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18C-088
City of Northampton 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: till W ec5o'. Oc The debris will be transported by: Wt Aw Y-�_, The debris will be received by: uW�_� Building permit number: Name of Permit Applicant Wcc WWI� � Date Signature of Permit Applicant -- --.- 1. The Insured: W Marek Incorporated DBA: Mailing address: 73 Southampton Rd FEIN: '••9473 Westhampton,MA 01027 Legal Entity Type: Corporation Other workplaces not shown above-. 2. The Foolicy period is from 02/10/2015 to 02110/2018 17:01 a.m.standard time at the insured's mailing addres,,. 3. A. Workers Compensation insurance: Part One of the policy applies to the Workers Corn states listed hero: MA Compensation Lew of the B. Employers'Llablitty Insurance:Part Two of to policy applies to work In each state listed in item 3.A. The limits of IIabINty under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ _ 500,000 policy Limit B se odily Injury by Disea $ ~_ _100,000 each ampioyso C. CKher States insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE: 4. The p•-emium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. AN information required below is subject to verification and change by audit. r Classifkationa Plum Basis — Rates Code i Estimated Per$100 Estimated j No. Total Anrwal 01 w Annual l Rsrrwrtsratlor► Remuneration Premium I INTRA 0117462 INTER SEE.CLASS CODE SCHEDU�E Minimum Premium $500 Total Estimated Annual Premium $6,586 GOV ®0�- Deposit Premium $1,84,3 STATE_'CLASS —MA State Assessments/Surcharges $6,618.00 x 5.8000'% ��//�� $384 This policy, •rncl sding all endorsements,Is hereby countersigned by ��&ea 02117/2015— /lu�oriz—io$ipn�tun`i — ate Service Office: KSK Ins Agency 54 Third Avenues 203 North Hampton Street Burlington MA 01803 Easthampton, MA 01027 WC 00 00 01 A(7-11) Inaludee copYstehtsd nsstsrte1 or to matlonai Council on Co"nsetlon Insraenoe, used with Its pen*sous. { SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: / t Not ApRlicable Name of License Holder: " � �V�, ` �<<J'' " II `` License,Numb Add s G Expiration D to Signature Telephone 9. i t r Home Imorovement Contractor. Not Applicable ❑ Company Name , Reg71j trati n Number t Address // Expirati Date Telephone` 8 Q 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...... ❑ 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 homeo er to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor CMR 780 ixth Edition Section 108.3 .l. Definition of Homeowner:P on(s)who own a par of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or t family dwelli ,attached or detached structures accessory to such use and/or farm structures.A person who constructs ore thad one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Xdder g Official,on a form acceptable to the Building Official,that he/she shall be res onsible for all such work rfor the buildiniz permit. As acting Construction Supervis your preNrce on the job site will be required from time to time,during and upon completion of the work for whi this permit is ued. Also be advised that with re ence to Chapter 15 Workers'Compensation) and Chapter 153(Liability of Employers to Employees for injuries no esulting in Death)of the assachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeo "certifies and assumes re onsibility for compliance with the State Building Code,City of Northampton Ordinances,St 'and Local Zoning Laws nd State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Q JlRoofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0) Decks [p Siding[01 Other[E} Brief Description of Proposed Work: I `} � '.� U ?, CKN:- y t!: 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 followina: a. Use of building:One Family O�, 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. 1. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR}C,�ONJTRACTOR APPLIES FOR BUILDING PERMIT I, ti* t�� 9 row ✓l as Owner of the subject property , hereby authorized to my behalf in all matters eI tive to work authorized by this buildin permit pplication. C Signature of Owner Date 1, t 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 and r t pains and p alties of perjury. l✓✓ 'V/ t�'/(.�,✓fi�C._. Print Name Signature of Owner/Agent Date/ 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 1.,: R:_ L: R: Rear Building Height Bldg.Square Footage % Open Space Footage (Lot area minus bldg&paved Arkin #of Parking Spaces Fill: volume&Location)r' A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO © DON'T KNOW 0 ES Q IF YES,date issued: IF YES: Was the permit recorded at the Regist of Deeds? NO Q DON'T KNOW ® YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , Date Issued: C. Do any signs exist on the property? YES Q 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. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES © NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only of Nc t mpton Status of permit: i\! , Fj A, in. pep rtment Curb ultN yP 21.E- m eet Seyier/SepAvailabltity Water/1 oll Availability �,ectnc p m mpton, MA 01060 TWO Seft of Structural I Plans 413-587-1240 Fax 413-587-1272 Plot/Site Plans Cutter Spedfy. 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-PROPER Y OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: (� �1 I C<<(l ►,t'D t� A � � to �Q Ct S` c ✓1 f� r1 ��l /V�r-��t�c&,L e t Name t) Curre ng Addres 1. — �q _ _ U Telephone SigrWure 2.2 Authorized Agent Name(Pri ) CFIN t Mailing Address: �—� 01 c��3 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building } ocx (a)Building Permit Fee 2. Electrical �•1 (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 Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 64 GLEASON RD BP-2016-0360 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18C-088 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:ROOF BUILDING PERMIT Permit# BP-2016-0360 Project# JS-2016-000577 Est.Cost:$6000.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Group: WALTER MAREK III 055201 Lot Size(sa. ft.): 13852.08 Owner: BROWN DAVID zoning URB(100)/ Applicant: WALTER MAREK III AT. 64 GLEASON RD Applicant Address: Phone: Insurance: 73 SOUTHAMPTON RD (413) 527-7667 O Workers Compensation WESTHAMPTONMA01027 ISSUED ON:911612015 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE HOUSE & GARAGE ROOF 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 9/16/2015 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner