18C-141 (22) REMOVE
SCREEN ue 4� let c Z.
WALL AND �Iti Q�K
INSTALL
6' WALL, � O-
INSULATE
,DOOR
AND
WINDOWS,
EXPAND
FROM 3'
TO 4' EXISTING PORCH
EXISTING HOUSE --INSULATE
EXISTING GARAGE EXISTING
WALLS
AND
CEILING
12 ' X 7 ' - 6 " PORCH REMODEL
COMMUNITIES
B ❑ NDE CONSTRUCTION 529 - 2176
The Commonwealth of Massachusetts
Department of Industrial Accidents
= Office oflnvestigations
600 Washington Street
Boston,MA 02111
wwmmass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(BusineWOrganizabon/individual):Bonde Construction
Address: 205 Park Street
(City/State/Zip: Easthampton,MA 01027 Phone.#:
413-529-2176
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with 2 4• ❑ I am a general contractor and I
employees(frill and/or part-time).* have hired the sub-contractors 6. E]New construction
2.❑ I am a sole pi oprietor or partner- listed on the attached sheet. 7. remodeling
ship and have no employees These sub-contractors have 8, ❑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.
required,] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 LE]Plumbing repairs or additions
myself.[No workers'comp. - 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.)
*tiny 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 anew affidavit indicating such.
lContractors 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 employces,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: Travelers'Insurance
Policy#or Self-ins. Lic,#: 313985388UB Expiration Date: 3/13/2015
Job Site Address: City/State/Zip:Mag_T14A M CaIolo-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.
Ido,herely'EcrYyy under the pains and penalties of perjury that the information provided above is true and correct
Si mature•- Date:
Phone#: 413-529-2176
Official use only. Do not write in this area,to be completed by city or town ofjiciaL
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 Lkmnmd n or�,r: Not Applicable ❑
t.imse Number
, z 'Z7 5 "A, d k bZZ I-Z-I Q
Address Expiratbn Date
Sure I4"hone
Not Applicable ❑
Comparw Home RegisTration Number
Address Expiration gate
Telephone 404 5 Z a--Z1-I b
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.t..c.152,$3508))
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.
ned Affidavit Attadred Yes....... P--- No...... ❑
11.- 9m.Own a Remy-don
.�. I�Ii�Ili1 .�YYIY.AMI �li1.
The current exemption for"homeowners"was extended to include Ommr-occuDied DweUhm of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,DrQYided that the owner acts
as suDerYlow,CMR 78W, Sixth Edition Section 108.3.5.1.
Pftson(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 faun
structures.A go=who constructs more hire home in a two-year period doff not be caarsldered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,,that he/she shalt be
amble for all such wvsf„mformed under the building Dermit.
As acting QpWKUgft Superfdaw 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 Leath)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 4. ZONING AU 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 Ida awnt
Lot Size
Frontage-
Setbacks Front
Side L R L: R-
R=
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of EagqU Spaces
Fill:
volume&Location
A. Has a Special Penmt/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW (er YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Regist of Deeds?
NO Q DONT KNOW V YES Q
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 O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained V Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and location:
D. Are there any proposed Changes to or additions of signs intended for the property? YES O NO
IF YES, describe size, type and location:
E. Will the construction ac"disturb( nng,grading,tNq_ption,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.
SECTION 5-QESCRIPTION OF PROPOSED WORK icheck all applicable)
New House ❑ Addition Replacement Windows Alteration(&) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs Decks JE1 Siding pj Other[0
'Brief Description of Proposed
Work: z f.1 t i--- 'p
Alteration of existing bedroom Yes u'.,No Adding new bedroom Yes L No
Attached Narrative Renovating unfinished basement Yes __A,,:::—No
Plans Attached Roll -Sheet
Ga. It New house and or additiolIQ lcistina housing, cnlmalete 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.
1. Septic Tank City Sewer Private welt City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Li z'. -_7 ,as Owner of the subject
Property
hereby authorize �A Nor r
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of 0%Snir—_____L 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 under the pains and penalties of perjury.
Print Name L2 ,
Signature-ofbAer/Agent - Date
Department use only
of Northampton Status of Permit:
Btl iding Department Curb Cut/Driveway Permit
- - 12 Main Street Sewer/Septic;Availability
Room 100 Water[Well Availability
WC ( � �U Ng;6 mpton, MA 01080 Two Serfs of Structural Plans
-1240 Fax 413-587-1272 PlotlSite Plans
Eiec+r c,Pntr G r.^:h -,0
ri 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
., A,A,P-&,*A i w(A zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Nameiprint) Current Mailing Address:
Telephone
Signature p
2.2 Authorized ASent:
._ e.t 1= 1 5 rz1. i i' l~Ih:tiJl. �r 1.!P-�11
Name(Print) Current Mailing Address:
Sign�( -. 41"� 52el
Telephone
SECTION 3-ESTIMATED CONSTRUCTION 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 ti
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
ore-
6. Total=(1 +2+3+4+5) - Check Number A
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0652
APPLICANT/CONTACT PERSON MARK BONDE
ADDRESS/PHONE 205 PARK ST EASTHAMPTON (413)535-9529 Q
PROPERTY LOCATION 680 BRIDGE RD-26 CRABAPPLE
MAP 18C PARCEL 141 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildina Permit Filled out
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
I7PR16AT-ION 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
QeaWliti el
Sign re of Building O ficial 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.
680 BRIDGE RD-26 CRABAPPLE BP-2015-0652
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 c.142A)
Category: ELECTRICAL BUILDING PERMIT
Permit# BP-2015-0652
Project# JS-2015-001249
Est. Cost: $15000.00
Fee:$90.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK BONDE 67758
Lot Size(scl. ft.): 1497897.72 Owner: LATHROP COMMUNITY INC
zoninz: Applicant: MARK BONDE
AT: 680 BRIDGE RD - 26 CRABAPPLE
Applicant Address: Phone: Insurance:
205 PARK ST (413) 535-9529 () WC
EASTHAMPTONMA01027 ISSUED ON.1211212014 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 Siznature:
FeeType: Date Paid: Amount:
Building 12/12/2014 0:00:00 $90.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner