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23A-016 (3) • AA d / Q9 t ns a rzd 1 5 "J 0S I 1 A � •� /1 h 5-100 -6,S not 210 2 - 3 ,t ra ) rj ) -7 S 49 . 2 73 151 f� f > � wi G d b � i,f � i ko 0 . � �C 0 ri d d 9 /J)M / 4! }� a 9 ///A S Y S 5.4d d ()l5- off.. awa -IS fi j d 9 /l'"'' �} a !9-i 34( 5' 4 / — d Jl) op) 0 -1 poiod_ d Q fi )/J )/AI 5Ad d ad/ d b d.) J 3,1)15562)1d - s N O 10 wv 51 C, 5 /Jv1,/ 3/ y/ - vi! dPO) o., at1o d9 / /rz4 5P1.1 74 dill Cut ..► d 95 (& i 5,iM,►j �I 44 -foil &dd mo z )2 9d5 a9 1/,1 (1) c1/v loom dwok x z V .0j1)l!y79 ?9 pm v 6e c'-, The Commonwealth of Massachusetts t .d Department of Industrial Accidents Office of Investigations 4.,, 600 Washington Street it : , ` Boston, MA 02111 '44-,-'i,`' ;'` " WWW massgov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information 6-1-2-e-1:1,-1 Please Print Legibly Name (Business/Organization/Individual): F "rz-} t t) ( NL (TO -0c . j 1 r Address: \ 1 E t ` I ��n1 City /State /Zip: - "' \ «fur' , t ( 0to t1 Phone #: t� 52°1 C%5' l' I Are you an employer? Check the appropriate box: Type of proleet (' eqnired }: 1. I am a employer with 2- 4. 0 1 am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors b ❑ New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. ► Remodeling ship and have no employees These sub - contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.# 9. Building addition required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *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 cheat 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. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Ft r K- . PE i2t2A - -S 1. tit S) l2. L A at, Gam( — G ACF- O Policy # or Self -ins. Lic. #: S. E. W C Z a 1 . 3 6 Li Expiration Date: `[ 12 1 I i Z Job Site Address: /q Par k S t Y e e e City/State/Zip: R r P kl r p J IM ©/ C 6 Z 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 agryinst 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 certify un r - e a d penalties of perjury that the information provided above is true and correct Signature: Date: (/ 4 A 0 2_ Phone #: 4 t S 5 .Zd) C, 9 ✓✓ Official use only. Do not write in this area, to be completed by city or totwn 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 Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: " c Not Applicable ❑ Name of License Holder : Sean , / (� Q 1` > � 0 7/ CJ q License Number 8 Tihr( Gas2`4o peon /t /1/2 / ojz Address Expirati Date /cf13) 27-05'4/4 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable El � C yovic/ Greet') /Sour) Je~�-�cvds l3 / 27 Compan Name Registration Number Address Exit tion D e �. ' Telephone ('4 /3) 2 c /_0 SyJ/ 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) jr Roofing ❑ Or Doors E Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other [0] Brief Description of Proposed , Work: C e 01( G4he 'f(1 Q(�d 71Q ex' z', f erAi f it? co state/ /'ova (art Walls /it baseolenr and wwY, {?S 1O (•' tl. Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. 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? 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, gar, Y S t� r k i t1 , as Owner of the subject property hereby authorize Ll O41 ci 6 rE>P t/! to act on my behalf, in all a relative to work authorized by this building permit application. / /9 // Signature of Owner/ 4 " Date I, Sear) Te - o v 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. Seat TYP{ o 4 Print Name / ..�. �� 2 Signature of Owner /Agent Date 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 parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T 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 Q DON'T KNOW ® 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 i 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 ® NO Q 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 ® NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • Department use only - ECE�VE� City of Norampon Bui Department rt t Status of Permit: Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability • 4 2012 Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans OF BUILDING INS 41 3- 5 87 -1240 Fax 413- 587 -1272 Plot/Site Plans NORTHAMPTON, MA crmso Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: / This section to be completed by office 1 1 fa r S L Map Lot Unit Yre o Ce ,/ 4 Zone Overlay District l Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: P o c �� r f or kW) I f Pa r k- S ,P /114 Floe k� c. Name (Print) _ . Curren Mailing Addres T . (2 ?1 0 K S Z f Telephone Signature 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature r Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 9) coo (a) Building Permit Fee 2. Electrical / (` (b) Estimated Total Cost of rf V �/ Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection _ ll 6. Total = (1 + 2 + 3 + 4 + 5) if 1 0 0 Check Number � "t3 jt7 This Section For Official Use Only Permit Number: Date Building Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -0632 APPLICANT /CONTACT PERSON SEAN JEFFORDS ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON (416) 529 -0544 PROPERTY LOCATION 14 PARK ST MAP 23A PARCEL 016 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ��qq Fee Paid / o " f A d Typeof Construction: INSULATE BASEMENT WALLS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 074539 3 sets of Plans / Plot Plan THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I ATION 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 D ition II - - y C _� / — ) /- Signature of Building f icia 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. 14 PARK ST BP- 2012 -0632 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A - 016 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit # BP- 2012 -0632 Project # JS- 2012- 001088 Est. Cost: $12000.00 Fee: $70.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SEAN JEFFORDS 074539 Lot Size(sq. ft.): 25395.48 Owner: SORKIN ROGER & EVA CAMACHO - SANCHEZ Zoning: URB(100)/ Applicant: SEAN JEFFORDS AT: 14 PARK ST Applicant Address: Phone: Insurance: 13 TERRACE VIEW (416) 529 -0544 WC EASTHAMPTONMAO1027 ISSUED ON:1/11/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSULATE BASEMENT WALLS 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 1/11/2012 0:00:00 $70.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck— Building Commissioner