18C-141 (33) City of Northampton
Building Department
Plan Review
INSULATE WALLS R-21 212 Main Street
EXISTING GARAGE Northampton, MA 01060
INSULATE CEILING R
RILED INSULATION ON FLOG
k19f 8'X12' EXISTING
AIR SEAL FL❑❑R"AN1) CEILIN LIVING ROOM
2X6 WALL STUDS
ANDERSEN WINDOWS .28 U FACTO
1/2" SHEETROCK
ANDERSEN SLIDER 28 U FACTO
VAPOR BARRIER
1/2' PLYWOO OUSE WRAP
3
BONDE CONSTUCTI❑N / LATHROP COMMUNITIES 413 535-9529 / �-1 �t���"�-ic�r�►•� ,
�\ ____ ......vJr .ra waaaw►easaersa
Department of Industrial Accidents
Office of Investigations
I Congress Street,Suite 100
Boston,MA 02114-2017
y www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Aaulicant Information Please Print Legibly
Name (Business/Organization/Individual): -:> t� "�,XmoN
Address:�.65 t�2�rC, Sr,
City/State/Zi CD '7Phone#: t �2.
Are,y�o—u-'an employer?Check the appropriate box: Type of project(required):
s
1.� i am a employer with� 1 4. []-am a general contractor and I 6. ®New construction
employees(full and/or part-time).* have hired the sub-contractors
213 1 am a sole proprietor or partner- listed on the attached sheet. 7. [R-RSmodeling
ship and have no employees These sub-contractors have g. ®Demolition
working for me in any capacity. employees and have workers' g ®Building addition
[No workers' comp.insurance comp.insurance.
required.] 5. ® We are a corporation and its 10.®Electrical repairs or additions
3.❑ 1 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.[3 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.[1 Other
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 insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: seAWE,tiSM' t 7T4ei-
Policy#or Self-ins. Lie. #: ?L Q Expiration Date:
Job Site Address: tj 7 c la E i E�I�?r.! �-� > City/State/Zip:V6 'A 4310b0
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 cerVf fyy under the pains and penalties of perjury that the information provided above is true and correct.
Signnatum: �� f�t Date:
Phone#: l2 V 2C1~Zt iL1
Official use only. Do not write in this area,to be completed by city or town of,Icial.
City or Town: Prer .icense#
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#:
i
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: /k✓L�2 (✓i'�i _ - CS 17 -6 C�
License Number
Address Expiration Date
:td, 2, Z�-L Zl\ :1 if,
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
.2 c f�A2 '-2, - 13--16
Address e \ Expiration Date
��+ �> � A-M D� 1'� Telephone 5 514-z17le
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....... M- 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 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all annlicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ED
or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs MI Decks [❑ Siding El Other[A
Brief Description of Proposed
Work: C of m u r-cam- 7 VaPe—. I wy�5 k-fib I_t hill 11 t.-&EVS-v --' K(ItA WN
Alteration of e)asting bedroom Yes ✓No Adding new bedroom Yes _ /Tto
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 Fan*
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 900 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.
t. Jeptic T City Sewer "Private well 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 1
hereby authorize
to act on m beh !f,in all matters relati rk authorized by this building permit application.
e e#_
Dzft
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 enalties of perjury.
Print Name
Signabxe of bwrwmamr-
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To incomplete information
Udsli rg Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(I_nt area mms bk .&pavfd
parking)
#of Parking S s
Fill:
(VxM $ 9ti
A. Has a Special Permit/Variance/Finding ever been issued forlon the site?
NO O DONT KNOW Q YES 0
IF YES,, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW YES O
IF YES: enter Book Page and/or Document#
13. Dom the zite coMain a of water or wetlands? NO DONT KNOW E)YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained 0 , Date Issued:
Cr. N zmyi*Vn tq&t ore t±-&propertf. YU 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO
desc�sizk, type locatio :
E. Will the construction activity disturb(clearing,grading, eLxcavytien,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YEE O NO V
F YES,then a Northampton Start Water Marw9ement Pennit tam fd
City of Northampton Status of Permit:
Building Department Curb GuVOriveway Permit
RECEIVED 212 Main Street sewer/SepticAvailabift
Roam 100 WMedW e11 Ava tat►ility _
OCT 13
h ne 13-587-1240 Fax 413-587-1272 PIot1Sft Phan
Other Specify
"oR STRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Ski 1- rlR"T
1.1 Property Address: This section to be completed by office
�.Jd.' ►'rZ�t� Cc>wAt*4.ffy Map Lot Unit
fL4 7Tri2.etioeN
�► i t ► Elm sir District ce Dish
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 QXW*f
Name nt) Current Mailing Address:
!A I-A
,( Telephone
Signature &*,
Name(Prirrt) Ckwask h4aft Armes:
(41,25
e T
Item Esbma*d Cost(00ffars)to be Officud Use Only
icant
1. : B
Tow cost
f
3_ PkuTitrirtg
4. Med .(
5_Fire
T _ Use gnft
EhAkft Permit Numbw:_ t
1
Signal=:
"*V CwMT&3ionttl D
File#BP-2016-0500
APPLICANT/CONTACT PERSON MARK BONDE
ADDRESS/PHONE 205 PARK ST EASTHAMPTON01027(413)535-9529 Q
PROPERTY LOCATION 680 BRIDGE RD-47 FIRETHORN
MAP 18C PARCEL 141 001 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: CONVERT 8 X 12 TO LIVING SPACE&REPLACE KITCH CABINETS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 67758
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9RMATION PRESENTED:
proved 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
molit' n ay �e
Signature of Bu -ding fficia 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.
680 BRIDGE RD-47 FIRETHORN BP-2016-0500
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map-Block: 18C- 141 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2016-0500
Project# JS-2016-000726
Est. Cost: $15000.00
Fee: $97.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK BONDE 67758
Lot Size(sq. ft.): 1497897.72 Owner: LATHROP COMMUNITY INC
Zoning: Applicant: MARK BONDE
AT: 680 BRIDGE RD - 47 FIRETHORN
Applicant Address: Phone: Insurance:
205 PARK ST (413) 535-9529 O WC
EASTHAMPTONMA01027 ISSUED ON:1011512015 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONVERT 8 X 12 TO LIVING SPACE & REPLACE
KITCH CABINETS
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 10/15/2015 0:00:00 $97.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
680 BRIDGE RD-47 FIRETHORN BP-2016-0500
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C- 141 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2016-0500
Project# JS-2016-000726
Est. Cost: $15000.00
Fee: $97.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MARK BONDE 67758
Lot Size(sq. ft.): 1497897.72 Owner: LATHROP COMMUNITY INC
Zoniniz: Applicant: MARK BONDE
AT. 680 BRIDGE RD - 47 FIRETHORN
Applicant Address: Phone: Insurance:
205 PARK ST (413) 535-9529 O WC
EASTHAMPTONMA01027 ISSUED ON.1011512015 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONVERT 8 X 12 TO LIVING SPACE & REPLACE
KITCH CABINETS
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 Siiinature:
FeeType: Date Paid: Amount:
Building 10/15/2015 0:00:00 $97.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner