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PO G .V t -�- € Property Reference_: ',< g6/12 County To the Bank limited of Texas, P'SB Deed Bar.. 3.x`5' f Pg. lPlaa Bk. ?o- and the Commonweaith Land Title Inst To the best of my knowledge, 1r-format i CITF /TOWNt, /4l .729W1!` ? +�. a — and belief, I hereby report that I h i examined he premises and that this Osmtr: ge.1..2ALO.C• 4 .1 T inspection plat shows the buildings a i Address: '' LE 't1�£ located ou the premises described, th the buildings are entirely within lot rflr7eZ — WeVs 12z . „. 4 . ! 5 5 lines, and that there are no en roacl: upon the premises described by.au4ldi pare: { - -/993 Scale: i Q _ .._. of any adjoining premises, except as indicated. I further report that to t i bogy: n f ��r i i yesn<.a s .1""-a are re, vi D . sBM _ L u earcf rf f ile r s3 tr e �� ti vv. $ia�.`w`a :Iz....::�. a as _: ^art, r r LAND Gt�[7tTAlw#iS certify that )7ltis property is not i. r-- L f e I q ._ C ., ma c . _ The Commonwealth of Massachusetts Print Form . Department of Industrial Accidents • -Mlit Office of Investigations _ 1� 1 Congress Street, Suite 100 Boston, MA 02114 -2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information // Please Print Legibly Name ( Business /Organization/Individual): Al re Aa hoe / A /vim a K+ dt cie" Address: 6 6 One. k S� City /State /Zip: Ea 5 3 list o r r,, ( 01 0 a 7 Phone #: `1 / 3 - a 5 — 3 3 0 v 7 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part - time).* have hired the sub - contractors 6. 10 New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. n Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. Buildin addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I 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.n 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 cheek 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 workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: 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 $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 verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature.! Date 1 '/ /0 //k!. Phone #: 1 / 3- 1 ro 200 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): 1. 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: I Not Applicable ❑ ,` / 4 / Name of License Holder : IVe`117n AI ert.E ,hC' E'h /0167? License Number (6 Cl ark Ens -h, h. 4 o i c9 q3yf ,r `7/ -1 50 3007 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ N « 1F1t 0.nrl/ t yh., 4, ' 6. Company Name Registration Number 66 C1 ork S4- Co s +tih-►4 h14 D I O J "7 Address Expiration Date /7 � Telephone "1/ 3 -.2 S v - 3 4 30 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. Sinned Affidavit AttarhPd Yes No fl 11. - Home Owner Exemption Tha nnrrant avamntinn far "hnmana.marc" ..,•c avtanflafl to in ,!12440. fla ilu,ni linno of nna (1 ) ar t.un(')\ f mil 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 .S, 0 i. .n..euded Lo be, a one ui i,:'o fainily .1wefli g, aLLa: :ed of d tacheo sir.........L e5 accesso Ly L....1ci. use audi 01 fain: 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 raonnno:hta far all o....l. ar,nrir .. -f : .marl ..n.lar th 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 Fmnlm,aac fnr ini,,riac not rnenttinn in ila.,th\ aftl.o h,focclrhncattc ranar „l T o c Ar+nntota,1 i ,m. m_ a, b Imhln fnr narcnn(c) 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 n Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [$) Siding [DI Other [Ell Brief Description of Proposed Work: 10 a 0 + � ,rfe.,5;;,., i '4' evis 4- iw5 f v. L► 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? a. Proposed Square footage of new construction. Dimensions e. Number of stories? f Meth o f heating? Firepl or Woods :o:ees N o f e g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? - Type of construction ;ir n i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No I i north of hacam nr collar fInnr halnw finichari nraria 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, CA4 i\ M t A N` /.IA - , as Owner of the subject property 1 r hereby authorize i nAral Al iieLt.4.12.4- to act on my behalf, in all matters relative to work authorized by this building permit application ati C 8 / ,), / aoi Signature of Owner Date I , No - 4m vlty e ( /f I ✓rte k /Ad eve , as /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 perjur N o flu me) e/ (✓iPh i r/en- Print Name S / ; Signature of Owner /Agent Date I � f _ _ 'I o n . A % �n nib _ • I f i ♦nr, nn ( n :,.., u... -. p r .a n......:a r..., n....:.,.+ n.... r .. f..c ............. Existing I Proposed Required by Zoning This column to be filled in by Ey BuildingDepariment Lot Size ;. 0 1 L crt5 Frontage C Y Setbacks Front Side L: 38) R: � L: R: Rear S J Building Height 141 • Bldg. Square Footage lIOJ Rio • Open Space Footage (Lot area minus bldg & paved parking) 1 # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO DONT KNOW 0 YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES O IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0. DONT KNOW © YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained O , Date Issued: C. Do any signs exist on the property? YES V NO IN IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for 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 0 NO TO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: 1 ( B Department Curb Cut/Driveway Permit \-- 212 Main Street Sewer /Septic Availability AUG 2 I 2012 \ Room 100 Water/Well Availability orthampton, MA 01060 Two Sets of Structural Plans p T 0,06 413 -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 1.1 Property Address: This section to be completed by office Rd, Map Lot Unit ' 31 R ne v ©I ley Zone Overlay District N0 rill 0 "hp +on ll Elm St. District__ CB District SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT 7:1 r>wnar of Racnrti7 / p Ron -t Cin dY CA,Idt 3 1 Pi le t' o ll e y ryd. Name (Print) Current Mailing Address: 0.)./g4 ejA:64 1 Y.IY'l 11 lII II IY 4 1/3 — 5-86 -a6N6 Signature 2.2 Authorized Agent: Hertii / Al ihriP..r e4 Oar S Ensthrtwspto / O Name (Print) Current Mailing Address: ` /13 2SO-300`7 Signatu a Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical 500 (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) GSOo Check Number X3.5 r r" This Section For Official Use Only Y Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0194 APPLICANT /CONTACT PERSON NATHANAEL ALMEKINDER ADDRESS/PHONE 66 CLARK ST EASTHAMPTON (413) 250 -3007 PROPERTY LOCATION 34 PINE VALLEY RD MAP 35 PARCEL 185 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 635— r,�•¢ -- Fee Paid �� Typeof Construction: EXTEND PORCH 10 X 20 New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 102079 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF M MATION PRESENTED: V 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 /7- 5/2 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. 34 PINE VALLEY RD BP-2013-0194 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35 - 185 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ADDITION BUILDING PERMIT P ei init # BP-2013-0194 Project # JS- 2013- 000315 Est. Cost: $6500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: NATHANAEL ALMEKINDER 102079 Lot Size(sq. ft.): 134600.40 Owner: CHILDS RONALD L & CYNTHIA M CHILDS Zoning: Applicant: NATHANAEL ALMEKINDER AT: 34 PINE VALLEY RD Applicant Address: Phone: Insurance: 66 CLARK ST (413) 250 -3007 EASTHAMPTONMA01027 ISSUED ON:8/24/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: EXTEND PORCH 10 X 20 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 8/24/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner