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18C-141 (29) INSULATE WALLS R-21 EXISTING GARAGE INSULATE CEILING R-3 8---\< RIGED INSULATION ON FLO❑ 8'X12' EXISTING AIR SEAL FLOOR AND CEILIN LIVING ROOM 2X6 WALL STUDS ANDERSEN WINDOWS .28 U FACTO 1/2a SHEETROCK ANDERSEN SLIDER .28 U FACTO VAPOR BARRIER 1/2" PLYWOO OUSE WRAP ADJUST STEP WHEN NEEDE BONDS CONSTUCTION / LATHROP COMMUNITIES 413 535-9529 The Commonwealth of Massachusetts Department of Industrial Accidents Office of-Investigations 600 Washington Street Boston,MA 02111 wwww.mass govtdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name(Business/OrganizationthWividual): 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(full and/or part-time). , have hired the sub-contractors 6 El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [BVemodeling ship and have no employees These sub-contractors have 8, []Demolition working for me in any capacity. employees and have workers' 9. []Building addition [No workers'comp.insurance comp.insurance.t required.) - 5. [J We are a corporation and its 10.El 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 of exemption per MGL 12.❑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#I must also fill out the section below showing their workers'compensation policy infomration. t Homdowners who submit this affidavit indicating they arc doing all worts and then hire outside contractors must submit anew affidavit indicating such. iContractors that check this box must attached an additional sheet showing the name ofthe sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy numbu. 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 3B985388UB 3/13/2016 Policy#or Self-ins.Lic.#: Expiration Date: arc tL Job Site Address: City/State/Zip:41"�(ZP tiaMt 7C , 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 cerlif y under the pains and penalties ofperjury that the information provided above is true and correct. Sienature., Date: Phone#: 413-529-2176 ©fftcial use only. Do not write in this area,to be completed by city or town official. City or Town: Perniit/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: L 1-7' ex,-I:1-5 License Number c5 Address Expiration Date �/1 r Lt `7 to Signature Telephone 9.Reaistered Home Improvement Contractor: Not Applicable ❑ �l�li'�� (����j►��C��L C� i� L ��Z Z� Company Name Registration Number Address Expiration Date � (1( Telephone ����''?J 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 b ilding 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 peen 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 AlterWon(s) Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs MI Decks [0 Siding M] Other[[� Brief Description of Proposed Work:44A4A -f!L 3 `� C} Z�c�ru 2�>�e- 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 ey" I, f-2- as Owner of the subject property hereby authoriz to act on my b al , in all mattes relative to work authorized by this building permit application. Signature of O 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 Date Signature o Owner/ gent 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 % (l.ot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Sp 'al Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW O YES Q IF YES, date issued: IF YES: Was t permit recorded at the Registry of Deeds? NO V DON'T KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO �DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O 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 activity disturb(clearing, grading,excovgtion, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YEE O NO \./ IF YES,then a Northampton Storm Water Management Permit from the DPW is required. milli Department use only co City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit - Qo 212 Main Street Sewer/Septic Availability, coo Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans one 413-587-1240 Fax 413-587-1272 Plot/Site Plans r Other Specify ( TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE I FORMATION This section to be completed by office 1.1 Proraerty Address: Map Lot Unit Zone Overlay District tip-1ta� / A Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ;1 C, 1 ycq�ss t�'TT' �'►Z�c3 k Name(Pri �— Cqe1ntvlailing Address- -5 —5524 Telephone `' Signature 2.2 Authorized Aaent: H ke kk ��—/.j r>r 2,D '7A� k- '12 A-0 PJZFJ Name(Print) � Current Mailing Address: Signat re Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bV permit 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. Fire 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-2015-1109 APPLICANT/CONTACT PERSON MARK BONDE ADDRESS/PHONE 205 PARK ST EASTHAMPTON01027(413)535-9529 Q PROPERTY LOCATION 62 GOLDEN CHAIN- 680 BRIDGE RD 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 o®, t� Fee Paid Typeof Construction: ENCLOSE&INSULATE REAR PORCH&REMODEL KITCHEN 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 INF9RMATION 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 Demo ition Dela 12ll" 5--13 -45 Si e of Bui 14 rir4 Official 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. 62 GOLDEN CHAIN - 680 BRIDGE RD BP-2015-1109 GIS#: COMMONWEALTH OF MASSACHUSETTS MV: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:renovation BUILDING PERMIT Permit# BP-2015-1109 Project 4 JS-2015-002093 Est. Cost: $17000.00 Fee:$102.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MARK BONDE 67758 Lot Size(sg_II.): 1497897.72 Owner: LATHROP COMMUNITY INC Zoning: Applicant: MARK BONDE AT.• 62 GOLDEN CHAIN - 680 BRIDGE RD Applicant Address: Phone: Insurance: 205 PARK ST (413) 535-9529 O WC EASTHAMPTONMA01027 ISSUED ON.511312015 0:00:00 TO PERFORM THE FOLLOWING WORK.-ENCLOSE & INSULATE REAR PORCH & REMODEL KITCHEN 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 5/13/2015 0:00:00 $102.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner