The URL can be used to link to this page

46-049 (6) City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit 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: 107 f5/14-0c� /201 , Nose4w-W p— m The debris will be transported by: 2 cw // � e The debris will be received by: AIIA-11•e y 4ee c yC M 6- Building permit number: Name of Permit Applicant V14-611 1�W i`/L SAe L/C�u,C- Date Signature of Permit Applicant The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers Compensation Insurance Affidavit: BuilderslContractorslElectricianslPlumbers Applicant Information ( / / Please Print Legibly Name (Business/OrganizatiorAndividual): u�f3t:1/m/2 J/l e yC/J U.f: Address: /,7-7 Leon":mZ01 City/State/Zip: TT[rr�T�✓�i'rn, j� O/oo/ Phone#: z113 --.386- S /Z 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 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.M I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g• ❑ Demolition working for me in any capacity.h• employees and have workers' 9. E] Building addition [NoworkeW Comp.insurance comp. insurance.* required.] 5. ❑ We are a corporation and its 10.❑ 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 ofexemption per MGL 12.❑ Roofrepairs insurance required.]t c. 152, §1(4),and we have no 13.9 Other employees. [Noworkers' comp. insurance required.] Any applicarttthatd=ksbot#1 mustalsofill out the secdonbelawsl-a ingtheirworkerd corqxro#ionpolicy irionnabon. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name ofthe sub-contractors and state whether or not those entities have employees. Ifthe sub-contractostweernployees;they must prwidetheir workers'camp.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 theworkers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition ofcriminal penalties ofa fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the farm ofa STOP WORK ORDER and a fine ofup to$250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of Investigations ofthe DIA for insurance coverage verification. I do hereby certify der t pains and penalties o at the information provided above is true and correct. Sian afore: Date: y' 7— 201 Phone#• y/3 —3 8,1 -SZ Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: yf� I_ Not Applicable ❑ Name of License Holder: Aa d I m l r- �,1-us—, kV IL G',S,5 L - 7)992-0 4 L�� {�1� License Number IQ0 BU 0lY\ 4`Dr\ b �iU2 �ee�ih ITl ��S i I 0►030 /O�/212015 Address � Expiration Date y 13 -38 -SZ/2 Signature Telephone 9:$Reaater+i:d'#i©me Impratiement Contractor. Not Applicable ❑ 1505117 Company Name Registration Number Address 4 n Expiration Date 12l LeoV1i�2-Jl S� .,N& l.� AM MA-01001 Telephone y1j -3U-.SZ)2 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...... ❑ 1=1 -.Hones .Owx>I r. EI MIDtion The current exemption for"homeowners"was extended to include Owner-occupied Dwellings ofone(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 buildinE permit As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion ofthe work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability ofEmployers to Employees for injuries not resulting in Death)ofthe 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 ofMassachusetts General Laws Annotated. Homeowner Signature X SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House Addition Replacement Windows Alteration(s) Roofing Or Doors Accessory Bldg. Demolition New Signs [ ] Decks [ ] Siding['A Other[ ] Brief Description of Proposed Work: Zr7574411/rl6:: V1 P Alteration of wdsting bedroom Yes No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa;If.New.hause air 14©ro- diti6h to exi` ous n cam late the#allowin ": 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. 1. 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, X 747- a ,as Owner of the subject property / hereby authorize V Ll�}R�n?i{2 ��eyC_4L/K- to act on my behalf,in all matters relative to work authorized by this building permit application. � L Signa of Owner Date I, V 4 d i m 6L (UR yc 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. V/"t dl M IN �A�vchU� Print Name A S/ 7 119 Signature of Owner Agent Date City of Northampton _ 0 Building Department t i 212 Main Street ' Room 100 ' t Northampton, MA 01060 �f MAY 12M 413-587-1240 Fax 413-587-1272 An Ele i_. Nortr,am ONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: TT ZS[Ft n Q R'd .� Map Lot Unit N O(R+V\Pt vr�F� l O 10 6 0 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: X 70 Name(Print) Current Mailing Address: x Telephone Signature 2.2 Authorized Aaent: x \ILPoli mill f evchcw,,- X /27 Name(Print) Current Mailing Address: � X 4/ 3 -386 - 6-2 Z Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by rmit applicant 1. Building �-/O, E)OO (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee h 4. Mechanical HVAC a ( ) 5.Fire Protection 6. Total=(1 +2+3+4+5) /c/ o oil Check Number This Section For Official Use Only Date Building Permit Number Issued: Signature: Building Commissionedlnspector of Buildings Date 107 ISLAND RD BP-2014-1188 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:46-049 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: vinyl siding BUILDING PERMIT Permit# BP-2014-1188 Project# JS-2014-002008 Est. Cost: $10000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VLADIMIR SHEVCHUK 099209 Lot Size(sa. 111 6621.12 Owner: ELIA TALA Zoning: Applicant: VLADIMIR SHEVCHUK AT. 107 ISLAND RD Applicant Address: Phone: Insurance: 100 BURLINGTON DR (413) 386-5212-0 FEEDING HILLSMA01030 ISSUED ON.511212014 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL VINYL SIDING 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 5/12/2014 0:00:00 $35.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner