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44-090 964 FLORENCE RD BP- 2011 -0907 GIs #: COMMONWEALTH OF MASSACHUSETTS Map:Bloc 44 - 090 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: replacement windows /siding BUILDING PERMIT Permit # BP- 2011 -0907 Project # JS- 2011- 001479 Est. Cost: $12000.00 Fee: $72.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RANDALL ROBERTS 042573 Lot Size(sq. ft.): 74487.60 Owner: BERGERON LEONARD & MARY ELLEN Zoning: SR(100) / Applicant: RANDALL ROBERTS AT: 964 FLORENCE RD Applicant Address: Phone: Insurance: 321 RUSSELL ST (413) 530 -2703 O WC HADLEYMA01035 ISSUED ON: 516120110:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL2 GARAGE REPLACEMENT WINDOWS, COMPOSITE DECKING /RAILS & VINYL SIDING 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 5/6/20110:00:00 $72.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner File # BP- 2011 -0907 APPLICANT /CONTACT PERSON RANDALL ROBERTS ADDRESS/PHONE 321 RUSSELL ST HADLEY (413) 530 -2703 Q PROPERTY LOCATION 964 FLORENCE RD MAP 44 PARCEL 090 001 ZONE SR(100) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiny Permit Filled out Fee Paid Typeof Construction: INSTALL 2 GARAGE REPLACEMENT WINDOWS, COMPOSITE DECKING/RAILS & VINYL SIDING New Construction Non Structural interior renovations Addition to Existin Accessory Structure Building Plans Included: Owner/ Statement or License 042573 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: pproved 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 Z 11 Signature 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. of Northampton satusat>?erm,>: B ing Department v Perrntt 3 Main Street S ewer6Sep�cAvailabtlrty Room 100 W aterwa]V A 41 abiiity Northampton, MA 01060 Two Sets of Structural Plans ne 413 - 587 - 1240 Fax 413 587 - 1272 Plot/Site Plans ae r Spe - PLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING , SECTIQf�f_ 1 SCi E - - • 'Chissection-fo.6e completed by office. 1.1 Property Address Map Lot Unit w ar x Zoire Ouertay District - 1/0 // / (f/ °EItrSLDfstrict GB.Utstiict -SEC - nON 2 1 RQPERTY'OWNERStifRlAlrFtfORf 2.1 Owner of Record Name (Print) Curomq Mail! g Add Telephon r l J Signature uthorized Ace / 21 v e C N e (Print) urrent Mailing Address: zo Signature Telephone SEC710N -3 E5lllllfATED�CONS rTREICTCON.Cd�TS Item _ - Estimated- Cost {Dollars�to -be Use Only_ m feted by ermit applicant 1. Building ©rD (a} Building Permit Fee 2. Electrical fib) F..st 7atal,Cost,of. bnstruchon from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) -.Check Number _. = Th rat;'U'se,On1 . Date Building Permit Number; Issued: Signature: Building CommissionerAnspector -of Buildings Date � r Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplet nformatio b. Existing Proposed Required by, Zoning / �'** V This column ti be filled in by uf� Building Depar , r �' Lot Size Frontage Setbacks Front } I+ Side R:' 4 L: Y R- i Rear Building Height Bldg. Square Footage % j Open Space Footage ___� __ %_� (Lot area minus bldg & paved i l p arkin g) # 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 YES 0 IF YES, date issued:: IF YES: Was the permit recorded at the Registry of Deeds? NO 0" DO KNOW YES 0 IF YES: enter Book Page and /or Document # ' B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained , Date Issued: C. Do any signs exist on the property? YES NO 1 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended the property ? YES 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 O NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required_ �tv SECTION 5- DESCRIPTION OF PROPOSEDsWORK. (check all adplicableY V -A New House ❑ Addition ❑ ReplacemeRtyWndows Alteration(s) J z Q Or Doors Accessory Bldg. ❑ Demolition ❑ W. Sign [O] Decks [Q Sidhig [p] Other [U Brief Description of Proposed Work: �/ Alteration of existing bedroom Yes iL .No Adding new bedroom Yes 9�—�No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6 a :if New - -thouse°and -or..atrdit o 6ii r .Eira>lr c> g> o teY [t"avrxl t4 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 AUTHORIZAT101+F TO BE COMPLETED WHEN y OWNERS AGENT OR CON7 RACTOR APPL'[ES ." BUIf: I PERMIT as Owner of the subject property �( - hereby authorize 4 1A I to act on my behalf, in all matters reI ve o work authorized by this building permit application. -ALiAA1VJ.4 4 Cf,u �L 2-6 Signature of Owner I I Date JF 1, ��cc E66es--k , as Owner uthorize e hereby declare that the statements and information on the foregoing application are true and accurate, to the best of owledge and belief. 4tN der the pains and p Itie f perjury. rJ w l e of Owne n t Date t • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable 0 Name of License Holder 4 Qa L ' / Sp t L 5 / 1 9 'tense Number dku Address Expiratio Date s` 30 d 763 , Signature Telephone r Not Applicable ❑ 9 <:Re ° "stebe @_Efdmnam `r `eme Coritracfor" _ a 6g rIa fl / Com ramy Name Registration Nu ber _71f5 aaf6Z Address Expiration Date Telepho4 SECTION 10- WOR C OMPENSALION.INSURANCE AFFI©A1i'1T (M.G:L -e. 152, § 2sc,(sii 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....... No...... ❑ 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)vho 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 n be considered a homeowner Such "homeowner" shall submit to the Building Official, on a forth acceptable to the Building Official. that he/she shall be responsible for all such work performed under -the buildine pe rmit As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion eeEthe- work - for- Nltieh this pe -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_Amnotated. Homeowner Signature 111C 1..u111111unweQ1tu VI IM215521l:llusCLls = _ Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 vvww.mass.ZoY1dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Le 'bl Name ( Business /Organization/Individual): Q a d a V L rj: 171 Y Address: City /State /Zip: R. ld 3 Phone( f fj— j Are you an employer? Check the appropriate box: Type of project (required): 1. -- I am an employer with 4. — I am a general contractor and I 6. -- New Construction Employees (full and/or part- time)* have hired the sub - contractors 2. — I am a sole proprietor or partner- listed on the attached sheet - I Remodeling Ship and have no employees These sub - contractors have g- — Demolition Working For me in any capacity- workers' comp, insurance_ 9. — Building Addition [No workers' comp- insurance 5- -- We are a corporation and its 10 ... Electrical repairs or additions required.] officers have exercised their 3. -- 1 am a homeowner doing all work right of exemption per MGL 11- — Plumbing repairs or additions myself. [No workers' comp- C_ 152, ' 1(4), and we have no 12. — Roof repairs insurance required.]H employees. [No workers' 13_ — Other comp. insurance required.l ' Any applicant that checks box # I must also fill out the section below showing theirworked compensation policy information. H Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. I Contractors that check this box must attach an additional sheet showing the name of the sub - contractors and their workers' I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site infor m ti aon Insurance Company Name: . V D _ Policy // or Self-ins. Lic_ #: / loJ `/ ! _ Expiration Date: I/ Job Site Address: For all. 'towns 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 Investigations of the DIA for insurance coverage verify tion. I do hereby certify un r th pain nd penalties ofperjury that the information provided above is-true and correct. Signature: Date: Phone #F: L ! CA Official use only. Do not write in this area, to be completed by city of town official. City or Town: Permit/License #: Issuing Authority (circle one): 1. Board of Health 2_ Building Department 3. City/Town Clerk 4- Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: a S