29-460 (6) City Of Northampton 212 Main Street, Northampton, l\,fA 01060
Solid 'Waste Disposal Affdavit
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 I11, S 150A.
Address of the work: L3 Cre,4v LeLO TY• f lU(-2nce—
The debris will be transported by: \i�c g lkme-
The debris wilt be received by: \)',Aeu R ono\
j
Building permit,number:
Dame of Permit Applicant pome St u
Date Signature of Permit Applicant
ihe com-monweaun of1niassacnaseaes
r- - department of Industrial Accidents
Office of Investigations
' 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Afpldavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please >r iPnt Legibly
Name (Business/Organization/Individual): Q A'Ift,\1�l� xx TmQY-b\, 1�C%4�
Address: y�, ��`�V`�' '�� {
City/State/Zip: �(�f��1C� \ r `(1� ` shone#:
Are you an employer? Check the appropriate box: Type of project(required):
1. I am a y em p to er with_ 4. [] I am a general contractor and I
* have hired the sub-contractors 6. E]New construction
employees(full and/or part-time).
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.F1 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 MiGL 12.❑Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13Other 1
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
fi 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 ornot 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.#: ooc )CD U)02— .S Expiration Date: a 9
(03 c-�;�f Ieco A� City/State/Zip:/State/Zi Ffconce, MA D*k`D-
3ob Site Address: t3' p�
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 DI A.for insurance.coverage)erification.it
Mo hereby certify n die pah. a d pe—Ift ,. perja�ry that the informadon prodded--hove is trace and core ec-
4 �
-� 1 ,
f J
Date:
Si afore: �; %�`+ •� .�
Qffacicai use only. Do not write in this area,to be compieged by city or town ofj�"aCW
f!!{
City of Town: Fern {IL eezz�e
f �
Issuing Authority(circle one):
B oayd off P p± 2. �r fl Tag epar?`ment y City/Town Clerk ?.0ertrical inspector S.Plum
L��InGV�ect.or
a. Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Con structi�on`°Supervisor: Not Applicable ❑
Name of License Holder: l�l '�� � ®(D 0-2- O
>kw,u T7M p���, Cn� 1L License Number
p o - c��a� �ore�lcr 1�a
0\0b2- R L 22.l!I
Address Expiration Date
1_k G-SS4- i Szz.
Signature Telephone
9.Re istei"ed Home rn iovement Cdntractbtr .. Not Applicable ❑
Company a Registration Number
Address Expiration Date
Telephone�� �'���Z
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;:.... ❑
-her xeM ion
The current exemption for"homeowners"was e,.tended to include -Dwellf ngs of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,Rt Wdled that the ew?ter act's
as sullervisor.QvIR 980, Sixth Edition Section 10U.S.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 ti erson wbo constructs more than one home in a two-gear roerio€Il shall not be considered a homeowner.
Such"homeowner"shall submitto the Building Official,on a form acceptable to the Building Official. drat he/sire shall be
responsible for all such work performed under the buildfigg permit.
As acting Construction uuperyisor your presence on the j ob 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 tray 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 Sicruature
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::.k_...__._: R:.._._.....: L:>......,......: R:.............. _._..._..:
Rear _..._.. ..
Building Height w.........
Bldg. Square Footage %
Open Space Footage o
(Lot area minus bldg&paved
parking)
##of Parking Spaces
Fill:
(volume&Location) _._.__....._.____....._...._..._._.___.__.:,.....___._.._._._...._.._—.--_._._____.__.._........
.,..
A. Has a Special Permit/Variance/Fi ing ver been issued for/on the site?
NO DONT KNOW YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW 0 YES 0.
iF YES: enter Book {cages and/or Document#
B. Does the site contain a brook, body of water or wetlands?. NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
heeds to be obtained 0 Obtained 0 , Date Issued:
�i�r_� exist on the property? YES NO
C. Do any .
IF YES, describe size, type and location:
__...._.. .,._...__.............._._.......:..._._...._,._,... ..__.._. . ,
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NOxl
IF YES, describe size, type and location:
disturb i r,l._: .. ,�.._ .r.f., iii 1 over'; sc� or is ii p=El o!a GrJ�It'!ii�r l�llcfl
E. V ill the GonstruGtlon activitli disturb (Gear ti! ,y^ a t! [ten, Or T a n�j
that will disturb over i acre? YES X10
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S.DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition E] Replacement Windows Alteration(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [❑ Siding ] Other[
Its icr--,
Brief Descri 'on of Propose
air sail n ics,irk c prof ttyen s,ir)S '`cell ore--fo � fever R
Work:a r5tr�ta,_1r1So4* Sill ct) a1-G( Rig Frr Gc,� l2e.
Alteration of existing bedroom Yes No Adding new bedroom Yes "<- No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.:if Flew:hoUse:and or addition to eKI'stind hou' sint.66itigfete�h' e fad ens€6-g:
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
Iq 1LG`Yl as Owner of the subject
property ` rr
hereby authorize W e�aW �Q A " \46nnt-- L
to act on my behalf,in all matters relative to i,,lork a!tho.' ed by this building permit a plication.
See 4D-%+ S
Signature of Owner date
O j, C, C �i �c�S sr Inc— as Owner/Authorized
Age!�t hereby ceciare that tl,e state,,,15nts and forr!:ation on the foregoing application are true and accurate,to the best of my knowledge
and bziiaf.
Signed under the pains and penalties of perjury.
j Print Name
{
Signature of O� r/Agent Dzt-
r (gib rxf ,rrt�tttrt}�t�n
DEPARTMENT OF BUILDING INSPECTIONS .ply
212 Main Street . Municipal Building Yry
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 1st floor
.30 " " " " 2nd floor
.20 " 'A 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$61K 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 Occupancy $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
�uild�n Northampton
Dehartmtent cuab Cof Permit •. .
' y p
c g p ut/Dnveway Permit
�p l AUG 4 2015 g 212 Main Street Sewer%SepticAvallability
� i 1 Room 100 Wat erAlYe°ll Avauilabilit
y
Nf, hampton, MA 01060 wo Sets of Strctural P
ans
Electri F ;;
N � phor£e 413-W-1240 Fax 413-587-1272 Plot/Site Plans
Vg 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
(o;3 CreShtte-Lo Map Lot Unit
Hof nce iuA OtO(vr " Zone Overlay District
Elm St.District CB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
AM-haw-t-CheQ f N tchhen Fiorencc; M4A-ciao ,
Name(Printv Curr t Mailing Addre
/3_ 504-C)CD
Telephone
L
rized Agent:
n Sh► le �(� JRiveCsIde D1- Rorence)MA oic
) Current Mailing Address:
t Q ��� '113- S814-75�Q-
Sin lure Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building OA C) W (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=0 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number Number Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2016-0148
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522
PROPERTY LOCATION 63 CRESTVIEW DR
MAP 29 PARCEL 460 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building_Permit Filled out C>
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 106006
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFCTION 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 ' ion Delay
ture of wilding 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.
63 CRESTVIEW DR BP-2016-0148
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-460 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category INSULATION BUILDING PERMIT
Permit# BP-2016-0148
Project# JS-2016-000244
Est. Cost: $2800.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 106006
Lot Size(sa. ft.): 10018.80 Owner: MICHON CHERYL A&ANTHONY W
Zonin : Applicant: VALLEY HOME IMPROVEMENT INC
AT. 63 CRESTVIEW DR
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.81612015 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 signature:
FeeType: Date Paid: Amount:
Building 8/6/2015 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner