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43-059 BP- 2008 -0810 (AS 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 1'c, - mit # BP- 2008 -0810 Project # JS- 2008 - 001251 Est. Cost: $700.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 16465.68 Owner: MOLINA EUPHEMIA & JESSE Gonin�: SR Applicant: MOLINA EUPHEMIA & JESSE AT. 31 WESTHAMPTON RD Applicant Address: Phone: Insurance: 31 WESTHAMPTON RD (413) 584 -2726 (� FLORENCEMA01062 ISSUED ON :313112008 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL ABOVE GROUND POOL 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 3/31/2008 0:00:00 $25.001352 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo File # BP- 2008 -0810 APPLICANT /CONTACT PERSON MOLINA EUPHEMIA & JESSE ADDRESS /PHONE 31 WESTHAMPTON RD FLORENCE (413) 584 -2726 Q PROPERTY LOCATION 31 WESTHAMPTON RD \1;11' 4, PARCEL 059 001 ZONE SR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid B uildin > Permit Filled out 44 A ] , cc Paid 0 of Typeof Construction: INSTALL ABOVE GROUND POOL New Construction Non Structural interior renovations _ Addition to Existing Accessory Structure Building Plans Included: O wner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding_ Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay SiL, nature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission, Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information. Department use only tll y'of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 - Main Street Sewer /Septic Availability 2 �oom�100 Water/Well Availability e� l` N�rtt3pton, A 01060 Two Sets of Structural Plans phgne 4,4, °3$; Fax 413 - 587 - 1272 Plot/Site Plans s Other Specify ARPLICATI N TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be completed by office 1.1 Property Address: 31 w Map Lot Unit �� (Q Mk Zone Overlay District Elm St District C8 Distrlct SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ' 4�: qoheu o s O�i,�r� 31 (,ur'cu+n bfe6� Name (Print) Current Mailing Address: G11- 52I"I- �k Telephone Signature 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS In H / JO ( LA Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applica nt 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction_ from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = 0 +2+3+4+5) Check Number j o1 O This Section For Official Use Onl Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector - ofBui dings Date r 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 Side L: R: L: .. .._ R: 1 Rear Building Height Bldg. Square Footage Open Space Footage % (Lot area minus bldg & paved parking) _._- _..._._._.. # of Parking Spaces -. Fill: (volume & Location) - mm -.. - . A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KNOW YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES 0 y IF YES: enter Book Page„ and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained t Obtained 0 Date Issued: C. Do any signs exist on the property? YES Q NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO EV , then - IF YES, then allorthampton - Storm Water Management Permit from the DPW is required. SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors F7 Accessory Bldg. ❑ Demolition ❑ New Signs [ [3) Decks [M Siding [ ❑j Other [U --"- Brief Work Description of Proposed �� 1 pa l l t _ C14 Alteration of existing bedroom Yes H No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa. If New house and or addition to existing housing: complete the following: 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? FireXorWoodst Number of each g. Energy Conservation Compliance. M asnce form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes N 00 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade / f . k. Will building conform to the Building and Zoning reg Yes No. I. Septic Tank City Sewer Privat' e well City water Supply SECTION 7a -- OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, h C l / /14( as Owner of the subject property _ hereby authorize �� fech to act on my behalf, in all matters relative to work authorized by this building per T it a plication. Signature of Owner Date I , as Owner /Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name Signature of Owner /Agent Date r SECTION 8 - CONSTRUCTION SERVICES ` 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9. Registered =Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10- 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....... 6' 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 108.3.5.1. 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 -vear 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, you 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 �� .. j ... ie lini�12 of h1_.;,,. Ct. ?ecadents Office of lnvestigations 600 IV ttshington Street = - Boston, J1.4 02 711 www. rnass. ov /din Workers" Compensation Insurance Affidavit: Builders/ Contractors /Electricians "PILmbers l,3, icant Information Please Print Legibly Name (BUSiness.'Organlzan ;Individual)' cluui eJ.>. City/State/Zip: Ro r 0 U 0/ 06p Prone #: Sfl' c) t-,, Are you an e rplo3 -er:' Check the appropriate box: ko-0 a- V Type of project (required): 1. J I am a employer -with 4. a I am a ae� actor and I 6. ❑ New construction employees (full and/or part-time)- ^ have lured the sub - contractors 1 ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling h have ship and have no employees These S. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition comp. insurance. o workers' com insurance required.] p 5. ❑ We are a corporation and its 0. F__1 Electrical repairs or additions 3 . ❑ I am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions right of exemption per MGL myself. [No workers comp. 12.7 Roof repairs insurance required.] c. 1�2, §1(4), and we have no employees. [No workers' 13.© Other comp. insurance required.] `Any applicant that checks box rl must also fill out the section below showing their workers' compensation policy information. Ho meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. - Contractors ti at checl< this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If [lie 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: A J .11 S AWI_ Pollcv r or Self -ins. Lic. r: 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 S 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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certif• tinder -tlze gains- a-ndpena- lties- ofperjtsy- that -the information provided ahov is truce and correct. Si- nature: Date: Phone __ _� .O£fic iaL ii se__on l D�_r�oLxvute�n_this_area� to be completed cit ou_towtzf_tcal T tv or Town: Permit/License uing Authority (circle one): Person: Board of Health I Building Department 3. C ity /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Other ;?hone a -- 7 Rfumarall E uil —�; -U r N4,-.D �nk-.;Ylff ()";VINTER L- The State oll allows the homeowner the 1- under 78 OCAAR 108 to er con S c ' sur - es - H me er" a , P - act -,,-L la L; D o own s (S) who o-,,ms a parcei on which he/she resides or intends to be, a one or twofa?n: d�ve-T att ached orde:ached strict res accessory to such use and/or fa-= S= person - Who cant acts More than one home in a vt Wc-year pelilod shall not be considered a home o-"Mer." The bLii£InQ eucris for the City Wan-as any person(s) Who seek tO LI L the h O e owner ex. P, on, to act as Llie-L 0'7iM CGZStrLI.-'-C= to be a -va: that by do so y ©u become responsible for compliance with state building codes and re- The inspe--tion process requires that the building derar tm-ent be called tc inspect worik at various stagges, which include Foundn (before backfill). so-notube holes (before pour). a rough buRding inspection (before work is car-Cenjed). iRsuhtti" ins:pection (if reguired) a-n&a-fma- inspection. The buEdLing depar=ent r these las-pections before the work is conee-zled, failure to secure the . se inspections can result in failure to obtain a certifeate of occupancy umtil--the-wark Ethe h= hires other trades to pe = work (electricaL plumbing & gas) the homeawner will be res to make sure that the trades hired secure their proper -er=ts m conj to Elie building - MUt issued, and that they get their required er, inspections. Failure of the individual trades to se--are the pe=ts and inspections as p e r mits and inspec ar � pect u - IIAY the r f n t such time as the proper per ec+ ons requuredf can D'AI7 Oj made T OwI iun- -,t /01 der.and the above- n (Hom,- owner lresi&ent's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permmit to me D. ate location RvIa olc)O MAR -17 -08 MON 12:02 POOLTECH 4135349869 P.03 .. w ......•, a.+s ar, cusiaarw. �:: a,. �a:.:.:- tcm.. vr, eria wyxcs�n�x, �^ a,' �tw- �a.^ �ramomiraeawwunvaa► w.+ a�x�.«. rexss�v.+ nwin; �wwsutauaxn�zat ;ck.�nt'at.ra�rrsa'.v.a Feu >� - �..,. 2e�_-;,., cv. : :. n, xr�: s: �a.• c# s^: TM• �: sxt�+ i.. a. .�.:iA�r.ri�•� r�rl.'Ffiili'rri� ANETtFICATE OF L IN _ _ ~- �....K._. DA7EtMPhtDDIYYYYI �ti o�rMwak t 413j 536 -0804 y FAX (413) 534 -7$74 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ((' FAar'C #n J. Clayton Insurance Agency, Inc. ONLYAN4 CONFERS NO RIGHTS UPON THE CERTIFICATE ( 1C�A 4 Nt L*t4:$tr Eton Street HOLDER, THIS CERTIFICATE DOES NOT AMEND, TEND OR t1 A LTER THE C CRAQF By THE Pf fLt�'FE5 l�Fx�.S�W .. f'.. 0 • Box 939 _ Hol yoke. MA 01041 -0999 INSURER AF FORDING COVERAGE NAIC INLUir;D :FiChrtrd DupLLi INSURER& AIM MUtUaI CO. Qa "1 ORA: f U01 Tech INSURER 8: -------- ----- _..__...-•- - -- .._.._ .__._. 17 .0. Box i 05 INSURER C; Holyoke MA 01041 INSIIRER P; r?d� _ __ TH(" POL101E9 OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEOABOVEi FOR THE POLICY PERIOD INDICATED NOTJ '� ii 117_1 t•:G ANi' RF,QU1r0r?AeNT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TH!S CERTIFICATE IVI}.Y BE ISSUED OR VIA, ''PE THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS 0- ='JQLI Jr.-S AC44RQrA' -F LIMIT 9 SHOWN MA HA BE EN REDUCED BY PAID CLAIMS. t•5'�J LICYE' TiVH P CY 'PW.ATI ...y___..__.-•-_----- __ -- -_ IEdIFnR( TYI''CO{+IN9UPJINC & -' POL(CYNUM _ U'AlTa (VENERAt_ "AF UTY - 64,0H OCCURRENCE — _ - -- - - -- - -- - _.__... I CORAMEW71AL CvFNFRAL LIABILITY DrMAG�6RENTED t j I - =1 CLA"wIs MADE F OCCUR MED EXP fAny"porw5k S PER a ADV INJURY { I GENERALAr,GREC 3 i CEN'i. AfYe GIRTGAIL, LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG S • . J ^OLICY IGCT t AUT0WYDILL UAWLFTY ^u — 1N COMBINED 6LF LIMIT ,..I ANY "ITO If a Fecxten {} A'..L OWNED AUT08 BODILY INJURY ^ - -- - � -- _.... ..• ' :r)igDULI:O AUTOS (Ptir permf\) t � { HIR7;[lA�,i'f0a BODILY INJURY ! • NQN CLNNF0 AUTO• (Par eccldont) 3 PROPERTY DAMAGE 0AFAGn LIABILITY AUTO ONLY yEAACL_IDEN? ANY AUTO OTHER THAN EA ACC 3 M, AUTO ONLY: Arr �XC0AAJAt@RELLA LIAEIluTy �..�. EACH OCCURRENCE f OCCUR } CLAIMS MADE ,_._} AGGREGATE 5 WORKeMSCONVIUNSA'RONAND VWC600254701 08/04/2007 08 44/2008 X W-CIATU - T Or t - (JAMU ._...._.__.._.._,.,..,,..,. -._ I > NSr I.+Y> FC re EYL1MiI L �t�fi. ANY PR�} FRtr ; rORJPN2TNLft'EXECLITIVE E. L. EACH ACCIDENT _ I r►fiFtCfRtMEMB &R t XCL UD[09 100 , i!` w:�, B.Ll,".l ?ph WtCrK 1S ! . QISEASH •• LA CMr ^ LQ 'Yt`.' ' $ _. —. QI� CCIAL P ROVISIONS bdlav E,L, UI$7 A$E _ PQLiCY LIMI? 5 500, 00 CIit Of f"TiOOS l LOCATIONS l VEHICLES I EXCLU810 N6 AI1DlEt') BY EN60R&EM1:NT1 SPECtAI. PROYtSI0I15 - `__..._.,---- ._..- --.....--_- .----- -.._..._ ..........•... .,,.....- ...._.„.........,.M,.. SHOULD ANY OF THE ABOVE DESCRIBE;; POLICIES er; CANCELLED iaamLiAc T}IE,..^ -..,. EXPIRATION DAT& THEREOF, THE I$SViNG INSURER WILL ENVEAVO ?i TO MA!L 10 DAYS WRITTEN 140TIOG TO TH9 CERTINUAlle t - OLVER NAMED TO THE L! FT POOL TECH BUT FAILUpE TO MAIL SVCH NO TICE SHALL IMPOSE NO OBLIGATION OR L1AMLI -Y ! F 0 BOX 705 OF ANY KIND t iPON THE INSURER, ITS AGENTS OR REPTRESENTATIVU. HOLYCK£ MA 01041 --- .- ... _ t AUTHORIbEO REPRESEN E s rivi.l4ttGs rim t 4orri ACORD 2t (2001108) FAX. 534 -9869 — - - -_ / 1 )ACORD CORPORATION 19$8