35-208 (9) City of ylortllampton 212 Main Street, Northampton, MA 01060
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: 5L--q We54hWi)Dfon .
The debris will be transported by: Ujeq Home- - m=4emtnj-
T he debris will be received by: Re-gAcjinq
Building permit number:
Dame of Permit Applicant AWsc n Shy lef v9,J lei j Hwit-Tmrme �
Date Signature of Permit Applicant
ilte c wnonweaun of juassacauNeus
Department of Industrial Accidents
Office Investigations
�_R= o f
1 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information } Please Print Legibly
Name (Business/Organization/Individual): a,�-etk
Address:
City/State/Zip: Vhone:#:
Are you an employer? Check the appropriate box: Type of project(required):
1.M I am a employer with �9 4. E] I am a general contractor and I 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 S. ❑Demolition
working for me in.any capacity. employees and have workers' 9 F-1 Building addition
[No workers' comp.insurance comp,insurance.
required.] 5. We are a corporation and its 10.F1 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 -1 Roof repairs
insurance required.] � c. 152, §1(4), and we have no '
employees. [No workers' 13.XOther �►�sU��x �
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 insurancefor tray employees. Below is the policy and job site
information.
4 n
Insurance Company Name: ( h7 iG�- L �i � G-3 tr j—p
Policy#or Self-ins. Lic-.#: � 0 Expiration Date: a ! '
Job Site Address: '���t I�V`t�� 61Y11� 1 City/State/Zip: t'�GrP.nC ,M(� Ol(�(0�
Attach a copy of the warkers' 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 WORD 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.
f
ado rtea°e3y certafy r d tlae pains aid pettalti� e4 perjtry{hat the ixafortaaatiora prodded--hove is trace and correct
�1'G<
Date:
Signature:
C.
Official gage erajy. Do not write ire Ellis are--,to be cOM-Pleted by city Or t a��rcica
fl
City or T awn: F"ermitl een�e
s
Im,n g Aartlaacity(circle one):
E I.
Beard�f health 2 r� L�eF_.a,.! e t 3.City/Tav?7n Clem? .�,lectTgcal ingpector 5�Mumb;p-Inspector
I 6. Other
Contact Person: phone#:
SECTION is-CONSTRUCTION SERVICES
8.1 Licensed Con struction1Supervisor: \_ ` Not Applica/b-le ❑
Name of License Holder: "!r•O, 1 `JW\��`1 ®t0bSCO
V L. zr-�L License Number
p o - �np1o2r borer c.r 'V�a O\®b2 R[22 l 1 ;
Address Expiration Date
L113-5��1= sZ-z.
Signat re Telephone
9;Re isfered Home Inipr6Vemenf Contractor. Not Applicable ❑
aU � do�su�
Company Mafme Registration Number
Address Expiration Date
Telephone*)-�E�
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25.C(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...... ❑
lie ®f W-n6 xe t!�
The current exemption for"homeowners"was c-,tended to include Oyzinar-accurgied Dwellings of one(1) or two(2)far-nilies
and to allow such homeowner to engage m individual for Dire wbo does not possess a license,pt ovf ded that the c vuner acts
as supervisor.CIWR 780, Sixth l ditlan Secgdn 101DL3.5.9.
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 tai*o-year nerlod shall not be consldered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official.that he/she shall be
regpoaisible for all such work performed under the bu ldLug rrermlt.
As acting Construction Smeryisor your presence on the job site will be required fl•om 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 mar 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.
Homeovimer Sigrtature
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
LotSize _. ........... ........... ...................
Frontage ......_. ........,..._.._ _... .._......_...._ _..._....__ _. ..._....-
Setbacks Front
Side L::. ..._ R L:'...........:.. R:...-:....,... _....
Rear
Building Height
Bldg. Square Footage
Open Space Footage - -°
(Lot area minus bldg&paved -
13arking-)
#of Parking Spaces _....__
.... _.._ --._ ......._...
Fill:
volume&Location _,_-_._.:_...____........._....___,_...._
A. Has a Special Permit/Variance/Fi ding rrer been issued for/on the site?
NO Q DON'T KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
iti0 DONT KNOW � YES
iF YES: enter Book Pages and/fir Document#
B. Does the site contain a brook, body of water or wetlands?. NO DONT 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
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. VVN the construction activity disturb (ci ing,grading, Vctiu 1, Or VIM ' Over l o E ,.._.t o comri orf Plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicabley
New House C] Addition [7 Replacement Windows Alteration(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [❑ Siding[0] Ot er[
insota' rA
Ojr sea ins' i ry r ven al/ 4''celuf�se -b .br{nq -b R�r
Brief Descriptjon o Proposed �1
Work: 'LU
Alteration of existing bedroom Yes - No Adding new bedroom Yes _ N
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.(f 1�ew:hc��ase` €�d or a c ition to 6xist1hd�66M6% 66iti W6 th6 f�11®
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
[. 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 Pdvats wall 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 C
hereby authorize&I e%oq y\'t� # �� 1 , ��rt� Uvr t°6�PfiY��Y � zy-�-C-
to act on my behalf,in all matters relative to work authorrZed by this building permit application,
Signature of Owner Date
\�aAo e as Owner/;authorized
J
Agent hereby d:.c[are that the statements_:,d trfartnation on the foregoing application are true and accurate,to the best of my knowledge
and balk-[.
Signed under the pains and penalties of perjury.
Pflilt Narric
Sig ature of 0 e /Agent «
�n,�
Titlj jurf X0rt4U1nVtI71T
DEPARTMENT OF BUILDING INSPECTIONS ,
ill t��'�"✓... J�;a _a���
`..x•.tlf�rT 212 Main SLreeL . Municipal Building
Northampton, MA 01060
LOUISHASBROUCK BUILDING PERMIT FEES Phone: (413)587-1240
BUILDING COMMISSIONER Effective July 21,2008 Fax: (413)587-1272
DEMOLITION $ 20.00 ACCESSORY STRUCTURE
$ 35.00 PRINCIPAL BUILDING—Residential
$200.00 PRINCIPAL BUILDING-Commercial
*NEW CONSTRUCTION $ .50 per square foot for 1't floor
.30 " " " 2"'floor
.20 " 1A floors,attic,basement,garage
STRUCTURAL ALTERATIONS IN ALL USE GROUPS
$6.00 per thousand dollars of estimated cost or fraction thereof,
with a minimum fee of$55.00
$25.00 WOODBURNING STOVE
*NEW ACCESSORY STRUCTURES one hundred twenty(120)square feet and over
$ .20 per square foot with,a minimum fee of$25.00
*NEW ACCESSORY STRUCTURES under one hundred twenty(120)square feet
$25.00 per inspection
*SWIMMING POOLS $30.00 for above ground
$60.00 for in-ground
*SIGNS&AWNINGS $30.00
*DECKS $50.00
REPLACEMENT WINDOWS $35.00
SIDING&ROOFING
Residential $35.00 per structure
Commercial $55.00 min.per structure OR$6/K of estimated cost
TENTS $25.00
*ZONING REQUEST FORMS $15.00 (includes home occupation registration)
REISSUE OF LOST PERMIT $25.00
CERTIFICATE OF ANNUAL INSP. $100.00 (minimum)
Temporary Certificate of OCCUpanc $25.00
PERMITS REQUIRING ONLY 1(1)INSPECTION WILL BE A MINIMUM OF$25.00;ALL OTHERS WILL
HAVE A$50.00 MINIMUM. PERMIT FEES SHALL BE PAID TO THE ORDER OF THE City of Northampton
AND SUBMITTED,WITH THE COMPLETED PERMIT APPLICATION,TO THE OFFICE OF THE BUILDING
INSPECTOR. WORK STARTED WITHOUT PERMIT IS SUBJECT TO DOUBLE NORMAL FEE.
!! NO CASH -CHECKS OR MONEY ORDERS ONLY !!
*Filing deadline is 12:00 pm(noon)on Wednesday.
Department use only
�= City of Northampton Status of Permit
-- Building Department Curb Cut/Dnveway Permit
_1 201 12 Main Street SewerlSeptic Availability
Room 100 Water lWelIAvailability
v` mpton, MA 01060 Two Sets of Structural Pians
-1240 Fax 413-587-1272 Plot/Site Plans`°
Electric.F �e
Other Specify;
x r
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property ddr
This section to be completed by office
A,, �es�s`:�
j39 ujesf►Kt,i��ph Map Lot Unit
(7-1oQruI Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: Q
c A i ` okion 53 9 6tk a.m- an d. Ranence
Name(Print) Cu n ailin Address:
Telephone
Signature
2.2 Authorized Agent:
NP��an Sht-$le: ValleiA 3b fi�tvec5Lde
Name(Print) Current Mailing Address:
X13 -584
Signature V Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building o v (a)Building Permit Fee
a sue.
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) a`j( „CX Check Number
This Section For Official Use Only
Building Permit Number. Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2016-0159
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522
PROPERTY LOCATION 539 WESTHAMPTON RD
MAP 35 PARCEL 208 001 ZONE
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 INSULATION AIR SEAL&WEATHERIZE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory 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
INFORMATION 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
lit. lay
Signature of Buil ing 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.
539 WESTHAMPTON RD BP-2016-0159
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 -208 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categoa: INSULATION BUILDING PERMIT
Permit# BP-2016-0159
Project# JS-2016-000265
Est.Cost: $2500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 70567.20 Owner: TSERING PEMA&TASHI YOUDON
zonine: Applicant: VALLEY HOME IMPROVEMENT INC
AT: 539 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.81712015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL INSULATION, AIR SEAL &
WEATHERIZE
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 Sijjnature:
FeeType: Date Paid: Amount:
Building 8/7/2015 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner