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24C-29 (2) 88 NORTH ELM ST BP- 2012 -0133 GIS # COMMONWEALTH OF MASSACHUSETTS Map-.Bloc 2V e ' a 9 CITY OF NORTHAMPTON Lot: - PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: windows replaced BUILDING PERMIT Permit # BP- 2012 -0133 Project # JS- 2012 - 000196 Est. Cost: $7224.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: R K MILES INC 10388 Lot Size(sq. ft.): 24654.96 Owner: YACUZZO DANIEL J & GAIL B Zoning: URB(100)/ Applicant: R K MILES INC AT. 88 NORTH ELM ST Applicant Address: Phone: Insurance: 24 WEST ST (413) 447 -8300 WC WEST HATFIELDMA01088 ISSUED ON. 814120110:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 9 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 8/4/20110:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner r--� -- Department use only y E J City of Northampton Status of Permit: Building Department Curb Cut /Driveway. Permit 212 Main Street Sewer /Septic Availability .. Room 100 WaterMell Availability orthampton MA 01060 Two Sets of Structural Plans 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans Other Specify_ APPLICATION 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 0�2 /i 1 r. L J Map Lot Unit f Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Own f Record; VA C[4 400. A2, Ezn! aatT Name (Print) Current Mailing Address: A 6 Telephone � Signatur 2.2 A horize ent: 1'x /I/a�s �4Ij E T S7 P J - Fl 7��,� Name (Print) Current Mailing Address: 4f 3 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 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 = (1 + 2 + 3 + 4 + 5) ,2 Check Number _ This Section For Official Use Onl Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date ...� �� '�e�� -, �, , '.: :: 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: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved p arking) # of Parking Spaces Fill: (volume & Location) 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 Q DON"f KNOW 0 YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained- Date Issued: C. Do any signs exist on the property? YES 0 NO 0 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 0 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 0 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 ❑ Replacement Windows Alterations} Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs (01 Decks Siding [01 Other [ Brief Description of Proposed L n C � M ��� / \ Work: [ f / / Lf Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If Newhouse 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? 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 BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, � as Owner of the subject property hereby authorize 1 to act on my behalf, in all matters relative to work authorized by this building permit applicatio . J Signatur4 of Owner I Date I, V a2z r as Owner /Authorized AJbe reby de are th t e statements and information on the foregoing application are true and accurate, to the best of my knowledge anf. Sind er the pains and penalties of perjury. 6 Print Name Signature f Owner /Ag nt Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor / Not Applicable ❑ Name of License Holder DA �I / ND�S /a= License Number Address Expiration D to Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Numbe Address `` A Expiration ate LV, F l a / Telephone 7 f " O 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....... 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 -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, 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 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street •+ Boston, MA 02111 www.mass gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): -- Address: City/State/Zip: l 191M Phone #: ��J� �7 / 0 Are you an employer? Check the appropriat b x: Type of project (required): 1. F-1 I am a employer with 4. >`'" 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. ❑ Remodeling ship and have no employees These sub - contractors have g Demolition workin for me in an ca aci employees and have workers' g Y P n'• 9. Building addition [No workers' comp. insurance comp. insurance.- required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work officers have exercised their 11.[) Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ oof repairs insurance required.] t C. 152, §1(4), and we have no employees. [No workers' U.Nother 110 "W comp, insurance required,] /�t-` / *; / G � - *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors 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 1porkers' compensation insurance for my employees. Below is the policy and job site information. /-,-, , Insurance Company Name: 1 —�-1 v.S N CF / Policy # or Self -ins. Lie. # � I zy�J� +� �� 3 _ Expiration Date: /�f Job Site Address: c City /State /Zip: /0 7 ��� IVA 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 o the DIA for insurance coverage verification. I do hereby ce t#P under a pal, s and penalties ofper r a t the inform provided above is ue and orrect - Si nature: M9(1 - Date: Phone #: �/ ' 2 4 � ; J 7 � 2 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): - L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Plione #: a+ SINCE 1940 L ES BUILDING MATERIALS SUPP'LIBR i Installed Subcotrars Project: / I� ��/ l - V A C 11 ZZ16 17� �, ELL, o o>� Subcontractors: If you have employees you must provide your Workers' Compensation Insurance Policy Number Subcontractor Name: Address: 10-4 1-d, E1_ � 4��6� I i i Insurance Company: — NT-5R ; (This form must be attaclied to Project Workers' Comp. Affidavit) i _. Installed Project Subcontractors 2/12/2010 ..