23A-104 (6) BP-2024-1414
3 TRINITY ROW COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
23A-104-001 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-2024-1414 PERMISSION IS HEREBY GRANTED TO:
Project# ALTERATIONS 2024 Contractor: License:
Est.Cost: 45000 MATTHEW DERY 064404
Const.Class: Exp.Date:06/23/2026
Use Group: Owner: BARRY BOUTHILETTE,NONA RYAN &
Lot Size (sq.ft.)
Zoning: URB Applicant: MATTHEW DERY
Applicant Address Phone: Insurance:
408 HOOSAC RD 413-374-8686 WC5-315-375318-044
CONWAY, MA 01341
ISSUED ON: 10/28/2024
TO PERFORM THE FOLLOWING WORK:
ALTERATIONS TO MAKE HOUSE WHEELCHAIR ACCESSIBLE
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: 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: 1�. P
Fees Paid: $338.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
I(At 'RECEIVED
The Commonwealth of Massachusetts
Board of Building Regulations and Sta dar4 o cT 2 4 024 FOR
W
Massachusetts State Building Code, 78 CM MUNICI➢ALITY
Building USE
• Permit Application To Construct,Repair,Re ovate um`tui.'` .aIAo,�wse Afar PP P G ` s� ot�' d 2011
One-or Tuv-Family Dwelling
This Section For Official Use Only
Building Permit Nmber: f '.)-'1..1cf_1__c Date Applied:
14U l KosS / 2 ID-ZS-Zoiy
Building Official(Print Name) Signature Date
SECTION 1:SITE LNFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
3 Trinity Row
23A 104
1.la Is this an accepted street?yes X no Map Number Parcel Number
1.3 7nning Information: 1.4 Property Dimensions:
URB Residential 17.862 78'
Zoning District Proposed Use tot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
21'+- 8' 33' 80' !-
1.G Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public X Private El Municipal_ Outside Flood Zone? Municipal IX On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP' 78
2.1 Owner'of Record:
Nona Ryan& Harry Bouthilette Florence,MA 0I062
Name(Print) City,State,ZIP
3 Trinity Row 413-244-5105 nonie bouthilettcla<yahoo.com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building x Owner-Occupied x Repairs(s) 0 Alteration(s) X Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work=:
__Renovate upstairs bathroom to make it wheelchair acecasibic,install new,wider door into Master Bedroom,install a
_chair stair lift on main stairway and construct a wheelchair ramp from side deck down to the driveway
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
l.Building S 36,300. 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ 3,200. ❑ Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 5,500. 2. Other Fees: S
4.Mechanical (HVAC) S List:
5.Mechanical (Fire
Suppression) ` Total All%jftf
45,000. Check No. Check Amour : Cash Amount:
G.Total Project Cost: S 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) (644(14 6.2z/26
Mathew Dery License Number Expiration Date
Name of CSL Holder 408 Hoosac RD List CSL Typo(sec below)
No.and Street Type Description
Conway,MA (11341 U Unrestricted(Buildings up to 35,000 cu.ft.)
City/Town,State.ZIP R Restricted l&2 Family Dwelling
M Masonry
RC Roofin:Coverin
WS Window and Siding
4 l?-?7 i-8686 blkdibld(o-aol.cotn SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 163763 7/1/26
Mathew Dery
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
408 I loosac RD blkdibldta aol.com
No.and Street Email address
Conway.MA 01341 413-374-8686
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 0 No 0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT )
1,as Owner of the subject property,hereby authorize t R# ►/e r7, 3 q(!1r 1)/Q'sic Old :a it(
/"
to act on behalf;in all matte relative t• wor authorized by this building permit application.
• / I1
9'I hr24
PnM Own s Tame(Elect nic alum 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.
�—' 9/21/24
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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(H1C)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. I 42A.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/dos
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
Numbcr 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"
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: 23A 104
LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
See Attached Site Plan
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
•
City of Northampton
S s
q ' Massachusetts 4'"
DEPARTMENT OF BUILDING INSPECTIONS • '
1" 212 Main Street • Municipal Building 0^ .nb�
ry 4 �.
• Northampton, MA 01060 ry yt1
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: ValleyRecyeling
The debris will be transported by:
Personal Dump Trailer
Name of Hauler:
C=- MLI
Date:
: /6
Signature of Applicant: {
_ \ The Commonwealth of Massachusetts
Department of Industrial Accidents
y � 1 Congress Street,,Suite 100
sA`f=: Boston. .'! -;I 02114-2017
., www.ntass.govitha
Workers'Compensation Insurance Affidavit:Builder /CentractorsfEElettri+ciansI'1'lumhers.
TO RE FILED WITH THE PERMITTING AUT1IOWI'1`Y.
Annficdttt lternrrnation Please Print LetiiltIs-
atne lliusin `C rtptati~zatuu tndividuall: Mathew Dery,Black Diamond Building
Address: 408 Hoosac RD
Cit+"JStateiZip. Conway,MA 0134In Phone#: . 413-374-8686
Are%tuts an employier?Check itib6 appropriate htlx4 Type of project(required):
L.#tarn a c+x�n{.loya with employees tfX dAstpatt-time),' 7_ ,•j New ConStruCtiOn
20 I men a sole proprietor r or itnc^rcthip and have has employees Working .liar mein X. 0 Remodeling
my ca xxity.['ttfoworkers'romp.insurance required„) �--#
10 I Ytet t homavoµnea acing call work myself_[No workers"airlift s.at;inanee required. '
9.. 0 Demolition
4.l I homeowner a h and will 1:>rd hiring zttt�tie�bettilrtt ail�tthrk Oh my property. 1 u ill I 0 Building addition
lure that all contmetors either have iwekete oa aria wtaricm rrsen:a ae or arc sure l 1.0 Electrical repairs or addition
prtsprietors with no employers.
120 Plumbing repairs or additions
Sri 1 sin.a general ruinsachirsend 11tavelnred the sobYcuntmetctcc listed on the amtattcd sheet 1
These iris-einkiraicturs lead esaplrty sod have workers'tramp.tnsuranet.t
60 We are a t- i and its officers have exercised their right refex n per MCA.S. 14. Other
132.f 1(4 wed We hash no eropl syts.[No workers`a ornp.insurance required]
`Any applicant that chocks bum 44 ii melt ataci fill out the section below showing this workers'co pensuriurt tasrtic+ infer matron
t Homeowners with stet this affidavit indicating they are doing all work and then hire outside contractors meat t submit a ace auto,it m ottitig such.
tc,Na(t ruses that cltei't(this.bak burst atta'.4ted an additional sheet showing the mime of the oth-corttrieters and state whether or not those entitim haw
employees It the sulscontractors haw eitsplayc*ea.they must provide their workers'comp_policy number_
I am an employer r that is providing workers'compensation insurance far my employees. Below is the policy end fob site
Informatini t
Insurance Company N LM Insurance Corp.
Policy#or Self ins.Lic.#:- VVC5-315-375318-044 Elation Date' 9/27/2025
3 Trinity Row Florence,MA 01062
Job Site Address: .City#Suite.#Zip:
Attach a copy alike workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MCL c. 152,§25A is a criminal violation punishable by a fine up to Sl, iltl.0il
at 'or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tiitee of up to$250.00 a
day against the violator.A ally of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pctins turd penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone
4
Official use only. Do no!write in this area,to be completed by city or town official
City or Town: PermitiLicense a
Issuing Authority(circle one):
I.Board of!Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5. Plumbing Inspector
. 6.Other
Contact Person:_ Phone#
leC 99 SO 04 01-23 POLICY JACKET WC 00 00 00 D
WC 00 04 22 C 01-21 TERRORISM RISK PCM REAUTH ACT DISCL E)'DT
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WORKERS COMPENSATION AND EMPLOYERS LIABILITY
INSURANCE POUCY 1,I.ibcrty Mutual.
INSURANCE
AR INFORMATION PAGE
I,I __.$_aawa,w a41+e
4auea Cy 1.14 INSURANCE CORPORATION 27243
Pcay Nul.brr WCS-31S-375318-044 hyat:Y,9 Office 016C
REKEWAL CI': 14C5-315-375318-043 tss,aDat4 39-09-24
ACCouiI NUMMI( 1-37531E Sue Acca:nt 0000
t. Insured are Malang Adams
l.%TI'NE'W DERV Dlai FLACK DIAMOND OVII.DING
RISK ID 00010bS65
Alt IIIKIIAC ROAD
1-(PMNA 1'.11141 l41
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Bodily Inlury by Accdant S 130,000 each acrsdr11
Soddy tnwry by Oiserse S 500.000 pact'Irn(
Mode Inpry ty I1.e4see S 100,000 two amok:roe
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Rasta;Pans.Al hifocn'dian ragweed below is wAjoct to wt9Icaua"anti clumps by audit
Code Premium Oa dd Totd Rom Mr$100 ESSmi led Annual
CAM.Itheseass Nunrer Eatomied Annual rearsneralion of f(rtuttWOMO Pramkm'
Sea Ottoman d Information Page
MYvnmt Plwtium S S00 (MA) Too Estes and Anottai Runti e E 4,640
Protiamsra de had ANIUAL
Mcruow 00040141I3
ENCHANTER INSURANCE LLC
UNIVERSITY DRIVE
A?OEHRST IIA 01002-2217
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