31A-208 e: d BP- 2011 -0339
GIS #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2011 -0339
Project # JS- 2011- 000555
Est. Cost: $35000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DAVID CHICOINE 061582
Lot Size(sq. ft.): 10497.96 Owner: ARCESE ERIC G & CHRISTINE S
Zoning: URB(100)/ Applicant: DAVID CHICOINE
AT: 8 WASHINGTON AVE
Applicant Address: Phone: Insurance:
16 EDGE HILL PLACE (413) 246 - 7536
AM H E RSTMA01002 ISSUED ON:10/13/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 10/13/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
Departmentuse only
City of Northampton Status of Permit.
Building Department Curh Cut/Daveway Permit `:
212 Main Street Sewe{JSepttcAvaitaoility
c y \ Room 100 Wafer/Welt Avalabihty
°, Northampton, MA 01060 Two Setsof Structural Plans
phone 413 - 587 -1240 Fax 413 - 587 - 1272 Plot/5rte Plans
" Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SI INFORMATION J
1.1 Property Address: This s ectronxa tie-toinpleted 6y of _rce
Aa.4 n7 Ad /1 v� Map " Lot Unit .
Zone Overlay District
Elm St. District CB Dtstrict
-
SECTION " 2. - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized A ent:
c
Name (Print) Current Mailing�ss:
Signature Telephone
SECTION 3 ESTIMATED "CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building } (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
- Construction.frorn (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) ,/f >Dv Check Number #35 —
This Section For Official 'Use Only
Building Permit Number: Date
. Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
. 7V/' ,
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size .________.
Frontage
Setbacks Front r__
•
•
Side L: R: L:_ R: '
Rear
Building Height
Bldg. Square Footage
. i
Open Space Footage
(Lot area minus bldg & paved I
parking) .
# of Parking Spaces
Fill: .
(volume & Location) - i
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:! ,
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW a YES 0
IF YES: enter Book Page: and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO er DON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission? •
Needs to be obtained Q Obtained ' 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 6
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO eJ
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excav on, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition [I Replacement Wj ows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [El Siding [O] Other [O]
Brief Description of el di.. l _4,47 � , f z ei f 0 / / //
Work: �� �.� t� O Gc // 7/ srlc 7 N ✓F- ,�4�7` /�Ja I''✓
Alteration of existing bedroom Yes INo Adding new bedroom Yes 1
Attached Narrative Renovating unfinished basement Yes .e-- No
Plans Attached Roll - Sheet
sa_ If New house and or addition to existing housing; complete' the = following: /r7
a. Use of building : One Family Two Family Other /�
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER .AUTHORIZATION ` -TO COMPLETED WHEN
OWNERS,AGENTOR RACTOR AP LIES FOR - BUILDING PERMIT
I, �� 1C (?-6t [5. , as Owner of the subject
property
'
-l'`‹ hereby authorize (Ti. //
%Cdi/7
to act on m • alf, in as I _ ers relative to work authorized by this building permit application. •
i
S' ."7 re a er Date
I, 1 - ✓e � �/ .. I , as Owne utho '
(A2prittvereby declare that the statements and information on the foregoing application are true and accurate, to the best o my nowledge
and belief.
Signed u ains and penalties of perjury.
re ✓i'G( -� C.4i e_ �A-4 7�
Print Name ,,,06:
..._1.
Signature of Owner/Agent Date
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
•
Name of License Holder : /2• GAi GG/ Z / G f a
License Number
��‘ r �/ 7 A /ef A4 /z � �-�
Address Expiration Date
, i €. - Gamf3 ✓3�
Signature Telephone
- - -- �• - - -- _ .. _ .._..
9. Regis / t i ered Home Improvement Contractor_ / , „ },_ _ '. _ Not Applicable ❑
C�%Gv /4{ /�r Cvs. n 4,✓ ✓=tine!! .��/G �/C / 4( f / L , s'
Company Name Registration Number
' -
<•_72 ; // 7$ E / 1 4 /- 0 -/-/ / 4 0/. /O�-�. o /2 //
Address Expiration Date
Telephone /f V "7/f'
SECTION 10- WORKERS' COMPENSATION! INSIJRANCEAFFIDAVIT'(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 buildin permit
Signed Affidavit Attached Yes No ❑
11 - HOme Owner Exemption
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780. Sixth Edition Section 1083.5.1.
Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers•to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, von may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
•
The Commonwealth of Massachusetts
Department of Industrial Accidents
� ►. . Office of Investigations
600 Washington Street
tra c.. l.t_
Boston, MA 02111
.. _•• • www.mass.gov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): lid' GY.'Got7/ C:n
Address: 7 /''d f
City /State /Zip:�4.- 4../ i1 /lj/1 Phone. #: 4/7 Z V 7,47f
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction
2. ❑ I am a sole proprietor or partner - listed on the attached sheet. 7. Q Remodeling
ship and have no employees These sub - contractors have g, Q Demolition
for me in any capacity. miloyees and have workers'
working Y P tY• 9. Q Building addition
[No workers' comp. insurance .mp. insurance.$
required.] 5. [ We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their
3. ❑ I am a homeowner doing all work i l.❑ Plumbing repairs or additions
myself. [No workers' co right of exemption' per MGL
Y comp. 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no a' #444'1
employees. [No workers' 13. Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
employees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: City /State/Zip: .
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 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
Investieations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
Signature: Date: / - / d/
Phone #: «/7' Z4l 7/f./
Official 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):
1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #: