32A-113 (4) City of Northampton
.kM Massachusetts
A.
} N
DEPARTIMNT OF BUILDING INSPECTIONS Z
212 Main Street • Municipal Building
Northampton, MA 01060
Property Address: 7q Sfree
Contractor
Name: l Home- lmaDw+ne,�1
Address: 5qc) gj\jeA'5 de-
City, State: F l U r2*1(-e, m pv
Phone: q13 - 56/-/ --75,: �
Property Owner -� /
Name: f�amekl- 14y f
Address: -7q 1garJ<e4- S
City, State: N,2241M�7�2 W C)I"'n
I,W(e�A e- Win„ogyewo-+ (contractor) attest and affirm that the building I intend to
insulat does not have any open air(knob and tube)wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature <
Date
D %
,A ,. The Commonwealth ofiVassachusetts
- 13ep as nwnt of Iaa ' t�ia�rds� dents
Office ofInvestigailons
600 Washington Street
Boston,AA 02111
www.rnass.gov/dia
'workers' Compensation Insurance Affidavit: Bu-Uders/Contractors/Elect>riciaIlns/Plumbe>rs
AD-Plica>nt Information Please Print Legibly
Name(Business/Organization/Indivi(fual): �Y f�� j�-.rte /el�fZ//Z—Z/// y�1
Address: ,1 i
City/State/Zip: At,/41,4- 6V 0 Phone#: -5—,7 - 7S Z 2—
Are you an employer?Check the appropriate box: Type of project(required):
1.[N I am a employer with J 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 g. ❑Demolition
working or me in an capacity. employees and have workers'
g Y P tY• $ 9. E]Building addition
[No workers'comp.insurance comp.insurance. 10.❑Electrical repairs or additions
required.] 5. ❑ We are a corporation and its P
3.❑ I am a homeowner doing all work officers have exercised their 11.El Plumbing repairs or additions
myself. [No workers' comp, right of exemption per MGL 12.❑Roof repairs }}
insurance required.]t c. 152, §1(4),and we have no 13XOther Tn�b 1041 Un
employees. [No workers' /
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
I Homeowner;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'compensatdon insurance for away employees. Below is the policy and job site
information.
Insurance Company Name: _�l �j
Policy#or Self-ins.Lic. 6 Expiration Date: Z//
Job Site Address: �7 �( /� City/State/Zip:/U(�I-A9Mp7 Q/��
Attach a copy of the workers'compensation policy dec➢aration page(slowing the po9ucy number and expiradou dste).
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 egr d 19nder th oadaas and enal77w�71-2112
ry that the information provided above is true and correct
Signature: � Vii! /� !�1 Date: a� l
Phone#: �C>i�
Official use only. Do not write in this area,to be coaaapleied by city or town ofj7ciad
City or Town: Perrmit,'License n
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.'Elect*rica3 Inspector 5.Mumbhm.,lnspeetor �
6.Other
Contact Person: Phone T:
SECTION 8-CONSTRUCTION SERVICES
— —7
8.1 Licensed Construction Supervisor: 1 Not Applicable ❑
Name of License Holder �V„�56n SWN u ,4 12)( 0-2-�
00
VQk`e� �soc
z7yvN 3- tic— License Number
P.o tCGD , 'P kYen.C.r \A0. 0\0162- 9 [22( l`}
Address Expiration Date
k �13-51`��1=��z2.
Signature Telephone
9.Reciistered Home Im rovement Contractor: Not Applicable ❑
�aikm J6W TM ffnerry MlC_ 10 5s(A5
Company Nadne X Registration Number
Address �� Expiration Date
Telephone�t6-'E94 1ebZZ
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....... X 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 108.3.5.1.
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 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 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) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[p] her[
Brief Descri ti n f Pro Qped
Work:�S c auto.
1,)/9"cellulose +06rina +D H q q insulate sd Z ,�)fn ced f i�-eieaAertze
J
Alteration of existing bedroom Yes X 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?
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
T[
1, U Ret t 0 t-I i j I � ,as Owner of the subject
property r f '
hereby authorize Nan sh,4«k . Va��Lta�Om�aYnP�aJPM2Ybk ��cXt L
to act on my behalf,in all matters relative to work autho ' ed by this building permit application.
Signature of Owner Date
�pmc ero4cmcrvk ,-aac. as Owner/Authorized
Agent hereby declare that the statements andfiriformation on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
\e,15on
Print Name
Signature of Owner/Agdfit Date
Section 4. ZONING Alt 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/Findin ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO X DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO E�0
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,excavation,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.
r (Zt�i�j-uf �LTY`t�MIIT�ttOrlt , _� s�
1, ti 'lttssttc!)usrfts t c• "`'`,
DEPARTMENT OF BUILDING INSPECTIONS ���; 'l
212 Main Street 9 Municipal Building
Northampton, MA 01060 M i
LOUIS F AS'BR UCK BUILDING PERMIT FEES Phone: (413)587-1240
BUILDING COMM1 SIONER Effective July 21, 2008 / Fax: (413)587-1272
DEMOLITION $ 20.00 ACCESSORY STRUCTURE
$ 35.00 PRINCIPAL BUILDING—Residential
$200.00 PRINCIPAL BUILDING-Commercii
*NEW CO 'TRUCTIO $ .50 per square foot for 15`floor ern
.30 2nd floor r
.20 " 'A floors,;ittic,basement,garage
� f
STRUCTURAL A TERA ONAN ALL USE GROUPS +
$6.00 per thousand dollars of�§timated cost or fraction thereof,
with a minimum fee of$55.0
25.00 WOODBURNINGOVE
*NEW ACCESSORY STRUC RES oundred twenty( 0)square feet and over
$ per square foot ith a minimum fee of$25.00
*NEW ACCESSORY STRUCT RE under ne hundre twenty(120)square feet
5.00 p r inspe t!on
*SWIMMING POOLS $30. for ve ground
$60.00 1 round
*SIGNS&AWNINGS $30.00
*DECKS $50.00��
REPLACEMENT WINDOWS $35.0A
y
SIDING&ROOFING
Residential $ 5.00 per structure
Commercial 1 55.00 min.per structure 0 $61K of estimated c
TENTS $25.00
*ZONING REQUEST FORMS $15.00 (includes home occupatio registration)
REISSUE OF LOST PERMIT $25.00
CERTIFICATE OF ANNUAL SP. $100.00 (minimum)
Temporary Certificate of Occupancy $25.00
PERMITS REQUIRING ONLY 1 (1)INSPECTION WILL BE A MINIMUM OF$25.00;ALL THERS WILL
HAVE A$50.00 MINIMUM. PERMIT FEES SHALL BE PAID TO THE ORDER OF THE Cl of Northampton
AND SUBMITTED,WITH THE COMPLETED PERMIT APPLICATION,TO THE OFFICE O HE BUILDING
INSPECTOR. WORK STARTED WITHOUT PERMIT IS SUBJECT TO DOUBLE NORMAL F
!! NO CASH -CHECKS OR MONEY ORDERS ONLY !!
*Filing deadline is 12:00 pm(noon)on Wednesday.
Department use only
City of Northampton Status of Permit:
Department Curb Cut/D,riveway,Permit
In Street Sewer/Septic Availability
OCT 100 WaterNVell Availability
OC " � rth n, MA 01060 Two Sets of Structural Plans
pl hone 413-5 0 Fax 413-587-1272 Plot/Site Plans
Nom mbin9 8 j' . Other.Specify
APPLICATION TOZ`6idTRUCT LTER,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:
�Y ST. Map Lot _ Unit
0(0(PC) Zone Overlay District
Elm St.District CB District_
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
'7q l hr-/,ef S/-,
Name(Print) Current Mailing Add ss:
i yl3 3 �W
Telephone
Signature
2.2 Authorized Agent:
NJ, son 3gD Rivemide Dr. Ebrer)CP
Name(Print) Current Mailing Address:
q/3 -,6--Fq-'75�zz
Signature 7 17 Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building /'� O U (a)Building Permit Fee
'7
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
i
6. Total=0 +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-2015-0378
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 74 MARKET ST
MAP 32A PARCEL 113 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
AccessoKy Structure
Building Plans Included:
Owner/Statement or License 060300
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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
' 'on elay
Sign re of Building fficial 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.
74 MARKET ST BP-2015-0378
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A- 113 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-2015-0378
Project# JS-2015-000694
Est. Cost: $2400.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 5619.24 Owner: HYJEK PAMELA H
Zoning: URC(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT. 74 MARKET ST
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.101712014 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL ATTIC INSULATION
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 10/7/2014 0:00:00 $55.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner