23A-129 (6) BP-2021-2018
46 MIDDLE ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
23A-129-001 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-2021-2018 PERMISSIONIS HEREBY GRANTED TO:
Project# NEW GARGE Contractor: License:
Est. Cost: 67000 GOUGEON BUILDERS 075029197294
Const.Class: Exp.Date:09/06/20221 1/20/2021.
WALMSLEY KATHARINE R&JENNIFER L
Use Group: Owner: SPENCER
Lot Size (sq.ft.)
Zoning: URB Applicant: GOUGEON BUILDERS
Applicant Address Phone: Insurance:
1261 HAWLEY RD 4136259337 WCC50050141042020
ASHFIELD, MA 01330
ISSUED ON:10/14/2021
TO PERFORM THE FOLLOWING WORK:
DEMO OLD GARAGE AND BUILD NEW
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 ).2
• II
0
Fees Paid: $115.20
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
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The Commonwealth of Massachu tt4Ii1IiC
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C..� ,�� Board of Building Regulations and S nds F
,. Massachusetts State Building Code, 80 RBuilding Permit Application To Construct, Repair Re hC�� evise Mar 2011
One-his Section For Official Use Only RTkq"P oN MgAFcrie)
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Building Permit Number: _6p.A/'.) CHI Date Applied:
.; t, • : - .a ,D/)k/a(
Building Official(Print Name) Signature 1 I Date
SECTION 1: SITE INFORMATION
1.1�r�I���Address:,
d��ss��t / 1.2 Assessors Map&Parcel Numbers
1.1a Is this an accepted street?yes V no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required • Provided
o-C) k 7dr y fi /el `/ 70
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone.• _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
K � n;4er Serer F (oryKce )11- 0 (OoZ
Name(Print) ' / City,State,ZIP
(j M:dd/t c+ Y/3 320 f6 3 Y jen.,;6.-IS/tHeer Co g :I. cow.
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction)il Existing Building❑ Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition yel Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work': I erg p 0 i 6a• Ara e r_ 3..0( ' a ram
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only •
(Labor and Materials)
1. Building $ (, S:000 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee
)6 00 0 Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No.(f 13Check Amount: '515 ??h Amount:
6. Total Project Cost: $ (0 7)ODv 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
-3-A,...., 6.1 Zi e\ License Number Expiration Date
Name of CSL/Holder V
List CSL Type(see below)
a-- 6/ kluwiery R.
No.and Street I Type Description
4-&-
�`l� /„� �J `_� O U Unrestricted(Buildings up to 35,000 cu.ft.)
O Y' 1 /i - J R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding •
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 'q 7 d2 C1[./ 1/ �(
4 C I ILCS HIC Registration Number Expiration Date
HIC Compitn dame or HIC Registrant Name
No.and St et V G q G co.‘but det3 .cow
S/4 W13 t519 ,}y �J Email address
City/Town,State,ZIP / Telephone
SECTION 6: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 5 No 0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize Goa rw, 17c.,(IG efS
to act on my behalf,in all matters relative to work authorize by this building permit application.
a 3Preli+er 1-,cA_C /D- 7- 2oz/
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
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 of my knowledge and understanding.
7 G eon l0%7a-I
Print Owner' or Authotized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system _ Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Canrnron wealth of%laswtchusetts
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Department of Industrial Accidents nts
! Congress Street.Suite 100
Boston, MA 02114..2017
www nra.ss.gov/ilia
'1 inters'Compensation Insurance Affidavit:Builders/(Contractors/Electricians/Plumbers.
TO BE EILEll W LTIB TIIE NEIt mull(AI 11110Rhil".
Applicant Information Please Print Le
Name 11 itus1nc .Organization:individual l: TG C ttw,
Address: Ia.6( .1-ei fZC
C ityf State/Zip: a�d� 'f33 0 . Phone#: i-f(,3 CAS—`�3 3 Zi
Art yea an employer?'('ktch air appropriate box:
Type of project(required):
I.411 am a employer with 2 crrailoyces dull and,uor part-Linnet.' 7. 1 New construction
'_.n lam a sole proprietor or pcntnership and have no enrpkw xs working forme in S. ('"'� Remodeling
any capacity.!No workers'comp.insurance reyuired_j i JJ
9. 0 Demolition
3rj l am a h mno!rv:rrsr doing all work myself.I No voodoos"comp_insurance requnerl_t'
lU O Building addition
4.(`)I am a homeowner and will be hiring.contractors io ctnrduet all vs erk ore mn props-its'. I will
t..l enure that all et rat:ton. either leave worker."compensation insurance or are sole I ICI Electrical repairs or additions
proprietors with nu employees_
12.0 Plumbing repairs or additions
50 1 am a general contractor and I have hired the sub-contractors listed on the anaired sheet.
These sub-contractors have employees and have workers'comp.nwurance. 13 Roof repairs
6.0 We are a corporation and its officers have exercised then nglft of exemption per MC.L c. 14.❑Other
152. It4l,and we have no employees.[No workers'comp.insurance requited"
*Any applicant that checks box is1 must also fill nut the section below showing their workers'compensation policy untemnaiini.
+Itarncuwricrs who submit this affidavit indicating they arc doing all work and then hie outside ecnrtracton must submit a new atfidav It indicating sorb.
:Cuntrae10r%that check this box must attached an additional sheet show Inc the name of the sins-contractors anal state whether on not those entities hate
estlployces. It the sub-corrtraetors have trrsrluyees.they mnust pros ide then worker,'cuwir policy number_
l am an employer that is providing wailers'compensation insurance,for my employees. Below is the policy and job site
information.
Insurance Company Name: ii-,1.tn. rilvvwft CO,
Policy#or Self-ins.Lic.#: W LL— S-00— rO(4-1_j 61-1 -a0 (A. Expiration Date:1( 4-4/a-
Job Site Address: LI 6 Mi 1A e S--- City/Stale.zip:( o(enc,e1W A 01662-
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 S1,5(10.00
and'or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.(K)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 c y under e pains and penalties of perjury that the information provided above is true and correct
Signature: Date: 1 u_$"--a- I
Phone#: LI 1 6?--r a331-
Weial 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):
I. Board of Health 2.Building Department 3.(_'ity/Town Clerk 4.Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
r• ' Massachusetts 442 <
DEPARTMENT OF BUILDING INSPECTIONS S fr? m
.rr ' "` , 212 Main Street eh Municipal Building y_ Ca.
.,. Northampton, MA 01060 sSp 31:) .
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: Jq 11 e j Rec7 c i r j _
The debris will be transported by:
•
Name of Hauler: Gyovgu^ Cw 4 Lis
Signature of Applicant: Date: 1O/(/7-(
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Footing 4' below grade
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South Elevation
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East Elevation