31B-270 (2) 43 CENTER ST BP-2021-0124
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:3 1 B-270 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2021-0124
Project# JS-2021-000197
Est.Cost: $19200.00
Fee:$280.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use Group: HANS DALHANS 101628
Lot Size(sg. ft.): Owner: Bambi Rattner
Zoning:CB(100)/ Applicant. HANS DALHANS
AT. 43 CENTER ST
Applicant Address: Phone: Insurance:
11 CHERRY ST (413) 977-6094
EASTHAMPTONMA01027 ISSUED ON.81312020 0:00:00
TO PERFORM THE FOLLOWING WORK.-OFFICE RENO
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 8/3/2020 0:00:00 $280.00
212 Main Street, Phone(413)587-1240,Pax:(413)587-1272
Louis Hasbrouck—Building Commissioner
V
Jul
3 n 2020
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The Commonwealth of �f 7 °s'�tts
.Office of Public Safety and Inspections
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Semon For Official Use Only)
Building Permit Number: "' ate Applied: -ZO Z!I Building Official:
SECTION L•LOCATION
,,to oin6(E
No.and Street CityTo 7� Zip Code Name of Building(if applicable)
Assessors Map# Block#and/or Lot #
SECTION 2:PROPOSED WORK ,
Edition of MA State Code used If New Construction check here Q or check all that apply in the two rows below
Existing Building Repair❑ Alteration 40 1 Addition Cl I Demolition & (Please fill out and submit Appendix 2)
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 9 No ❑
Is an Independent Structural EnginegdQg Peer Review required? Yes ❑ No M
clef 'ption of posed Wor(c. '
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)
SECIZON 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business I E: Educational ❑
F. Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4❑
S: Storage S•1❑ S-2❑ U. Utility❑ 1 Special Use❑and please describe below:
Special Use Description:
n SECTION 6:CONSTRUCTION TYPE(Check asapplicablej
` IA O IB ❑ IIA ❑ IIB ❑ IIIA. ❑ MB ❑ I IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details oneach item)
Water Supply: Flood Zone Information: Trench Permit: Debris Removal•Sewage Disposal: Licensed D o al Site Qf
Public Check if outside Flood Zone❑ Indicate municipal IN A trench will not be �
Private E3or indentify Zone:- or onsite system 13required 9 or trench or specify
pernrit is enclosed❑
Railroad right-of-way Hazards to Air Navigation: 'vLk Historic Comaussi RecrieK Process:
. Not ApplicableIs Structure within airport approach area? Is their review compl �
or Consent to Build enclosed❑ Yes❑ or No Gal'-_ Yes❑ No
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
Name and Address offProperty Owner I -
FJca M la, It c1 1E itf\c-r �15- Qnk, 1c C)\r.c , r F koro c.4 t'1 Pt w O 6 L
Name(Print) No.and Street Ctty/lawn zip—
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner h by authorize \_
Name Street Address City/Totem . State Zip 7
to M71y M71for and act on the property owner's behalf,in all matters relative to work authorized by this building rmft application.
SECTION 30:CONSTRUCTION CONTROL(Please fill out Appendix 1)
If a building is less ihan 35,000 cu.ft.of enclosed space and/or not wider Construction Control then check here 13.
Otherwise provide construction control fors see section 107 in the code as uh-ed.
10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals)
�p Name(Registr Telephone No. a-mail address Registration Number
Street dress City/T State Zip Discipline Expiration Date
10.2 General Contractor
yN
rns C �� 5
Name of Person Respc ble fol Construction License No. and Type ifApplicable
Street Address city/To State Zip
-A NQS c ca�f�13Pr� G M2; • (Oy►1
Telephone No.(business) Telephone No.(cell) email addddrew
SECTION 1I:WOMMS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.15L§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 0 1 No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $lq U-0 O W Building Permit Fee=Total Constructi x here
2.Electrical $ , uJ appropriate municipal facto =
3.Plumbing $ , w
4.Mechanical (HVAC) s, �✓ Note:Minimum fee=$ (c alfty)
5.Mechanical (e'er) $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest the pains and penalties of perjury that all of the information contained in this
a plicationis true1 and accurate to the bes w dge andel understanding.
