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a � � `s f zxz #I 2npf an f^ *�
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DE.PARThMENT OF BUILDING INSPECTIONS _ { ttl� /
212 Main Street * Municipal Building
Northampton, Mass. 01060 �
WORKER'S COMPENSATION INSURANCE A'I'IDAVIT
/ c /51 //// t111,14- C
(licenser/permittee)
with a principal place of business/residence at:
f t:a•- e) / T .- A�",J,,, i ] Cf (phone #) , :- `" 7 (2 , 02
do hereby certify, under the pains and penalties of perjury, th2t:
s
''` (2m an employer providing the following worker's compention coverage for my
`, employees working on this job:
�c Cosngaty) (Policy Number) .' .:.n Date)
( ) I an- a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insulanx Company/Policy Numoor) (Expiration Date)
t
(N2mtz of Coot RC/or) (ln uranx Campany(Polic Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach atklitioaat (boat if n o uy to iaciuds imam ping w all coo aao:s)
( ) I. am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE: plea= be awn,a that M'bi10 homnowncrs rkto tmpiey pasom to do ma;nt.n rs z. alastructioa or ttpa'c N''''& oe a dwelling of
not more than those unite is which the bomoownc midis or cc the grounds appnrtanant Marto art not Carnally coasidaed to be
esaployets wrier the woita's ct>mpmsatian A . (GLI52,ss 1(5)), application by a homoownc for a lion= or ptrmittnay avian= tax
Iesal n of an esptvyer under rho Wociooes t ompemation ML.
I usldetatsad that a copy cf this sin + - s miry be fee wasdad to the Doper cocas ofl odus*iai Accidm ' Offroe of Imwaaoc for the
coverage vai$oatioa sad that failure to sazsse cavesga tsador Betio¢ 25A of Mat 152 ma aced sobs imposition of ctio:Mai pcinaltic
consisting of a hue of up to $1,500.00 and/or imiisoament of up to one year sa4 civil vanilla in the form of a Stop Work Older and a
fine of SI00.00 t day aping lac.
iii / / r dep.ttcoetss! 11.60 0111Y + / �/f� Fo
` Permit Number
m are of LirA*1 JPermittee
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : /0(,./S 6 ,2 �� ( S i'3—)
License Number
/ ;.2 f�iLi »i D R 0_ goh t 1, /1/9 0/00) /
Addre s Expiration D e
t e,r,AA ( 4/ Z.--C - :Y7 1 ' -- of 01
gnature Telephone J J c 0/e2.6
8. Registered Home Improvement Contractor Not Applicable ❑
Company -Name Registrati n N tu ber
Address Exp ation a te
, F A/ 4 e / C C/ � Telephona�9 9 el 63
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) n Roofing ❑
Or Doors E
Accessory Bldg. El Demolition ❑ New Signs [1::1] Decks [[[` Siding [D] Qt
Brief Description of P ed I
Work: .! i w �� . �- s �r �'L A �rt,1 �.. L "C C�) � ri 4'.N + `5 r i h. t '' . - 4
,4 !1 -re )1 ( C .
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No 1/i "1
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following: "lin
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 , l t S 1 u'k i v G`� , as Owner of the subject
property l
hereby authorize C. l 6 H / /L
to act on my behal , in all matters relative to work authorize,d by this building permit application.
_ � - 7X
Signature of Owner Date
I, iN ( -( ( - l i (1,/G f c / C g L as Owner /Authorized
Agent hereby declare that the statements and information on the foregding application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
`i c / S C `� "9 / / ( ' /t o
Print Na
e ,c,/( d1/04/2--
Sig ture of Owner /Agent Date
tiic
Section 4. ZONING All Information Must Be Co pleted. 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 1,0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO
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
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, e cavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO Vii'
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
C7 Building Department Curb Cut/Driveway Permit
212 Main Street SewerfStic Availability
t ttS 6 2�i Room 100 Water/Well Availability
orthamp M A 01060 two Sets of Structura Plans
g u uo APPLI war►+s� ei 4 3- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans
M A O toso other Spec ify
—
CATION 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
r 7 L r Map Lot Unit
/C 1 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
A l -1- pct , c � 3c �/ L - fl, �K ,�/ /�
Name (Print) Current Mailing Address: �
ice° `
Telephone
Signature C.:;1/ f
2.2 Authorized Agent:
Qc >.'S 6-C �11U�¢ lea �nlc ( " c� K � J 4 .. / i 'o, n ' � ' iY�crM� =/ � u / r � �,/i
Name (Prat) � Current Ma iling Address: / G/
e -/
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by p 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) Check Number / yt zt�
This Section For Official Use Only
Building Permit Number: Da
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
J
File # BP- 2012 -0716
APPLICANT /CONTACT PERSON TEAGNO CONSTRUCTION INC
ADDRESS /PHONE 228 TRIANGLE ST AMHERST (413) 549 -0803
PROPERTY LOCATION 309 ELM ST
MAP 31A PARCEL 004 001 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 Q
Fee Paid / 5b
Typeof Construction: REPAIR PORCH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 82248
3 sets of Plans / Plot Plan
THE F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
NF 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 Pei wits 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
I . :1 P a
400 0 1111) ". fr
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.
309 ELM ST BP- 2012 -0716
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 004 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2012 -0716
Project # JS- 2012 - 001262
Est. Cost: $6000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TEAGNO CONSTRUCTION INC 82248
Lot Size(sq. ft.): 19340.64 Owner: SANG BOOS KIT
Zoning: URB(100)/ Applicant: TEAGNO CONSTRUCTION INC
AT: 309 ELM ST
Applicant Address: Phone: Insurance:
228 TRIANGLE ST (413) 549 -0803 Workers Compensation
AMHERSTMA01002 ISSUED ON:2 /16/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPAIR PORCH
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 2/16/2012 0:00:00 $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner