31A-091 j _�
City of Northampton
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1,` Massachusetts * ,-
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DEPARTMENT OF BUILDING INSPECTIONS y. �
n Municipal * 212 Mai Street • Mun Building -'4:P. r ar
Northarpton, A 01060 t b�V k?�
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Property Address: i '
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Contractor 4 Ski �- � ,_ .,(. ,�
Name: f� ,�
Address: t ) '.A:k 1,,/e''
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City, State: r J/ ' �_.6 f-z I") l .' l J l l / 6 '?
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Phone: �/ D /v'- J --- ,
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Property
Name: Owner l (I /44/7/ 1
Address: 3 ) fAor j"311 j /
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City, State: AZ2) , , t 1�,r; ��'^ /- Yi
I, J 7 �. �,' -/i `/ (contractor) attest and affirm that the building I intend to
insulate does not have any open air (knob and tube) wiring in the spaces to be insulated and that I have
provided the property owner_�h a copy of this affidavit.
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Contractor sign u_ ( f
Date / 0 ) j /
The Commonwealth of Massachusetts PfitltFotm_
Department of Industrial Accidents
Y1 Office of Investigations
#= 1 Congress Street, Suite 100
== � Boston, MA 02114 -2017
'' s* www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): ( S ) ( • - i "✓ L'
Address: PO /�—.
co/ r f
City /State /Zip: Phone #: 41-3 J ��� 7
Are yo n employer? Che Ic the appropriate box: Type of project (required):
1. am a employer with 4. ❑ I 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 8. ❑ Demolition
working for me in capacity. employees and have workers'
g any P t) 9. 0 Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.0 R re -
insurance required.] t c. 152, § 1(4), and we have no ❑ p ,,.
employees. [No workers' 13 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 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 workers' compensation insurance for my employees. Below is the policy and job site
information. ' / 1 l,Lz
Insurance Company Name:
Policy # or Self -ins. Lic. #: t'x C / - 3 ) '"J'�� 7 c v / 1 Expiration Date: OS /3
Job Site Address:3 5 14"Ic►rl co-d4 A O� 0 6 6 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 certi - the pa' : d penalties o periury that the information provided above is true and correct.
Signatur-. _ ., 44 Datel -
Phone #: / y/3 - V7 Vg
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 Su ry r:
& rJ k )11 Not Applicabe ❑ Lf731/ / l /�/`►
License Num r !/
6 60/c. 1 - f � c off, ,'» 0/0a)
j 3
Address Expiration Date /� I 1
L ` �I - /a S/
'gnat Telephone
9. Regis #ered Home Improvement Contractor / L --LC Not Applicable ❑ /6 ci 7
Com an Nam Registration Number
6 q 0_16
Address � /t /'� V ) Da d ` .Y°17-5°
Expiration Date ` � / /
c- / 1 L e. ini L Telephone`s /5
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit ust be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildin permit.
Signed Affidavit Attached Yes No ❑
1: - Home Owner Exempt
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 Ls �
al Zoning L nd tate of Massachusetts General Laws Annotated.
Homeowner Si nature . ' / / �', a " �/ " 10lL.� 1
g I i
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House [] Addition ❑ Replacement Windows Alteration(s) n Roofing I I
Or Doors 0
'
Accessory Bldg. El Demolition I:=1 New Signs [D] D c s [❑ Siding [D] Other
Brief
Work Description of Proposs )v . I (4 ` j 4 ` `AR (a Pi k+r S
Alteration of existing bedroom Yes 17 No Adding new bedroom Yes ✓ No /
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll - Sheet
6a. if' Near house amt or addition to existing housing, complete the followfna
a. Use of building : One Family I 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, i /NA 1A , as Owner of the subject
property
hereby authorize # ort/AL
to act on my behalf, all matters relative to work auth rized by this building permit application.
X ) 7 1/J Pli -'-' ,-, ---- C. -)
Signature of Owner Date
I, r l^ k /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best f my kn ge
and belief.
Signed under t arcs and penalties of perj ry.
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Print Na m ,
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Signatu f 0 gen V 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 ver been issued for /on the site?
NO 0 DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Regi ry of Deeds?
NO 0 DON'T KNOW YES 0
IF YES: enter Book ! Page a d /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT 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 sued:
C. Do any signs exist on the property? YES 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, ex ation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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4."1",;75-711 otw,
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413E0 144r—nj
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rafigriFainia., t Department use only
City of Northampton Status of Permit:
SEP 1 0 2012 Building Department Curb Cut/Driveway Permit,
212 Main Street Sewer/Septic Availability,
II IIIROF111U11.01r10iNaPE0TIONS Room 100 Water/Weli Availabil4
,,, jrIttillitaLiliftotos) Northampton, MA 01060 ... .
Two Sets of Structural Plans
phone 413 Fax 413 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
I
This section to be completed by office
1.1 Property Address:
,-- .
/ f'- V-eri\- -) - Map Lot Unit
..../...."
t) Zone Overlay District
I( (//V: ,.. i ::) i i i , ,,,,) , ',1.- 1 1., , '
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Elm St District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
7 'N' ; :
Name ( rin Curpent Maili410 ,
0 kt,4.(4'7 /174L-L—r- /kit) i
Telephone
Signature 4 / .. * .5 )(;:i-:- ___v'
2.2 Authorized Agent: ,-
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,...j't L-)': 1 "e v 11 ,, Pi -- i /,)- 1 ,-
d i i„..., , ,...,, - / - (,.. o n ‘.. /-:(-,--, ,4„
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..------,
Narn,,efrnt) ,. . Current Mailing Address:
1
MIE!Tr Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 4. rik (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) , ,g--a--- Check Number A ' ir F. 3 S
This Section For Official Use Only
Date ' r t?
Building Permit Number: Issued:
-.
Signature:
Building Commissioner/Inspector of Buildings Date
Illomminomininummoim.,
CM-,(-- " K i J 0� t, u e�
File # BP- 2013 -0272 ? A ��dkv l
tissi RAN ' For-r4
APPLICANT /CONTACT PERSON JEFFREY BRADSHAW
ADDRESS/PHONE P 0 BOX 1276 CHICOPEE (413) 427 -5481 C f + F `� p
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) Lo-t
PROPERTY LOCATION 35 VERNON ST
MAP 31A PARCEL 091 001 ZONE URB(100)/WP(14)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT ��
Fee Paid / 6� <
Building Permit Filled out
Fee Paid /v 9g �.
Typeof Construction: INSULATE WALLS at
t"
Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 094734
3 sets of Plans / Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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
Demolition Delay
am. G ,9/1z
Si 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.
35 VERNON ST BP- 2013 -0272
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 091 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- 2013 -0272
Project # JS- 2013- 000439
Est. Cost: $1622.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JEFFREY BRADSHAW 094734
Lot Size(sq. ft.): 4761 1.08 Owner: HOLLANDER PAUL & MINA M HARRIS
Zoning: URB(100)/WP(14)/ Applicant: JEFFREY BRADSHAW
AT: 35 VERNON ST
Applicant Address: Phone: Insurance:
P O BOX 1276 (413) 427 -5481 WC
CHICOPEEMA01201 ISSUED ON:9/19/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: INSULATE 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 9/19/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner