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23 HOOKER demo application.pdfI' fB 22 0TheCommonwealthofMassachusetts. 2 Office of Public Safety and Inspections f ,//0, Massachusetts State Building Code(780 CMR) r Building Permit Application for any Building other than a One-or Two-Family] W T This Section For Official Use Only) Building Permit Number. .Z" 10 7 Date Applied: I Building Official: SECTION 1:LOCATION No. Stre City Town Zip Code Name of Building(if applicable) Assessors ap# 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 0 Alteration 0 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 0 No.'s' Is an Independent Structural Engineering eer Review required? Yes CI No Brief Descripti of Pro se Work: v , G erjy ) SECTION 3:COMPLE LE 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 A-5 0 B: Business E: Educational 0 F: Factory F-1 0 F2 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0 I: Institutional I-1 I-2 I-B 0 I-4 M: Mercantile R: Residential R-1 R-2 R-3 0 R4 0 S: Storage S-1 0 S-2 U: Utility Special Use and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA III HA CI IIB IIIA VIBE IV CI VA 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: PublicA trench will not be Licensed Disposal SiteCheckifoutsideFloodZone Indicate municipal required or trench or specify:Private 0 or indentify Zone:or on site system permit is enclosed Railroad right-of-ways/ Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable C'Y Is Structure within airport app ch area? Is their review completed? or Consent to Build enclosed Yes CIorNo Yes 0 No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code Use Group(s): Type of Construction Does the building contain anSprinkler System?: /1JO _Special Stipulations: Design Occupant Load per Floor and Assembly space: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Prtoperty Owner IictLivi fth 0/ 7 / fc -7 617n7z.c , ,1, sfd 4/%c Name(Print)No.and Street City/Town I Zip Pro erty Owner Contact Informationo Titlet Telephone No.(business) Telephone No. (cell)e-mail adcs tr a plic?a le,the properowner hereby authorizes: fit 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 0. Otherwise provide construction con7ol fn-ms(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 Compran Name f Name of Person Responsible for Construction LicenseNo. and.Type if Applicable t) .._tc,t4 1-'t-e(4 e_ ,‘q..,;_s tit kli (----* -0_, C..,/7 ilill- e I 6z2-; c Street Address City/Town State ZipL113- s,--Sli L;'// 7 , Telephone No.(business) Telephone No.(cell) e-mail address SECTION11: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 Materials) Total Construction Cost(from Item 6)=$ 1.Building Building Permit Fee=Total Construction Cost x i(Insert here 2.Electrical appropriate municipal factor)=$ 3.Plumbing 5P 17 /)1,+CC'1%`7 C 4.Mechanical (HVAC) Note:Minimum fee=$ contact ' /.municipality) l5.Mechanical (Other) Enclose check payable to f ,I'" 1 V, t,t^. 6.Total Cost contact municipality)and write check Amber 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 ac ate t6 the best of my knowledge and understanding. Nje(1.1,k:ten-pc-C?----______ex i, „kJ/A,4- 4/6 5-7ris0-9/ /14...9e--,9,j Please print and i name Title Tele hone No. ate 7brc etc e- w e. 'G % p19-- utA)s I-7- , c-2c,,wt ;'1_‘.-A%(,-p Street Address 1 City/Town State Zip Email Address LOY\ Municipal Inspector to fill out this section upon application approval: Name Date City of Northampton Massachusetts elL` s, I c DEPARTMENT OF BUILDING INSPECTIONS iNA 212 Main Street a Municipal Building gyp'\ Northampton, MA 01060 rs"""y i^` r 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: 6-2C6 (-C 10 Cc ,\\_ I ( e. 6/6 LlC_) The debris will be transported by: Name of Hauler: ,k) ?- I-e-r/v / (Ct c2,i c).- 'J 911 Signature of Applicant: 1 - Date: The Cannon wealth ofMassachusetts ltl= ll Department ofIndustrial Accidents 1— 1, I Congress Street,Suite 100 r Boston,MA 02114-2017 i www.mus gav/d/a 1}.o kers'Compensation Insurance Affidavit:Buiklert/ContractorsFElectriciansJPlumbers. TO lit 111.t:11 wrfll THE PERM rtiNG AUTHOR!IN, Appiieenttnformalion Please PPrint Lesibly Name.(3ueanss.Organzatfon Individual): iy ) 44c Ss k i(ij'4" / `Zi ' Address: . ' It(c c1e-f\-Os kJ r City/State/Zip: 11,1f, (4--;e al AA Phone#j/, ' 3 7 ---___5—.c AnA yea as estpiayv!Cheek fate xpproprFate tin: Type of project iregaired):. l. am a employer with if,) employees!full easat'aar pert-time n.• 7..a New construction 201 am a stile proprietor or pautneralup and have rw employers socking for me us Remodeling any easpaesty.No w inters'camp.uuuran.e requital]9. Demolition 301 tun a homeowner doing all wort myself.[Nu winker'curry.auturancawcruuud.l' l0 0 Building addition4.0 l am a humcVK'aa acid will be hints t_aararadurs to atauludd ail work uh my prop ref. 1 will ensure thatall rauara iura either brit workers'runipensation iraaurancu tie ant sole 1:1 a Electrical repairs or additions proprietors with nu etapluye s. 12.0 Plumbing repairs or additions 50 lint i general cuntrartur mad 1 lime hired the sub-contracture listeJ us the anajicti sheet 1 0Rlwfrepatr]These sub-euntractens haw employees tail tease workers'comp.tmuaanec.• 6.0 we c a ctatpuralivaaul its officers bus a alertLied their'Igluof a raptiest pa MGL e. 14.Other arc IS!.¢I)4),anti t..thave MO employee.[?Jo wurkent'comp.thsacu cr required.] rAtty applcaatt thatcheeksbox*Lassa also fill out the sonarsorlon showing their wurL ts'eumpenutiun polity infurmatie n.t kbn,wwaen who simatlitilattidssit in lecatnsit they are doing all work and then hueuutxialc contracwrs must submit a sew affidavit uadiexitiag each. Curitraeturs that dheek this hux must:duetted an ad.litiotal sheet show tag the name of the su -wars:tors and seat Whetha Of nut dose entities have eanpliayees. lithe at -eurrlra'kilt have c-u>rio}use.they muss provide their nurkers'imr.p p.,I,sli bier'sr. tam an employer'r that is providing winters'compensation insurance for nfy employees. Below is the policy andjob site information. p _ Insurance Company Name: 6.A IVt t2 e .c,<'I -t ct-"- CC. CLl " Policy at or Self-ins,Lic.#: WC-f 02C3S-b 3 h1 Expiration Date: i2//42-ed-c). Job Site Address: -HVV I`-C4 CitylstuteizipMai pirn 1// 7 copyAttacha of the workers'compensation po tc, declaration page(showing the policy number and e tlon date)I/' Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a rule up to$1;500.00 anit or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine ofup to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations ofthe DIA for insurance covera1Le verification t do h . certify der the pains andpenalties ofpetjury that the information provided above is true and correct.7)Signature J --- Date:aidy/9-4?- - Phone.e: 4/3 _. --- 7 / Official are only. Do not write in this area.to be completed by city or town official City or Town: Permit/License it Issuing Authority(circle one): I. Board of Health 2.Building Department 3.City/Toan Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#:_ NOTE- THIS PLAT IS COMPILED FROM DEEDS, PLANS AND OTHER SOURCES AND IS NOT TO BE CONSTRUED AS AN ACCURATE SURVEY AND IS NOT TO BE RECORDED. BUILDING LOCATION ACCURACY IS NOT GUARANTEED. CURRENT SNOW COVER NEGATES THE ABILITY TO ASCERTAIN ENCROACHMENTS UNDER SAID SNOW. NOTE: PROPERTY LINES SHOWN ARE APPROXIMATE, A FULL FIELD SURVEY IS REQUIRED TO ACCURATELY DETERMINE THEIR LOCATION. 90.7'± approximate location of abutter's shed BOOK 12652,APAGE219 IRON PIPE 53'±FOUND HOOKER AVENUE TO: CONNECTICUT ATTORNEYS TITLE INSURANCE COMPANY TO THE BEST OF MY INFORMATION, KNOWLEDGE AND BELIEF I HEREBY REPORT THAT I HAVE EXAMINED THE PREMISES AND BASED ON EXISTING MONUMENTATION ALL VISIBLE EASEMENTS, ENCROACHMENTS AND BUILDINGS ARE LOCATED ON THE GROUND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY WITHIN THE LOT LINES, EXCEPT AS NOTED. I FURTHER REPORT THAT THE PROPERTY IS NOT LOCATED WITHIN A FLOOD PRONE AREA AS SHOWN ON FEDERAL FLOOD INSURANCE MAPS FOR COMMUNITY #250167 NOTE— SURVEYOR: arn.Lt.SQ THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY AND DOES NOT CONSTITUTE A PROPERTY SURVEY tH of;. MORTGAGE LOAN INSPECTION PLAT—z S9° ti NORTHAMPTON, MASSACHUSETTSRANDALLIn 8 IZEPREPARED FOR IZER t/ADAM & PRISCILLA NOVITT SCALE: 1"=30' MARCH 5, 2021 ItiO suRvj ! HAROLD L. EATON AND ASSOCIATES, INC. REGISTERED PROFESSIONAL LAND SURVEYORS 235 RUSSELL STREET HADLEY — MASSACHUSETTS ASBESTOS REMOVAL All residential, commercial and institutional buildings are subject to Massachusetts Department of Environmental Protection (MassDEP) asbestos regulations at 310 CMR 7.15. Therefore, owners and/or operators (e.g. building owners, renovation and demolition contractors, plumbing and heating contractors, flooring contractors, etc.) need to determine al asbestos containing materials ACMs), both friable and non-friable, that are present at the site, and whether or not those materials will be impacted by the proposed work, prior to conducting any renovation or demolition activity. Examples of commonly found ACMs include, but are not limited to, heating system insulation, floor tile and vinyl sheet flooring, mastics, wallboard, joint compound, decorative plasters, window glazing, asbestos containing siding and roofing materials and fireproofing materials. Failure to identify and remove all ACMs prior to its being impacted by renovation or demolition activities, can result in significant penalty exposure, and higher clean-up, decontamination, disposal and monitoring costs. A DOS certified asbestos consultant must be contracted to determine if asbestos is present and whether removal/repair is necessary. If the building is a state owned facility, contact DCAM and DOS. DOS provides a list of licensed asbestos abatement contractors and consultants. You may wish to inquire if a contractor has any history of violations. Only DoS licensed and DOS certified asbestos abatement contractors and consultants may be hired to perform asbestos related work in Massachusetts. Received by: '''D`"'M kk0,S\? C)J'A\ --- Print Name Title i,\.Z-`21 Z Z ) zZ_ Signature Date BUILDING DEPARTMENT DEMOLITION PERMIT SIGN-OFF SHEET Date: 011)t,' Address: •,•g 1+6 G 74 Building Use: L;;v‹.-t,4 Owner: L'( l:'l Phone: 4/ —:270/7,2. — Owner's Address: I / ) r UTILITY CUT OFF Signature of Authorized Representative of Utility Department required) As required by the Massachusetts State Building Code (780 CMR), a permit to demolish shall not be issued until a release from the utilities is obtained, stating that their respective service connections and appurtenant equipment have been removed or sealed and plugged in a safe manner. Eversource (Gas) Signature Title National Grid (Electric) Signature Title DPW (Water) Signature Title DPW (Sewer) Signature Title DPW (Storm water) Signature Title DPW (Tree Warden) Signature Title DPW Director Signature Title Historic Comm. Review Signature Title