23B-089 (3) 187LOCUST ST COMMONWEALTH OF MASSACHUSETTS BP-2021-1965
Map:Block:Lot:23B-089-
001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2021-1965 PERMISSION'S HEREBY GRANTED TO:
Project# RENOVATION Contractor: License:
Est. Cost: 19500 GEORGE PROPANE 075223
Const.Class: Exp.Date: 11/27/2022
Use Group: Owner: GEORGE, MICHAEL G
Lot Size (sq.ft.)
Zoning: 01 Applicant: GEORGE PROPANE
Applicant Address Phone: Insurance:
P O BOX 102 (413)268-8360 UB8K5283632114G
GOSHEN, MA 01032
ISSUED ON:09/28/2021
TO PERFORM THE FOLLO WING WORK:
REPLACE WINDOWS & DOORS, INSULATE AND SHEETROCK INTERIOR WALLS
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.
Signature: I 4 >2 ��
U
Fees Paid: $140.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
I ECEIVE
Ty SEP 2 8Th Commonwealth of Massachusetts
,! 2021Office of Public Safety and Inspections
Massachusetts State Building Code(780 CMR)
()Par og eUri pI•: .•' = Perm' Ap ication for any Building other than a One-or Two-Family Dwelling
t - ___ .,"mmpio IN,ninri��s (This Section For Official Use Only)
Building Permit Number to Applied: Building Official:
SECTION 1:LOCATION
187 Locust St Northampton,MA 01060
No.and Street City/Town Zip Code Name of Building(if applicable)
23B 089-001
Assessors Map# Block#and/or Lot #
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below
Existing Building El Repair® Alteration ❑ Addition 0 Demolition ❑ (Please 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 ❑ No
Is an Independent Structural Engineering Peer Review required? Yes ❑ No El
Brief Description of Proposed Work: Replace windows and doors.Replace rotten sill and rear wall. Insulate,pad out,and
sheetrock interior walls.
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) 1 1,470 sq ft 1 1,470 sq ft
Total Area(sq.ft.)and Total Height(ft) 1,470 sq ft 14 feet 1,470 sq ft 14 feet
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 0 A-2 0 Nightclub ❑ A-3 ❑ A-4❑ A-5 0 B: Business ® E: Educational 0
F: Factory F-1 0 F2❑ H: High Hazard H-1 0 H-2❑ H-3 0 H-4 0 H-5❑
I: Institutional I-1 0 I-2❑ 1-3 0 I-4 0 M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4❑
S: Storage S-1❑ S-2❑ U: Utility 0 Special Use 0 and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 0 IB 0 IIA 0 IIB 0 IIIA ® IIIB 0 IV 0 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 ElCheck if outside Flood Zone El Indicate municipal
A trench will not be Licensed Disposal Site❑
Private❑ 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 I listoric Commission Review Process:
Not Applicable =+ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No® Yes 0 No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): B Type of Construction:
Does the building contain an Sprinkler System?: No Special Stipulations:
Design Occupant Load per Floor and Assembly space:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Michael George PO Box 102 Goshen,MA 01032-0102
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Owner 413 _ 268 _ 8360 413 _626 -9449 tngeorge@georgepropane.com
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❑.
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
Company Name
Robert Walden CS-075223 Construction Supervisor ,\ y'l )13.°
Name of Person Responsible for Construction License No. and Type if Applicable
PO Box 604 Goshen MA 01032-0604
Street Address City/Town State Zip
413 _695 _0539 nedlawn@hotmail.com
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® No Cl
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor 19,500.00
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ 19,500.00 Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)=$ .
3.Plumbing $ 1
I'J�`(')
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ 19,500.00 (contact municipality)and write check number here r (Q
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name bel ,I hereby a r st under the pains and penalties of perjury that all of the information contained in this
application is true and accu,.to to • .es of my knowledge and understanding.
Michael George Owner 413 626 - 9449 09/21/21
Please print and sign Title Telephone No. Date
PO Box 102 Goshen MA 01032-0102 mgeorge@georgepropane.com
Street Address City/Town State Zip Email Address
I Cgif
Municipal Inspector to fill out this section upon application approval: ti 1 �� 1 1/�1 a
Name ' Date
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City of Northampton
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nr Massachusetts ui
•
p DEPARTMENT OF BUILDING INSPECTIONS
�d"', «'� 212 Main Street • Municipal Building
.-- Northampton, MA 01060
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In 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:
Location of Facility: Valley Recycling, 234 Easthampton Rd., Northampton, MA 01060
The debris will be transported by:
Name of Hauler: Michael George
Signature of Applicant: Date:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Lafayette City Center
2Avenue de Lafayette, Boston, MA 02111-1750
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:George Propane Inc.
Address:3 Berkshire Trail West, PO BOw
City/State/Zip:Goshen, MA 01032-0102 Phone #:413-268-8360
Are you an employer? Check the appropriate box: Business Type(required):
1.0 I am a employer with 31 employees (full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. Non-profit
3.0 We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]** 11.0 Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.0 Other Propane marketer/plumb/heatinc
*Any applicant that checks box#I must also till out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#I.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:Traveler's Indemnity Co
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lie. #UB8K5283632114G Expiration Date:05/01/2022
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under§ 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 may be forwarded to the Office of Investigations of
the DIA for insurance c v age-ve'y ficat .
I do hereby certify, undera to s aigpenalties of perjury that the information provided above is true and correct.
Signature: Date:
05/01/2021
Phone#: 413-268 0
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority(check one):
1.❑Board of Health 2.0 Building Department 3.0 City/Town Clerk 4.0Licensing Board
5.0 Selectmen's Office 6.DOther
Contact Person: Phone#:
www.mass.gov/d i a
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual, partnership,association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity,employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the members
or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Lafayette City Center
2 Avenue de Lafayette,
Boston, MA 02111-1750
Tel. (857) 321-7406 or 1-877-MASSAFE
Fax (617) 727-7749
Form Revised 7/2019 www.mass.gov/dia