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11A-009 (4) 319 �v vT @ c<. n),4 ' ' 2 cox j ! / q.1 -p z CP 2k g _..- GWL 1 i 1 , s a r City of Northampton BtAkNng Department --------— Plan Review 212 Main SMwt Northampton, MA 01060 it 11,1a i. Ld 4 <IZ44 5/F,' C bX -7'f' 1-7 70 62,11111,1- -:771 1 -,k /7A Goh 70 jj! 1 f f s 1 City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of IVIGL 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 IVIGL c 171 , S 150A. Address of the work: L The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant Date Signa of Permit plicant The Commonwealth of Massachusetts Department of IndustyialAccidents Office of Investigations iv 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): f Address: .,, r 647- ell City/State/Zip: Phone #: 1113-67115---711 S.7 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 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.❑ Electrical repairs or additions 3.❑ i am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 oof 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 41 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. 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 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. #: Expiration Date: Job Site Address: City/State/Zip: 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 certify under the pains and penalties of perjury that the information provided above is true and correct Si atur1: � -�'" Date: Phone#: X113- 6;75 -7455J 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 M SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor. Not Applicable ❑ Name of License Holder: f . Air. r—,14( 1057 License Number 15o, 60A 6:- 7 L14 0AM 71i�l2oIt Address Expirat' n Da(e f lz-611�1 Z13 "c� J Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registrations Number 5/3 12,3 1 C. Address Expio�r Date Telephone J:m I " 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...... ❑ IL - Home Owner Exemption The current exe tion for"homeowners"was extended to include Owner-occupied Dwellings of one(1 two(2)families and to allow such ho owner to engage an individual for hire who does not possess a license, rov' that the owner acts as supervisor.ervisor.CM 78 xth Edition Section 108.3.5.1. Definition of Homeowner: Per (s)who own a parcel of land on which he/s�resi or intends to reside,on which there is,or is intended to be,a one or two dwelling,attached or detached struessory to such use and/or farm structures.A person who constructs more n one home in a two- en riod shall not be considered a homeowner. Such"homeowner"shall submit to the Building ial,on a form eptable to the Building Official,that he/she shall be responsible for all such work performed under the b n ermit. As acting Construction Supervisor your presence on th " s' will be required from time to time,during and upon completion of the work for which this permit is iss Also be advised that with reference to Chapter (Workers'Compensati and Chapter 153(Liability of Employers to Employees for injuries not resulting in D )of the Massachusetts General La otated,You may be liable for person(s) you hire to perform work for you u this permit. The undersigned"homeowner" ertifies and assumes responsibility for compliance with t tate Building Code,City of Northampton Ordinance tate and Local Zoning Laws and State of Massachusetts General La notated. Homeowner ' nature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aimilcable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors 1­1 Accessory Bldg. ❑ Demolition ❑ New Signs [E:3] Decks [M Siding 1[3] Other[Mf Brief Description of Proposed ti Work: a .v Alteration of existing bedroom Yes V No Adding new bedroom es ✓ No Attached Narrative Renovating unfinished basement Yes 1,No Plans Attached Roll -Sheet sa.If New house and or addition to existina 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? Wz' 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 i/ Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, /[P,t:..c. as Owner of the subject property hereby authorize to act on my behalf,in all matte elative to V6rk authorized by this building permit application. yy Signature ofr Dat as Owner/Authorized Agent hereby declare that&46 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 Signature of gent e 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 3 03 Side L ,0 R: 13 L: 7711 r R: i 3 Rear 167-" Building Height j7" /7 Bldg. Square Footage 126 % 12-6- 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 ( DON7 KNOW ® YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO (2( DON7 KNOW 0 YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO (2( DON7 KNOW ® 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 © NO QV 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,ex tion, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only —=--=1)- IIC of Northampton Status of Permit: 13';i ding Department Curb Cut/Driveway Permit ! JUN 4 2015 12 Main Street Sewer/Septic Availability Room 100 WaterNVell Availability Electric, �iur Ur,g&GG;i,�i; 1 ampton, MA 01060 Two Sets of Structural Plans Northampton, s 7-1240 Fax 413-587-1272 Plot/Site Plans 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 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing dress: �4�- Telephone Signature 2.2 Authorized Agent: u PSG 7W4 Name(Print) Current Mailing Address: ' Signature Telephone SECTION 3-ESTI ATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com I ted by rmit 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-2015-1218 AO APPLICANT/CONTACT PERSON EDWARD RICKEY �• _ ADDRESS/PHONE P O BOX 62 WILLIAMSBURGO1096(413)695-7059 PROPERTY LOCATION 59 EVERGREEN RD MAP 11 A PARCEL 009 001 ZONE URA(99)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiny,Permit Filled out _? Fee Paid Typeof Construction: ADD ROOF OVER FRONT DECK&REPLACE ROOF W/METAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building-Plans Included: Owner/Statement or License 96159 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: INFO 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 Delay 107- Si r e4d f Bult'o g Offi 6ia1 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. 59 EVERGREEN RD BP-2015-1218 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: I IA-009 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2015-1218 Project# JS-2015-002301 Est.Cost: $10500.00 Fee: $63.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin: EDWARD RICKEY 96159 Lot Size(sq. ft.): 18469.44 Owner: SAMSON NEIL R&DEANNE L Zoning URA(99)/ Applicant. EDWARD RICKEY AT. 59 EVERGREEN RD Applicant Address: Phone: Insurance: P O BOX 62 (413) 695-7059 WILLIAMSBURGMA01096 ISSUED ON.6115 12015 0:00:00 TO PERFORM THE FOLLOWING WORK.-ADD ROOF OVER FRONT DECK & REPLACE ROOF W/METAL 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 6/15/2015 0:00:00 $63.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner