32C-186 (2) BP-2021-2014
398 PLEASANT ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
32C-186-001 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-2021-2014 PERMISSION IS HEREBY GRANTED TO:
Project# RENOVATION Contractor: License:
Est. Cost: 25500 BAYSTATE RESTORATION 89485
Const.Class: Exp.Date:03/05/2022
Use Group: Owner: NIEDBALA, STEVEN J
Lot Size (sq.ft.)
Zoning: GB Applicant: J NIEDBALA, STEVENBAYSTATE RESTORATION
Applicant Address Phone: Insurance:
36 JOY ST
BOSTON, MA 02114
87 SHATTUCK RD (413)549-6824 6HUB-6B21339
HADLEY, MA 01035
ISSUED ON:10/21/2021
TO PERFORM THE FOLLOWING WORK:
12 REPLACEMENT WINDOWS, 2 DOORS, BULKHEAD, PROCH REPAIRS, KITCH&BATH 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.
Signature: 11-1
11 •
Fees Paid: $182.00
212 Main Street,Phone(413) 587-1240,Fax:(413)587-1272
Office of the Building Commissioner
RECEIVED
OCT - 72021
The Commonwealth of Massachusetts
n
F 6UILDING INSPECTIONS Office of Public Safety and Inspections
RTHAMPTON.MA 01060 Massachusetts State Building Code(780 CMR)
•
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Nurnberg.21.2.O/Y Date Applied: Building Official:
34' --I 5g M kSECTIOQN/:LOCATION -
No.and Street yN- City flown Zip Codede J Name of Building(if applicable)
3=-C.- Itic°
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 0 Repair-'Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2)
Change of Use ❑ Change of Occupancy 0 Other 0 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 0
Is an Independent Structural Enginee g P er Review requireed? Yes 0 No 0
B091 DescriZion of d P opP sed o k: 0 LAp l r r_
s �
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.)
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 0 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❑ R: Residential R-10 R-2 0 R-3 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 ❑ IB 0 IIA 0 IIB 0 IIIA ❑ IIIB ❑ IV 0 VA 0 VB p4
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 0 Check if outside Flood Zone 0 Indicate municipal 0
A trench will not be Licensed Disposal Site 0
Private 0 or indentify Zone: or on site system 0 required 0 or trench or specify:
permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable 0 Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 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
N and Addr ss of P op ty Owner
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
T. le Telephone No.(business) Telephone No. (cell) e-mail address
ppl'cab e, property owner hereby auth i es:
Ott,3
Name Street Address City/T n State Zip
to apply for and act on the property owner's behalf,in all matters relative to work authoriz 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
2
Ek SibRAlactn. C31S:We—
nD� '
i c)65
Name of Pers Responsible for C n truction License o. and Type if Applicable
2'7 5 ck wl fit— O 0 3�'�
0;et Address ��� City/T w State Zip
-WY ' 7/ 3 137161/p sh�uJ4)C .zne . Nas-r—
Telephone Nu.(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
and Mateerri�als)) Total Construction Cost(from Item 6)=$
1.Building $ /0, -Z U Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ 570zi appropriate municipal factor)=$ .
3.Plumbing $ JQ 0-(�
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ o) $ 5V6 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering y name below,I ebytest under the pains and penalties of perjury that all of the information contained in this
licatio is a and accura • . e e my knowledge and understanding.
uo
P as rint g(rname n ' A6(03 )ayqbcri ;u46.Tel
e hone No. Dat
p k '`cr
Street Address City/Tow State Zip I Email Address
Municipal Inspector to fill out this section upon application approval: I: I ,zII11� .Q. 32; `,r 10 QI I
Name � � Dat/
The Commonwealth of Massachusetts
kit Department of Industrial Accidents
,._:'%ill
__���= 1 Congress Street,Suite 100
_';V C= Boston,MA 02114-2017
-.„' .l�.. www.nass.gor/dia
hunkers'('ompensation Insurance Affidavit:Builders./Contractors/Electricians/Plumbers.
TO BE FILED WITH'I' PERMIITING AUTHORITY.
Applicant Information �^�� Please Print Iaeeihty
IO Name(Buaincssrganization'lndnidual): �i
"37
Address: Waal -k-- W
City/State/Zip: Phone#: _ !3 — 5-•
Are you an employer?Check the appruprka boa: Type of project(required):
rr!I ,n a employer with - employees(full and or part-kernel.' 7. 0 New construction
■ I am a sole proprietor or partnership and hate nu employers working for me in ling
any capacity-[Nu workers'comp.insurance required.]
9. noDemolition
3.01 am a homeowner doing all work myself.[No workers"comm ignorance rec[uiroi]"
10 0 Building addition
40 l ant a homeowner and will be hiring contractors so conduct all work on my property. I will
ensure that all co ttacturs either hate workers'eompensntiim insurance or am sole 110 Electrical repairs or additions
proprietors with no employem. 12.0 Plumbing repairs or additions
t
1 am a general contractor and 1 lime hired the sub-contractors Listed on the attached sheet-
13.❑Roofrepairs
. These r[sub-contractors hate employees and have workers'comp.insuran e i
ti.Q We are a corporation and its officera have exercised their right of exemption per MU e. I ()there
152,111'4),and we hate no employees.[No workers'comp.insurance required.]
'Any applicant that eh eks but a I must aLw fill out the section below showing their workers'compensation policy information.
♦homeowners who submit this alTidatit indicating they are doing all work and then bee outside contraetoos must suhnut a new afftdat it trxdicyyng such.
:Contractors that check this box must attached an additional sheet showing the name of the sub•contr.wtors and state w hether or not those entities hate
emplayec-s if the sub-contractors hate etrq>luyLes.they must prosidc their workers`comp.pulley number.
I am an employer that is providing workers'co sensation insurance for my employees. Below is the policy and job site
Information. cee:__ci.
c
Insurance Company Name: 2J
Policy#or Self`ins.Lie.#: (0 6()D-\331 Expiration Date: ' ' 3( a-a--
?1Qa. 3.411 V
lob Site Address: �1 City/StateiZip: at Olt
Attach aof the workers'compensationpolicy declaration page(showing thepolicy numb�ex expiration date).
copy Pe P g ( � P !
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a tine up to S1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a
day against r : iolator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage ye 4. 'e .
I do hereby f
Iv • the 'ns and penalties of perjury that the information provided a e I rue and correct.
t
Signature: Date: i 6 di
Phone 4: l 7-6 ag
Official use only. Do not write in this area,to be completed by city or town official.
('it% or Town: PerntiUl.icense#
Issuing Authority(circle one):
I. Board of health 2. Building Department 3.City/Torsn Clerk 4.Electrical Inspector 5. Plumbing Inspector
(,.Other
Contact Person: Phone#:
City of Northampton
off. S�5 Sic).
., Massachusetts �k?. ,. 'e"
w: *
. f DEPARTMENT OF BUILDING INSPECTIONS °, x
': 212 Main Street • Municipal Building Jy, ca
. ,�,,. ,.yam Northampton, MA 01060 �SMh, .1;0\
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:
I
Location of Facility: �. Q2 0)
The debris will be transported by:
Name of Hauler: _ ,- .- 0,,
., , ,
Signature of Applicant: Date: l
6/
From: c-S3A-k PT? L.42 9iL ,42/e441
arr Ark
OecJ-(12-\ � Dt o� (14 S 747 a7/
5
To:
Jonathan Flagg
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, I 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.
•.ectfully,