ens print and sign Tide Telephone No. ate )
�. _ - �i , .� y a i 1 .(LVA
Sheet Address City/Town State Zip Email Address
Municipal inspector to fill out this section upon application approval:*
Name Date
The City of Northampton
Building Department
t
212 Main Street
Northampton,Massachusetts 01060
Phone(413) 529-1402
Fax (413)529-1433
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance with the provisions of MGL c40, 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:
�L ( �
Location of Facility_ Q,_ _� (..,�
The debris will be transported by:
Name of Hauler_` S v S_ `� _ _ .— — — — — — — — — —
Signature of Applicant:_ _ _ ___ —Date:_I �l
The Conen>onwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
0
Boston,MA 02114-2017
wwtu7nass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians(Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibi
Name(Business/Organization/individual): GC
l�
Address:
City/State/Zip:��",A,-� t;., AtPhone#: I
Are you au employer?Check the appropriate box:
Type of project(required):
I.F-1 I am a employer with employees(full and/or part-time).' 7. ❑New construction
2.7 I am a sole proprietor or partnership and have no employees working for me in
capacity.(No workers'comp.insurance require $. Remodeling
d.]
9. Demolition
3.Q a homeowner doing all work myself(No workers'comp.insurance required.]'
10[]Building addition
4.F1 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 at arc sale I I.Ej Electrical repairs or additions
proprietors with no employees.
12.23Plumbing repairs or additions
5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance,
6.E3Ve are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§I(4),and we have no employees.[No workers'comp.insurance required.]
"Any applicant that checks box PI 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.
lam an employer that is providirrg workers'compensation insurance for uty 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 MGL c. 152,§25A is a criminal violation punisbable 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 1z
I do hereby certify un a pains a p talties of perjury that the information provided ove is true and correct
1JSisnature: Date:
Phone#: qlr,
Oct
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#:
Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
for work per the ninth edition of the
Massachusetts State Building Code, 780 CMR,Section 107
Project Title: Date:
Property Address:
Project: Check(x)one or both as applicable: New construction Existing Construction
Project description:
I MA Registration Number: Expiration date: ,am a registered design professional,and I have
prepared or directly supervised the preparation of all design plans,computations and specifications concerning':
Architectural Structural Mechanical
Fire Protection Electrical Other.
for the above named. project and that to the best of my knowledge, information, and belief such plans,
computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780
CMR), and accepted engineering practices for the proposed project. I understand and agree that I (or my
designee)shall perform the necessary professional services and be present on the construction site on a regular
and periodic basis to:
1. . Review, for conformance to this code and the design concept, shop drawings, samples and other
submittals by the contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the
progress and quality of the work and to determine if the work is being performed in a manner consistent
with the approved construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official,l shall submit field/progress reports(see item 3.)together with pertinent
comments,in a form acceptable to the building official. '
Upon completion of the work,I shall submit to the building official a'Final Construction Control Document'.
Falter in the space to the right a"wet"or
electronic signature and seal:
Phone number: Email:
Building Official Use Only
Building Official Nasse: rermit No_ Date-
Note
ateNote 1.Indicate with an'x project design plans,computations and specifications that you prepared or directly supervised.If'other'is
chosen,provide a description.
Version 01 01 2018
Appendix 1
Construction Documents are required for structures that must comply with 780 CMR 107.The
checklist below is a compilation.of the documents that,may be required.The applicant shall fill out
the checklist and provide the contact information of the registered professionals responsible for the
documents. This appendix is to be submitted with the building permit application.
Checklist for Construction Documents'
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing include local connections
9 Gas(Natural,Propane,Medical or other)
10 Surveyed Site Plan(Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Pro am
14 Fire Protection Narrative Report
15 Existing Building Survey/Investigation
16 Energy Conservation Report -
17 Architectural Access Review(521 CMR)
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other
21 Other(S )
22 Other(Specify)
'Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Wort:so identified
must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the
authority having jurisdiction.
Registered Professional Contact Information
Name(Registrant) Telephone No: e-mail address Registration Number
Street Address City/Town State Zi Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address Ci /Town State zipDiscipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address Ci /Town State Zi Discipline Expiraiiott Date
Please follow this link for construction control forms to be used by Registered Design Professionals.
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From: �. c
To:
Louis Hasbrouck
Building Commissioner
City of Northampton
212 Main Street
Northampton, MA 01060
The Massachusetts Building Code, section 107.1 allows for an exclusion from requirements for
construction control in certain situations. In accordance with code section 104.10, 1 request that you
grant a modification to waive the requirement for construction control of the project at
because the work is of a minor nature, will not affect structural elements, health, accessibility, life or fire
safety, and will be done in accordance with the prescriptive requirements of the code.
Thank you for your consideration.
Respectfully,
GI✓l 5 � c � c�,