Date: 4/8/2020
Phone#:413- 9-5254
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#: