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29-358 (3) City offlorthampton 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 1 11, S 150A. Address of the work: -,;61 A �–, brauk- Dr� FlorP,r e— The debris will be transported by: \(,[aj -OX TMj2''r1Xemefq The debris will be received by: Recut) (n- Building permit number: Name of Permit Applicant �O-Oel Nome nl:)�eme_� 7 30 !5 Date Signature of Permit Applicant , ire Lommonweaim oojiviassacausetts r— x _ Department of Industrial Accidents Office of Investigations G: 600 Washington Street Boston MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLibly Name (Business/Organization/Individual): .,- ' b\, 4"° Tn Address: b2 City/State/Zip: `(�f Pal(�. \ `hone##: L - 0�1~�l -2, Are you an employer? Check the appropriate box: Type of project(required): 1.M I am a employer with �9 4. ❑ 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 Building addition [No workers' comp.insurance comp.insurance.T required.] 5. F1 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. ri ght of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.XOther irgula-hc ) 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 bon must attached an additional sheet sbowing 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 dny employees. Below is the policy and joh site infor°m adon. Insurance Company Name: &be�G�. Policy#or Self-ins. "Lic.#: U(:J<J U p 02— S Expiration Date: Job Site Address: (Q 5( A cre_broo k 1]C. City/State/Zip: Attach a copy of the workers' compensation poUcy declaration page(showing the poUcy 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+ do hereby certify U11d tl�e psi;;s a.d pe�z�lti <. perjr�r'y that their. r'enatfor provided above is true and coreeeL Signature: ° '�' /� f�'`�� Date: l S Q frciai use oniy. Do not i vr"ite to this area to be completed by cky or iown of ciaL City or Town- ,Peraift/Lf ce=-e 6 Issuing Authority (cirete one): ! B oaYd ef HP r± 1 g P>e?arrment 3� City/Town Clerk ^.T,lecti-I-eal l nsp,�eetor° S.plamb'_' -inspectoa 6.Other Ii Contact Persom: Phone n: SECTION 6-CONSTRUCTION SERVICES 8.1 Licensed Con struction`Supervisor: _` 1- Not Applicable ❑ � Name of License Holder: '�Z Sb 1 sw'X r 14- r e)to b—w ZM(— License Number 'iP�oremr 'rAa o\o(o2 R.l 22-l Address Expiration Date Signature Telephone 9.Re `` red Ho me.Irripioyement Contractor Not Applicable ❑ mac_ tioss�3 Company R e Registration Number V-tc�- a 0(02 -I )l Address Expiration Date Telephone'A6-SS�'T�52.Z 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...... ❑ The current exemption for"homeowners"was e xtended to include Dwelf n¢s of one(1) or two(2)fkmi-1ties and to allow such homeowner to engage an individual for hire who does not possess a License, I raA !ed that the ots?ter acts as suRervis®r.CMR 990, Sixth Edition Section 108:s'.�.L. 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 trersom who constructs more than one hG me in a two-year 12eriod shall not be consiaered 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 buiilding permmit: As acting Construction Supervisor your presence on the j ob site will be required from time to time,during and upon completion of the worn for which this permit is issued. Also be ad-vised that with reference to Chapter 152(Workers'Compensation) and Chapter 153 (Liablity 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 Signature Section 4. ZONING ALI 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 Bldg. Square Footage Open Space Footage ° (Lot area minus bldg&paved _....,. _._ parking) #of Parking Spaces Fill. (volume&Location __..., ......____.._._._._._.__.,_..........____.._: .......... ,..__ ._____...._-_---•-.--_.___. A. Has a Special Permit/Variance/Finding yer been issued for/on the site? NO 09 DONT KNOW YES Q IF YES, date issued:�y y IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW (0 YES IF YES: enter Book : Page: find/or Document#11 S. 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 � , Date Nsued: �_. . ...._.: 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 10 NO .................._......._....... .......... IF YES, describe size, type and Location: E. 'vvll{the cGtrSiPUCitUfl aCiiviCy UiSiLiru (C1 @Srii—is,gra�;f(i� c'C--V^itCrt, Gr<i��n� GV ,. .t0 a Corl-(Mort f?I21"1 that will disturb ovsr 1 acre? YES 0 N0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all'applicable) New House Addition [] Replacement Windows Alteration(s) Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding[L7] t he [ Brief Descriptio of P pos atrs�a ,W e(-t�,IM 44 cei u dse 6Qrko eveI to Ri i Imo✓ Work: Llk w ly Fit f5�ri�r Alteration of existing bedroom Yes ><"No Adding new bedroom Yes � N Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a:if New house and or addition to exisUng housing, eon idle th6 fai6�v�s€cif: 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. 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 ! �A , ,(-eRrx as Owner of the subject property hereby authorize�Q JZ3,A C- to act on my behalf,in all matters relative to w6rk author' ed by this building permit application. :1/X30 I� Signature of Owner Date as Owner/Authorized Agent hereby declare that the tai (',torts cndlnfoi i cation on the foregoing application are true and accurate, to the best of my knowledge :end b%)^cf. Signed under the pains and penalties of perjury. i Print Name Signatu e of O�kn gent Date Titrj- urf Xtrrt4ttluvtart - 1S DEPARTMENT OF BUILDING INSPECTIONS `< l 212 Main SLreeL - Municipal Building Northampton, MA 01060 INSI'ECTOI2 LOUIS HASBROUCK BUILDING PERMIT FEES Phone: (413)587-1240 BUILDING COMMISSIONER Effective July 21, 2008 Fax: (413)587-1272 DEMOLITION $ 20.00 ACCESSORYSTRUCTURE $ 35.00 PRINCIPAL BUILDING—Residential $200.00 PRINCIPAL BUILDING-Commercial *NEW CONSTRUCTION $ .50 per square foot for V5 floor .30 " " " " 2-d floor .20 " '/,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 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 ty of Northampton Status of Permit: � �i Ilding Department Curb Cut/Dnveway Permit l 12 Main Street Sewer%SepticAvailabii AUG Room 100 WaterNi(ell Availability ,*rth mpton, MA 01060 Two Sets of Structural Plans Etectrt i'�r 'SsD�' -1240 Fax 413-587-1272 Plot/Site PlansY ' x :Other-Specify N' 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 �J1 4cre.&Oc)K �(tV�' Map Lot Unit t-1©rence, t A 010(oD- Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Q CL ur'eA!�f) 6amcef '?51 Ac rArvo lc br. Name(Print) Current ai ng Addres : Telephone EEG 021 Signat e 2.2 Authorized Agent: e[. �'h I -�1� ' U � I�fn rzs ,3�F0 !�I y i de. Fk) enc e 1414 orc& Name(Print) Current Mailing Address: 413 -5�4 - 75-2-a Si nature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building asoo, O© (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 114 4 6. Total=0 +2+3+4+5) 3600, Q 0 Check Number This Section For Official Use Only_ Building Permit Number. Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2016-0147 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 251 ACREBROOK DR MAP 29 PARCEL 358 001 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 INFO jD4ATION PRESENTED: pproved 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 D oli ' a Sig a of Building Of ici 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. 251 ACREBROOK DR BP-2016-0147 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29-358 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Catego1y: INSULATION BUILDING PERMIT Permit# BP-2016-0147 Project# JS-2016-000243 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.): 14069.88 Owner: NOVOTNY-SPENCER NOMINEE TRUST zonine: Applicant. VALLEY HOME IMPROVEMENT INC AT: 251 ACREBROOK 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: FeeTyne: 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