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31A-209 (3)
25 HARRISON AVE BP-2017-0827 GIS ft: COMMONWEALTH OF MASSACHUSETTS Mao:Block:3IA-209 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:window reIpaced BUILDING PERMIT Pennit BP-2017-0827 Project JS-2017-001382 Est. Cost: $20000.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: PAUL MATTESON 086090 Lot Size(sq.ft.): 12371.04 Owner: Jennifer Johnson Zoning: URB(l00)/ Applicant: PAUL MATTESON AT: 25 HARRISON AVE Applicant Address: Phone: Insurance: 30 GOLA DR (413) 219-8506 EASTHAMPTONMA01027 ISSUED ON:1/4/2077 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 21 REPLACEMENT WINDOWS 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 1/4/2017 0:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner / � City of Northampton 1fOt1uI "" Building Department2 `" ` r r r r - ° M1/ 4 ir <( ) itifb Room 140 1 Northampton,240, Fax 413-5 � � d.k, a� 'phone 413-587-1240 Fax 413-587-1272 yd,P1)0SG,.01 . � - A LIC BION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION bPI I7 fa 7 t.t Property Address: This section to be completed by office - ' Map Lot Unit .. ., , ci- ,i ' ,,t74:-.44,4- Zone Overlay District . ` Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Y• Name(Print) F • Current Mailing Address. Telephone Slgpature * — jcmfe'1 v . " .. ‘:1. ' ( t 4iu-ti Ar"irl 2.2 Authorized Anent: 1. ` Name(Print) _ Current Mailing Address- 1 i Signature Telephone LI/'1 d / y t i C 6 SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (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 ! /1/�Q 6. Total=(1 +2+3+4+5) ',�,i' � - Check Number 0 tic �(.l`( This Section For Official Use Only Budding Permit Number: Date Issued: { IP Signature: % /r. / ✓2 / F Building Commissioner/Inspector of Buildings 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 .R Lot Size Frontage L --.. I L__.—_ .__. _ _ . Setbacks Front `..`._-1 Side LL — _1 R:L-__I L-k.......: R:�..:I 1 1 Rea Building Height f_. Bldg. Square Footage Open Space Footage __ % ._._ (Lot area minus bldg&toyed I 1 r I v_ _..._._I �� parking) #of Parking Spaces r---} L_._-1 =II Fill: h (volume&Location) ---( ------- A. — '—'"A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW Q YES 0 IF YES, date issued:[ l IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book 1— I Pagel and/or Document#i l B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW O YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES © NO Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES a NO 0 IF YES, describe size, type and location: I E. Wilt the construction activity disturb(clearing,grading,/e'x�cavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO (3 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 Q Replacement Windows Alteration(s) n Roofing C Or Doors C Accessory Bldg. .0 Demolition 0 New Signs [O] Decks ID Siding[o] Other[0] Brief Description of Proposed Work: �� ._: ti..bvti. 'v.L-'—^t tet;_:_,. -:-v:u.�...A � _ ,o� Alteration of existing bedroom Yes "-No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet ing 5a If NOW h(S'use'arii�tif,addtlonrt4 exfstnq �ionusgtnq- ;.Complekefhe 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. 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 tv Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, +� , as Owner of the subject property hereby authorize t '-' '-r. 4 « 1.U' �.4 C ju r _ to act on my behalf,in all matters relative to work authorized by this building permit application. Sigdature of gerc - Date -- / t 44 -{ -( ,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 penaltieseof perjury. it Printtiamel . (ir `l• Signatu4k of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction^§upervisor: Not Applicable 0 � Marne of Licen&d Holder _F N `-- = f- _ = C' License Number �_ s') Q _0'54 ittl t f� .�1i4 �, _ '._I i 7 .. `f Address r1 Expiration Date Signature Telephone 5marJ r-� ;_t}12-1—ti f,b r` ,ut_ r}.ti-?. ft y,Reaistered Home Improvement Contitactor: . `, 7v7.' . Not Applicable C Company NameRe �9 strafion Number Address ,. _ Expiration Date .,.._ — . _ +t D `exo 141111 2 Telephone A—J SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152, §25C(8)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit wilt result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes 0 No Q 1, :Iolriiea.Owner Exemption The current exemption forhomeowners"was extended to include Owner-occupied Dwellines of one(I) 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 thispermit 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 perfonn work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with Be State Building Code,City of Notthampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature___ 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: 7 , t l ' t" ' <. R_ The debris will be transported by: : tv rk lH y - A The debris will be received by: Lt. Building permit number: Name of Permit Applicant jo, t t. t_ Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents Arit , _ Office of Investigations 1 Congress Street, Suite 100 — Boston,MA 02114-2017 us* www.nuz s.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zia: Phone #: _ Are you an employer?Check the appropriate box: A. I am a general contractor and I Type of project(required): I-C m (full with 0 it employees(full and/or part-time)." have hired the sub-contractors fi. C New construction 2.r') I am a sole proprietor or partner- listed on the attached sheet. 7. 31.Remodeling ship and have no employees These sub-contractors have g Q Demolition working for me in any capacity. employees and have workers' comp. insurance? 9. Q Building addition req d it workers' comp.insurance p MD Electrical repairs or additions required.] 5. 0 We are a corporation and. 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself: [No workers' comp. right of exemption per MGL 12.0 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 tit must also fill out the section below showing their workers'compensation policy information_ t Homeowners who submit this affidavit indicating they are doing ail work and then hire outside contractors must submit a new affidavit indicating such. tContraclors that check this box must atmched an additional sheet showing nwaame oldie sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide then 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. Lie.#: Expiration Date: Job Site Address: 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 eertky under the pains anlipenalties of perjury That the information provided above is true and correct. Si gent e: . ( t . Date- Phone#: atePhone#: f / / I` / s 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): I.Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical inspector 5.Plumbing Inspector 6.Other Contact Person: Phone t: