25C-084 BRIDGE ST-SHELDON FIELD BP-2022-0138
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-084 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ALTERATION BUILDING PERMIT
Permit# BP-2022-0138
Project# JS-2022-000244
Est.Cost: $9000.00
Fee: $0.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: CHADD MEERBERGEN 103548
Lot Size(sq.ft.): 629877.60 Owner: NORTHAMPTON RECREATION DEPT
Zoning: SC(96)/URB(5)/ Applicant: CHADD MEERBERGEN
AT: BRIDGE ST - SHELDON FIELD
Applicant Address: Phone: hisurmice:
51 LINCOLN AVE (508) 221-4609
NORTHAMPTONMA01060 ISSUED ON:8/6/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE DUG OUT
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. )2 • (�
:151T
Certificate of Occupancy Signature:
i • f �
FeeTvpe: Date Paid: Amount:
Building 8/6/20210:00:00 $0.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
��c � c
Fig . Fi�
S The Commonwealth of Masch • setts 'S �0
�� c rd 5 � � Office of Public Safety and Insp<ectiMis T �1
tar°-t Massachusetts State Building Code(780
vi<
N�RrNg1- /N�� B ildi,g Permit Application for any Building other than a One-or ,p.,,• , .we ing
Nc
Oh.f�q» NS (This Section For Official Use Only) ���of 60 6/S
Building Permit Nu r: Date Applied: Building Official:
SECTION 1:LOCATION
51k J do ic\4s 1)00r1,Ar. f 1z,- rtt4 d 16to0
No.and Street Ci yt/Ton Q 0,/, Zip Code Name of Building(if applicable)
Assessors Map# BlockC#and/or Lot #
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here Llor check all that apply in the two rows below
Existing Building 0 Repair 0 Alteration 0 I Addition 0 Demolition Er7Please 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 Er No 0
Is an Independent Structural Engineering Peer Review required? Yes 0 No Er
Brief Description of Proposed Work `hj'la C i At ac Al eY )c.anl � i en l' /'t.t ytc ,�-.a
t1 I '�► S rk- . 'F-I'l L/o 'h gti c ,t! l Q.i e/ a y�1 1,kft i - ►" _( +t-(. s'. J� I I 642
r'e fI a --i '?1' . a/7 out rr 6 1K So 4bca( d i a. to-ic(-
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.) 96v /0 8CO /0
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 13 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 I-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 CI IB ❑ IIA ❑ IIB 0 IIIA ❑ III B ❑ IVGi' VA 0 VB ❑
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 El- Check if outside Flood Zone 0 Indicate municipal Er
A trench w}•11 not be Licensed Disposal Site Er
Private 0 or indentify Zone: or on site system 0 required or trench or specify:
permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable fi " Is Structure within airport approach area? Is their review completed?, 1 4
or Consent to Build enclosed 0 Yes 0 or No Yes 0 No EY- /V
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: A)/it
Does the building contain an Sprinkler System Special Stipulations: Nlit
Design Occupant Load per Floor and Assembly space: /VA
_
D a City of Northampton
t K,,,,p,6 S -... S.
71:0'° ' 1 Massachusetts <?� _ '<<
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DEPARTMENT OF BUILDING INSPECTIONS 21 ,'
w' ` 212 Main Street •• Municipal Building vG•.. ,�
b.
Northampton, MA 01060 rfilY,•VON
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR COMMERCIAL &
MULTI-FAMILY NEW CONSTRUCTION/ADDITIONS/ALTERATIONS
1. Building Permit Application signed by legal owner and filled out by owner or authorized agent.
2. One set of plans and specifications of proposed work (Digital & Hard copy).
3. Site Plan with location of proposed structure(s) and setbacks.
4. Construction Debris Affidavit filled out and signed by applicant.
5. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
6. Contractors must supply a copy of CSL and proof of Liability Insurance.
7. Energy Conservation Compliance Certificate (if applicable).
8. Note any Conservation and/or Special Permit requirements (if applicable).
9. Driveway Permit (if applicable).
10. Proof of Water and Sewer entry fees paid (if applicable).
11. Trench Permit (if applicable).
12. Initial Construction Control Documents filled out and signed by the Registered Design
Professional in responsible charge.
13. Please provide the appropriate fee in the form of a check made payable to: The City of
Northampton
SECTION 9: PROPERTY OWNER AUTHORIZATION
CName and Address of Property Owner Ad-hew,
i o- or�.u� kN, t 0-10
Name(Print) No.and Street City/Town I Zip
Property Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property owner 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)
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
31(1, 1 V O c Co r-t c,wJ.
Company Name
( , ,,1 'il�„- .w., S �- C D 3 s
Name of Person Responsible for Construct jt License No. and Type if Applicable
Si L r<c ol_n A-v.c._ No 0 MA 6 t o to 0
Street Address City/Town 1 State Zip
6D$-2Zl- 4'teo`i 6b- (.ZZl - - ci 9 (LM e.e.r be_r j1 e Srn t �E-ce . o r J
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 0 No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor l
and Materials) Total Construction Cost(from Item 6) =$ -f Ct7'D
1. Building $41 per fir~, -
f Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor) =$ .
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable toAIA
9/' � (contactmunicipality)Total Cost $ munici ality)and write check nter here
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 f my knowledge and understanding.
(1k.Akt ties L / JLa4 1 4 f ( W vie z7-i - 5,,,,, 4/s/�2/
Please print and sin name Title Telephone No. Date t
/ L;nc. otvt eve- I��-Fh e /1Jrk al arm �ne�. n� 0 swt'Th Fc,-.01
Street Address City/Town State Zip Email Addieds
i
Municipal Inspector to fill out this section upon application approval: ; �
Name Date
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
Commonwealth of Massachusetts
IF;
Division of Professional Licensure
Board of Building Regulations and Standards
Constmctton otipervisor
CS-103548 Expires: 10/0112021
CHADD P MEERBERGEN
51 LINCOLN AVE
NORTHAMPTON MA 01060
Commissioner
City of Northampton
oatHa ro 5 '°' S
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Per ,0 _< 5�......... 1
Massachusetts ?r '<,
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DEPARTMENT OF BUILDING INSPECTIONS yt
212 Main Street • Municipal Building J`. A.
r
:*,!".-:1' Northampton, MA 01060 'r3' j���
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
!n 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: Ci, )o'r o;^*P 1vv1 Jc-%^-- �-S
Location of Facility: Vo ICl cA
The debris will be transported by: .t_ k)0,—ktr_ \ >1e'k`•clams
Name of Hauler:
Signature of Applicant: ri_ Date: / 3 /Zozd
_..„ The Commonwealth of Massachusetts
1 = ' i Department of Industrial Accidents
f C 1 Congress Street,Suite 100
"►.a a Boston, ,'IAA 02114-201• az.F- �
l►r►vw ntass.got'/dia
Workers'Compensation Insurance Affidavit: liuildersiContractorsll lectriciansfl'lutnhers.
R)BE I ILED 411111 I IIE PERMITTING ITTING At11'NORIT%'.
Applicant Information e� Please Print Le�iibls
Name(Business o ganiratiorll'lndividual): J'Mtl � \J6 c a..-`t-1 0✓Lck_52.,_
Address: &) L o c_k 5 - S f
City/State/Zip: N o MA, d i A‘,d'hone#: EP 3) 5 7 - / 4-/ /y
!ire you as employer?Cheek the appropriate beat;
6 'I";►pc of project(:rexlnircdi:
.'Ij I am a efIplaycs with...._ employees(full and`or part-time).` 7. Nevi construction
2..A lam a sole proprietor or partnership and have nu empkiyem working forme in K. 0 Remodeling
any opacity.[No workers'comp.insurance required.)
9. Rlierriolition
ICI 1 am a homeowner doing all work myself.[No workers'canto.irouranee requircul]'
4.0 I am a lwnaeca -surd will be hiring contractors to conduct all work on my property. I will
1(1® Building addition
o n
enure that al3 contractors either have workers'compensation otsuruaoct Cr arc sole 110 Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
40 I am a general contractor and I have hired the sub-contractors Listed un the attached sheet
13.0ROW-repairs
These stub-eunaractorx have employees and have.workers'comp.insurance.;,'
b.EI We are a conservation and its officers have exercised their right of exemptions per lvt[wt,e. l Other
152,r}lt4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that cheeks boa p1 must also fill out the section below show ing their workers'compensation policy information.
+Ftomoowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new aflidav it indicating such.
!Contractors that cheek this box must attached an additional sheet showing the name of the sub-contactor and state whether or not those entities have
employees.. If the sub-cuntracters have employees.they must provide their workers'comp.pubs,y number..
I am an employer that is providing workers'compensation insurance,for my employees. Beiota°is the policy"and job.site
information.
Insurance Company Name:
Policy#or Selt=ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation polky 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
andior one-year iznprisonn eat,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 the pains anti penalties of perjury'that the information proridrrf abort is true and correct.
.*7L.riktti.itc: Ok/2144",l' oa�ee Date:l "/1 S /20 Z/
P one SC) Zz -
t - t l;
Official use only. Do not ie'rife in this area.to be completed by city or barn official.
City or'Foam Permit/"License#'
Issuing Aut11itritw (circle erne):
I. Board of health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
ft.Other
Contact Person: Phone#: