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SCREEN
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EXPAND n'Llr-T=az AL rZ
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EXISTING HOUSE INSULATE
EXISTING GARAGE EXISTING
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. 2 ' X 7 ' - 6 " PORCH REMODEL
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/ L. ATHR ❑ P
❑ MMUNITIES
3ONDE C ❑ NSTRUCTI ❑ N 529 - 2176
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of fInvestigations
600 Washington Street
Boston,MA 02111
' www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business Organizationflndividual):Bonde Construction
Address: 205 Park Street
City/State/Zip: Easthampton,MA 01027 Phone.M 413-529-2176
Fyou an employer?Check the appropriate box: [7.ype of project(required}:
I am a employer with 2 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors . ❑New construction
I am a sole pi oprietor or partner- listed on the attached sheet. [remodeling
ship and have no employees These sub-contractors have 8. n Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp.insurance.t 9. F]Building addition
required.] 5. E] We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions
myself. [No workers'tromp. right of exemption per MGL 12Q Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees.[No workers' 13.❑Other
comp.insurance required.]
'Any applicant that checks box#1 must also fin out the section below showing their workers'compensation policy information.
t Hom&wners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
cmployecs. if the sub-contractors have employees,they must provide their workers'comp.policy number.
ram an employer that is providing workers'compensation insurance far my employees Below is the policy and job site
,information.
Insurance Company Name: Travelers'Insurance
Polic #or Self-ins.Lic.#: 3B985388UB 3/13/2015
y Expiration Date:
Job Site Address:__ 1114e7l?CLI 1..A.n45 City/State/Zip: OtIVA MM Z 1•.�l Q(Q(�
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 under the pains and penalties ajperjury that the information provided above is true and correct
Sign ature; �- Date: _
Phone#: 413-529-2176
t7jfciat use on(y. Do trot write in this area,to be completed by city or town offrciaL
City or Town: Permit/License#
Issuing Authority(circle one):
L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
MMW
SECTION 8-CONSTRUCTION SERVICES
8.1 11-j, _rZstnic tlon Sultervlsor: Not Applicable ❑
NW&of Lianas Holder: d-'
-� 110-75!R
, }} License Number
Address �- Expiration Date
2 V7 to
Signature 9 Telephone
t.Fl9glatered Home impmX2Ment Contractor: Not Applicable ❑
Cor Registration Number
Address Expiration Date
Telephone 413 5Za-Zt-1
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152,§25C(B))
Woiters 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 108.351.
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 ope home in a two-year period shall not be consldered 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 alit such work performed under the building permit.
As acting Construction SumrvWr 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 Habig 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 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 %
(int area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&L ocatlon)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW (2r YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Reg ist of Deeds?
NO a DONT KNOW YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES a NO a
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 Q---"'
IF YES, describe size, type and location:
E. Will the construction activity disturb(cl acing,grading,excayM non,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YEE NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
MOON J:DESCRIPTION OF PROPOSED WORK Mum*all aDdic-able)
Now House ❑ Addition ❑ Replacemen[jkxkMs A16mu ions) � Fang ❑
Or Doors LL11
Maeseory 8tdg. ❑ Demolition ❑ New Signs K3 Decks El Siding 01 Other[CI
'Brief Description of Proposed
Work r
P-bV 5 Irk xly- {ice CAR5 ` NEW,
Alteration of existing bedroom Yes_L,"-No Adding new bedroom Yes u No
Attached Narrative Renovating unfinished basement Yes L---No
Plans Attached Roll -Sheet
as.,f Nm hoxtstEe m d gj to IMISHM hoUskM e
a. Use of builds ng: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
L Is construction within 100 fL of wetlands? Yes No. Is construction within 100 yr. fkxodpiain 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGM OR CONTRACTOR APPUES FOR BUILDING PERMIT
` I,_ "t/L/j L,f „� ,as Owner of the subject
hereby authorize ►
to act on my behalf,in 811JA81tM relative to work authorized by this building permit application.
�f
Sanalu a of Date
as OwnedAuthorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
arni belief.
Signed under the pains and penalties of perjury.
� .16: axlAvc
Print Name
Z�w M
'- lure of Date
MW
Department use only
'i Northampton Status of Permit:
g Department Curb Cut/Driveway Permit
SEP t 6 2014 1 Main Street Sewer/Septic Availability
00M 100 Water[Weli Availability
a y pton, MA 01060 Two Sets of Structural Plans
Electric,Plum ,s�, 240 Fax 413-587-1272 Plot/Site Plans
Northa
Other Specify
APPLICATION TO CONSTRUCT,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:
Map Lot Unit
VAN Zone Overlay District
Elm St.District C8 District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 A ri Went•
_ kA M h,' n1,4t>c-
Name(Prints Current Mailing Address:
Litz, 6,52c.1 -ZV1 k2
Signat a Telephone
SECTIQU 3-ESTIMATED CONISTRUCTIC)N COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by 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. Dire Protection
6. Total= 1 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File# BP-2015-0302
APPLICANT/CONTACT PERSON MARK BONDE
ADDRESS/PHONE 205 PARK ST EASTHAMPTON (413)535-9529 Q
PROPERTY LOCATION 680 BRIDGE RD-5 ASPEN LN
MAP 18C PARCEL 141 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building,Permit Filled out 8*0 00a
Fee Paid
Typeof Construction: CONVERT 3 SEASON ROOM TO LIVING AREA
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 67758
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOR PRESENTED:
pproved 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
olition D y
Sig tur d' O i 'al
Daee�
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.
680 BRIDGE RD-5 ASPEN LN BP-2015-0302
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C- 141 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2015-0302
Project# JS-2015-000569
Est.Cost: $11000.00
Fee: $66.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK BONDE 67758
Lot Size(sq. ft.): 1497897.72 Owner: LATHROP COMMUNITY INC
ZoningL Applicant: MARK BONDE
AT: 680 BRIDGE RD - 5 ASPEN LN
Applicant Address: Phone: Insurance:
205 PARK ST (413) 535-9529 O WC
EASTHAMPTONMA01027 ISSUED ON.911712014 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONVERT 3 SEASON ROOM TO LIVING AREA
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 9/17/2014 0:00:00 $66.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner