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35-209 (7) City of Northampton 212 Main Street, Northampton, MA 01 060 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: S The debris will be transported by: }Y5/ The debris will be received by: Building permit number: Name of Permit Applicant 111:� I� Date Signature of Permit Applicant Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 178722 Type: DBA Expiration: 5/13/2016 Tr# 251877 DONE RIGHT CHIMNEY SERVICES CORY MCGILL P.O. BOX 1054 WILLIAMSBURY, MA 01096 Update Address and return card.Mark reason for change. E] Address D Renewal E Employment Lost Card SCA 1 Q 20M-05/11 C��ie�pomn2oou�ea��Ci6czc�uaeCt License or registration valid for individul use only Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: ME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Ux'Vegistration: 178722 Type: 10 Park Plaza-Suite 5170 p'ration: 5/1312016 DBA Boston,MA 02116 DONE RIGHT CHIMNEY SERVICES CORY MCGILL t' 6 WHITE RD GOSHEN,MA 01032 Undersecretary Not valid without signature 1 Massachusetts -Department of public Safety Board of Building Regulations and Standards Construction SuperNisor License: CS-107568 CORY MCGILL - 6 WHITE RD - = P.O.BOX 1054 Williamsburg MA 91096 Expiraticn �2 - 05/24/2017 Commissioner The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly Name (Business/Organization/Individual): �� G G Address: 6 u/k k 12ee,2 0 fax WE L/ City/State/Zip: 01686 Phone#: 2-11 3VO Are you an employer?Check the 4propriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. E] 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 for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp.insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its 10.E] Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.E]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] f c. 152, §1(4),and we have no employees. [No workers' 13 Other �� /� hP� 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. Insurance Company Name: — Policy#or Self-ins. Lic.#: 1J- Expiration Date: Job Site Address: S t/✓Y J Aa- rcJ City/State/Zip: 6106 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 certA under the pains a penalties of perjury that the information provided above is true and correct. Si ature: i�/`2 Date: Phone#: G/3-- 3 9 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: / Not Applicable ❑ Name of License Holder: �)r •I J r O� � License Number / +s �ja•� ® L44111,a ,441 010qt, �S�oZL/ 1. � 4� Address V Expiration Date z l - 3 q Si t Telephone 9 /R'�e_aiA ca stereddJ�Home Improvement Contractor: Not Applicable ❑ CW Comp v Name Registration Number ddress g� Expiration Date Telephone // -310-/,? 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 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 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 [0] Decks Siding[p] Other'V'Inr Brief Des ip'on of Proposed Work:TK?Y2r T d C L he/ JE/2 arm r1S,'ja le- Alteration of existing bedroom Yes 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 as Owner of the subject property hereby authorize 1r11 ( - [ to act on my behalfin--all m ers relative to work-authorized by this building permit application. — � Signature of 04er Date C'0 0Z M C , , as Owner/Authorized Agent ereby eclare 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. �S/ yl'1C t'l_I Print Name Si r f Owner/Agent 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 ever been issued for/on the site? NO 0 DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book Page and/or Document# i B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW O YES 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 0 NO 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 0 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 O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: 2 Building Department Curb Cut/Driveway Permit 12 Main Street Sewer/Septic Availability 7 Room 100 WaterMlell Availability Nov 13 ? hampton, MA 01060 Two Sets of Structural Plans �1i'�ne 587-1240 Fax 413-587-1272 Plot/Site Plans Electric, p;U — Other Specify I," 'r °mptor Spectio AP PL ON RUCT,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 ' j �� .J C� I (/I � T�l�tbvin rt Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Kam- ame( int) Current Mailing Add_r ss: � Telephone Signature 2.2 Authorized Agent: Pv �/ JAS l Name(Pri , j Current Mailing Addre .��V Signature Telephone SECTIO 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 71 (a)Building Permit Fee 2. Electrical i/ C7� (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) Check Number sd This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0556 APPLICANT/CONTACT PERSON CORY J MCGILL ADDRESS/PHONE P O BOX 1054 WILLIAMSBURG (413)340-1399 Q PROPERTY LOCATION 531 WESTHAMPTON RD MAP 35 PARCEL 209 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out li► Fee Paid Typeof Construction: REPAIR CHIMNEY TOP INSTALL LINER FOR FIREPLACE&INSULATE New Construction Non Structural interior renovations Addition to Existing Accesso!y Structure Building-Plans Included: Owner/Statement or License 107568 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOWWATION 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 D mol' ' n ay Si ature o Buildin O ficial Da e 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. 531 WESTHAMPTON RD BP-2015-0556 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35-209 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-2015-0556 Project# JS-2015-001069 Est. Cost: $2063.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CORY J MCGILL 107568 Lot Size(sq.ft.): 66646.80 Owner: YARROWS LEOANRD A&MARY L&STEPHEN M&JEFFREY R& LINDA M KING&JULIANNE M TOUCH zoning: Applicant. CORY J MCGILL AT: 531 WESTHAMPTON RD Applicant Address: Phone: Insurance: P O BOX 1054 (413) 340-1392-0 WILLIAMSBURGMA01096 ISSUED ON:11/17/2014 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPAIR CHIMNEY TOP, INSTALL LINER FOR FIREPLACE & INSULATE 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 Shmature: FeeType: Date Paid: Amount: Building 11/17/2014 0:00:00 $55.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner