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31A-314 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: t 35 Vernon S� , Noc a' a n,j2hn .00 O l of o The debris will be transported by: Ve h g �CDAUU --' it r The debris will be received by: �P.��a Prods AM Inc , IS Hca , S� Cx'-m�f Building permit number: Name of Permit Applicant Pe 1 1c, PMxf , k(- - Tamar mss 4 5�. I o 1,2, /S . Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 1 Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Pella Products, Inc. Address: 155 Main Street City/State/Zip:Greenfield, MA. 01301 Phone#:413-772-0153 Are you an employer?Check the appropriate box: Type of project(required): 1.M I am a employer with 49 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Q Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp.insurance.$ required.] 5. M 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.❑Roof repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] "Any applicant that checks box#I 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 insurance for my employees. Below is the policy and job site information. Insurance Company Name:Hanover Insurance Group Policy#or Self-ins. Lic.#:WHN-9399766-02 Expiration Date:01/01/2016 Job Site Address: 13�_) Wrizr% �)t 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer fy eder the pains and penalties of perjury that the information provided above is true and correct. Sian re: '` Date: t©h / Phone#• Above Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: l-(t/0 r 13ly s5 CS ()9(, 5 5 b License Number lc H )3u1 3 ) , 11( Addre Expiration Date X 311 Signatu Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Pe(Ic( Proau(fS Inc Treyo,- Ba>sS i.$")l5o Company Name Registration Number C1 c1 Addr Expiration Date Telephone I ") 73 1157--3 ) SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§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 buildin Tlermit. Signed Affidavit Attached Yes....... No...... ❑ 11. - Home Owner ExemiWon The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. 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 person who constructs more than one home in a two-year period shall not be considered 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 building permit. As acting Construction Supervisor your presence on the job 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 may 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 1\4 /� SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Wows Alteration(s) ❑ Roofing ❑ Or Doors [2 Accessory Bldg. ❑ Demolition ❑ New Signs [[:I] Decks [Q Siding[p] Other[d] Brief De cription of Proposed ,1 Work: CtiJ Iicklrt io eXISil,2 o oenn V10 fianocS �l�i t� n cj s S1/C 11NC. Alteration of existing bedroom Yes No Adding new bedroom Yes ✓/No J Attached Narrative Renovating unfinished basement Yes -----No Plans Attached Roll -Sheet 6a.if New house and or addition to existing 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? d. Proposed Square footage of new construction. Dimens ns e. Number of stories? f. Method of heating? Fireplaces r Woodstov s Number of each g. Energy Conservation Compliance. Masschec 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 fini hed 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 I, ?eAer W 1-Z►� ,,,, as Owner of the subject property n ` { hereby authorize C 1 CU a 1�t to act on my behal , i all s rela iVe to wgrk au orized by this building permit plication. Signature of Owne V. Date 1, �dla PMJ Li C 1 I^[, 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 under the pains and penalties of perjury. lr4 '\� �5 Print N Signatur 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 L: R: R: Rear Building Height Bldg.Square Footage Open Space Footage % (Lot area minus bldg&paved parking) #of Parking S paces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Regis 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 to YES Q 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 Q NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading, excavatidh, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO V IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permits C I Building Department Curb Cut/Driveway Permit 3 2T 212 Main Street SwmrlSeptic Availability Room 100 Water/Well Availability - N hampton, MA 01060 's _-- Two Sets of Structural Plans DES,or n�„Uar.u,�t�,r�ocss woxrH.nn ro".0 -587-1240 Fax 413-587-1272 PiotlSitePlans Other Specify_' APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: ' t) VQfr`or S This section to be completed by office NOc r�Arne U 1n M� I o1�(� Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT P"..t'1 lOn u ck RT2 A}- �� NGty �✓1 `( of 13�SS 6 Name( ' t) Current Mailin Address: -3---1 X13- 1151 Telephone Signature Lwn�r ©F Record: i/e)-r\011 S F wo � 4&n'+p}v i G lu C-c Name(P'nt) Current Mailing Address: _ 1413- 53 1 -6!j-9 Sign re Telephone SE ION 3-ESTIMATED STRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building r f U 3 (a)Building Permit Fee 2. Electrical �1 (b)Estimated Total Cost of V Construction from 6 3. Plumbing C Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) q-j q q-�A'� Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/inspector of Buildings Date 135 VERNON ST BP-2016-0475 GIs#: COMMONWEALTH OF MASSACHUSETTS MW Block: 3 1 A-314 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categ ory: REPLACEMENT DOOR BUILDING PERMIT Permit# BP-2016-0475 Project# JS-2016-000798 Est. Cost: $4799.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PELLA PRODUCTS, INC 096558 Lot Size(sq. ft.): 8145.72 Owner: WEITZMAN PETER&DIANE E TRAVI Zoning. URA(100)/WP(13)/ Applicant. PELLA PRODUCTS, INC AT: 135 VERNON ST Applicant Address: Phone: Insurance: 155 MAIN ST (413) 772-0153 WC GREENFIELDMA01301 ISSUED ON.1011312015 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT SLIDING DOOR 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 10/13/2015 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner