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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 <?� _ '<< /'.` • .Gy [ e 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 .i, Per ,0 _< 5�......... 1 Massachusetts ?r '<, t'..-f Ll X 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#: