11A-004 (2) City ofNorthampton 212 Main Street, Northampton, MA 01060
Solid Waste DisposalAfdavi
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work:
The debris will be transported by: 'At 6U L.—,
The debris will be received by- U t�
Building permit number:
Name of Permit Applicant 4td �—O ._
Date Signature of Permit Applicant
Massachusetts -Department of Public Safett/
Board of Building Regulations and Standards
Construction Suner0sor
License: CS-054248
ALLEN R GUIEL-`
63 CHESTERFIELD
WILLIAMSBURC MA „N
Expiration
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L`l The Commonwealth ofMassachusetts
Department oflndustrial.-lccidents
yOffice oflnvestigations
I Congress Street, Suite 100
Boston,M4 02114-2017
jru,sv.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applica nt Information Please Print Le ib
Name (Busi ess/Orgarrization4ndividual): _
Address: &L Ps-60'0
City/State/Zip: Phone #: 13 aeq C�9
Are you an employee Check the appropriate box: Type of project(required):
1.❑ I am a employer with _ 4. ❑ I am a general corrteactor and I
employees(fizlland/or part-tirne).r have hired the sub-contractors 6. E]New construction
2 1 am a sole proprietor or partner- listed on the attached sheet. 7. Rerrodeling
d_ ship and have no employees These sub-contractors have S. Demolition
working for rue in a ca P ac ny employees and have workers'
n3' 9. Building addition
[No workers' comp.insurance condo. insurance.: 10.❑E1QCtricalre airs or additions,
required.] 5. ❑ We are a corporation and its P
3.❑ I aur a homeowner doing all work officers have exercised their 11.❑Plu rbing repairs or additions
myself. [No titivrkers' comp. right ofexerrption per MGL 12.❑Roofrepais
insurance required.] ' c. 152. §1(4),and we have no
employees. [No Aurkers' 13.❑ Other
corms. insurarr~e required.]
*Any applicant that checks box=1 must also fill out the section below showing their workers'compensation policy information.
'Homeowrners who submit this affidavit indicating they are doing allw ork and thenhire outside contractors rrtrst submit a new•affidavit indicating such
Contractors that check this box crust attached an additiortalsheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,theymust pro%ide their workers'comp.policy number.
I am an employer tltat is providing►wrkers'conipensation insurance for nry enrplot'ees. Below is the policy and Job site
iq/ormation.
Insurance Conparry Name:
Policy#or Self-ins.Lie.#: E-VirationDate:
Job Site Address: CityfState/Zip:
Attach a copy-of the workers' compensation policy-declaration page(showing the policy number and expiration date).
Faflure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the irposition ofcrin nalpenalties of
fine up to S1,500.00 and/or one-year inprisornnent, as well as citiilpenakies in the form of a STOP WORK ORDER and a fine
ofup to S250.00 a day against the violator. Be advised that a copy of this statelrrnt may be forwarded to the Office of
Imestigations ofthe DIA for insurance coverage verification
I do her ift'unde he pains nd erralties of perjury that the information provided ove i true and correct.4 S tore: Date: `Oi 1
n
Phone#-
Official use only. Do not write in this area,to be completed 6y city or to»Ir official.
City or Town: Permit/License #
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk d.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES 7
8.1 Licensed Construction Su isor: Not Applicable ❑
Name of License Holder: 6W
License Number' ,y
Ad Expubtion Date
Signature Telephone
9.Re istered Home Im rovement Contractor: Not Applicable ❑
Company Name' Registration Number
Adcress (r g n Expiration Date
Telephone
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 esetnptionfor`lnmeoxvners"was extended to oxhide Ovvner-occupied Dwellings of One(1) or two(?)farmulies
and to allow suchhomeo-viner to engage anindividualfor hire N,.-ho does not possess a license,provided that the o«ueracts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner:Person(s)«ice o«n a parcelofland on%vhichhe,''she resides or intends to reside..on-,vhichthere
is,or is intended to be.a one or two farttrly dvvelling,attached or detached structures accessory to such use and.''or farm
structures.A person who constructs more than one home in a two-yearperiod shall not be considered a homeovvner.
Such`bomeo%NTrer"sballsutnrrit to the Building Official ona fommacceptable to the Building Official,that he/she shall be
responsible for all such work performed under the buildins permit.
As acting Construction Supervisor your presence on the job site will be required from tune to tone,during and upon
colypletion ofthe work for which this permit is issued.
Also be advised thatwitlmreferetxe to Chapter 152(Workers' Conpensation) and Chapter 153 (LiabilityofEnpbyers to
Enployees for injuries not resulting in Death)ofthe Massachusetts General LausAnnotated,you may be liable forperson(s)
you hire to perforrnwork fDr youuttder this permit.
The undersigned`lromeo�vner"certifies and assuues responsibility for conpliatxe with the State Building Code.City of
Northarrlpton Ordinances,State and Local Zoni W Lax,�s and State ofXlassaclnsetts General Lavvs Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House C] Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors D 1 '0
Accessory Bldg. ❑ Demolition ® New Signs [p] Decks [P Siding Other(pj
Brief Description of Proposed _( , f
Work: -o Y c.. t
Alteration of existing bedroom Yes K No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No (�
Plans Attached Roll -Sheet Py��
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, 1t1 y ► i� h S as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters rel tive to work authorized by this building permit application.
Signature of Owner Date
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 un r the pains and penalties of perjury.
, �3io-.
Print Name A%% -'Irk - 1 1
Signature of Owner! ent Date
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomp a Information
Existing Proposed 713iM*W by Zoning
tobe%tlledinby
partment
Lot Size
Frontage
Setbacks Front
Side R: /L: R:
Rear
Building Height
Bldg.Square Footage °ro
Open Space Footage
(Lot area n*Rn bldg&-paved
parking)
4 ofParkinLz Spaces
FilL
vol mw&Location)
A. Has a Special Permit/Variance/Finding ever been issued ibr/on the site?
NO O DON'T KNOW �+ YES Q
IF YE S,date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW a YES Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of wafter 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 Q Obtained 0 , Date Issued:
C. Do any signs exist on the property? NO
IF YES,describe size, type and location:
D. Are there any proposed changes t:)or additions of signs intended for the property? YES Q NO 1;
IF YES,describe size, type and location
E. Will the construction activity disturb(clearing,grading,,aavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
r; Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
' .SAN; 3 ii 20 212 Main Street Sewer/Septic Availability
I
Room 100 Water/Well Availability,
t Fic. .uas ins Northampton, MA 01060 TWo Sets of Structural Plans
X413-587-1240 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
Map Lot Unit/� /� Zone Overlay District
C� d S -1. Etm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: -7
`4 A�)� �� �v L�e �
Name(Print) Current Mailing Addres :
Telephone
Signature
2.2 Authorized Agent: rr
v 6,1, CgLinqmlew
Name{Prin Current Mailing Address:
_ l?
Signature Telephone
SECTION 3-ESTiMATEO CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building t ( �� (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing spy Building Permit Fee
4. Mechanical(HVAC) l 00 07
5. Fire Protection - -
6. Total=(1 +2+3+4+5) l C Af> lCheck Number
This Section For Official Use Only
Building ermit Numb : Date
g Issued:
Signatur
Building Commissionertlnspector of Buildings Date
17 EVERGREEN RD BP-2014-0847
GIs#: COMMONWEALTH OF MASSACHUSETTS
Man.Block: 11A-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-2014-0847
Project# JS-2014-001479
Est.Cost: $17900.00
Fee: $107.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ALLEN GUIEL 054248
Lot Size(sq. ft.): 22041.36 Owner: HOBBS DAVID B&LYNN SCHUMANN
Zoning:URA(102)/ Applicant: ALLEN GUIEL
AT. 17 EVERGREEN RD
Applicant Address: Phone: Insurance:
63 CHESTERFIELD RD (413) 268-9200-0
WILLIAMSBURGMA01096 ISSUED ON:21412014 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONVERT FULL BATH TO 1/2 BATH & LAUNDRY
& ENCLOSED PORCH TO OPEN 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 2/4/2014 0:00:00 $107.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner