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31A-117 (8) 34 VERNON ST BP-2017-0876 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 3IA- 117 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit. Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Plumbing BUILDING PERMIT Permit# BP-2017-0876 Project# JS-2017-001409 Est.Cost: $22000.00 Fee: $143.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: DAVID LEBLANC 80040 Lot Size(sq.ft.): 7274.52 Owner: DEAL SHARON H Zoning: URB(100)/ Applicant: DAVID LEBLANC AT: 34 VERNON ST Applicant Address: Phone: Insurance: 394 WEST LEYDEN RD (413) 834-3854 LEYDENMA01337 ISSUED ON:1/20/2017 0:00:00 TO PERFORM THE FOLLOWING WORK 3RD FLOOR - LAV, SHOWER, TOILET, WASH MACHINE & PIPING 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 4 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 1/20/2017 0:00:00 $143.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-0876 APPLICANT/CONTACT PERSON DAVID LEBLANC ADDRESS/PHONE 394 WEST LEYDEN RD LEYDEN (413)834-3854 PROPERTY LOCATION 34 VERNON ST MAP 31A PARCEL 117 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST EN OSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Vil) Building Permit Filled out Fee Paid Typeof Construction: 3RD FLOOR-LAV, ' 0 i SMET, WASH MACHINE&PIPING New Construction - Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 80040 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Demoli •• Hay / /9 /'7 Signa f Buil. gOfcial 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. REir.. %/r City of Northampton -ry}�r rt9 ,1�£ x �'^ :=uL-� i Building Department Ile1� ,IiYi7ItiG;rt a ` n` ,i -ro 212 Main Street eft- i-i't--ti "- rJtri Ilia — gyp Sig 2017 Room 100 llkte a .+H 'r'lL u, - Northampton, MA 01060 + v- ,Fyiss t licit a o -r el of ptsone 413-587-1240 Fax 413-587-1272 ,at7y [L t.tlla-4- a ;t,C- 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 34 Vernon s± Map Lot Unit Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT th2.1 Owner of Record: ,�{� r��.,_� i �.. Ivy' - ce'S I-"1" /-i4.(2K-YF= w1 /K0J,._ ...e r .,._ i 4-C kr''. -..ra. /4 Na , C Cu rent rent M essl'"3�Z k 01 Telepho�e f ,u Signature ,-'tnrl/ f p✓#rf'-'g-f .-3CrrCOl9M,/h6°1tt Z2 Authorized A ent: "fir C 07 _ r . 1 29V Zdesf Leydeat 0 Leyte• A2/1CI,.*7 Name(Pnn / Current Mailing Address: titter �c„- Yi3-ii Y-3E5F Signet Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant _ 1. Building /.. ,000 (a) Building Permit Fee 2. Electrical a 000 (b)Estimated Total Cost of Construction from(6) 3. Plumbing v O 0 Building Permit Fee 4. Mechanical(HVAC) �, 5. Fire Protection �^2�C *7173 u/ 6. Total= ,p;/3(1 +2+3+4+5) c<da©©0 Check Number 7 /3 This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspecior of Buildings Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Required by Zoning This column filled in by Building iogDepartment tobe Setbacks Front Side L: 6 :a l R: 2t Li= R:O i—in RearnsG `LTJ 1-1 Building Height alltalaMINIIII Bldg.Square Footage CAMBEIMMEM Open Space Footage �'',^, (Lot area minas bldg&paved #of Parkin- S•.ces 1111111.111111.11111.111111111111111.11111 A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued:L IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW pi YES Q IF YES: enter Book Page ,�(,I I and/or Document t_, �C B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservationn_ Commission? Needs to be obtained © Obtained O , Date Issued: I_ C. Do any signs exist on the property? YES C) NO ID r .. _— .. 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 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation, or filling)over 1 acre oris it part of a common pian that will disturb over 1 acre? YES O NO j IF YES,then a Northampton Storm Water Management Permit from the DPW is required. pECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) r to New Houser ❑ Addition ❑ Replacement Windows Alteration(s) ® Roofing ❑ Or Doors C Accessory Bldg. ❑ Demolition ❑ New Signs IO] Decks [[] Siding [O) Other[I7] Brief Description of Przpos ed -j- / 1 / Work: add R bat-b.-um 15 anelks Iiry �/ ad -f-lOv(" are Alteration of existing bedroom X Yes No Adding new bedroom Yes No Attached Narrative'! Renovating unfinished basement Yes No Plans Attached Roll -Sheet r/ Baraf Neat house and or addition to exiskinp hotisipp, compfat8.the followihp: 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 Private well City water Supply_,,,,,,_ SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR/ APPLIES FOR BUILDING PERMIT i i?a¢_- _m E - e- Z-^Z } }#FK J" "<+' 'e7r,f a.-s - , as Owner of the subject property hereby auth• ize As + I - ZRN - to - •. m :-half,in all't five to work authorized by this building permit application. age Signature of Owner /�. Date i, /' i j�// ,as Owner/Authorized Agent hereby declare hat 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. ` £use' Le,31an(i Print Name ) ,- a Signature of 0 , e..•gent „ Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: _ Not Applicable 0 Name of License Holdef 'Avid ie.3 /p _ LicenseNumber 3ppy Oct' Leyden kd Leyden /o OI-33 ! Ooo4 c) Addres imp / Expiration Date d' /' 9/3 -83V - 3854 7130,1 17 Signsre Telephone Email bearrnounfain ho mes@ y Yna I. Co m 9,Registered Home lmorovamen;Contractor ` ;' i ,„_,,,;a, , , Not Applicable 0 Company Nam Registration Number Bear 2 opnZ'lz Bv;/hers 175742 7 Address iciest // A'S/Leyden 7� / / Expiration Date ✓e)r/ Awdea Alai Leyden 2'4 Telephone Y/3 do y,3a'5J 415117 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 0 No 0 1L Home<Ovirner:Exemption The current exemption for"homeavners"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 accepable 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,duringand 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 de State Building Code,City of Northampton 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: .39 Vernon/ SI' The debris will be transported by: (—awl ,Le3IQh/C_ The debris will be received by: Valley /1 cye/i�IR Building permit number: Name of Permit Applicant cpai/iU LeBlinC.— Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents .JOffice of Investigations t= 1 Congress Street, Suite 100 @' 1 Boston, MA 02114-2017 .:" www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business!ChganlzatioMndtvidual): Lf(J'j,Jtd LeB/ ncp / Address: 39V P f P den City!State&Zip: ,<€ 'fieri 0/33;7 Phone#:_ 4/3 á'3V- 315 IL Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 4. 0 I am a general contractor and 1 employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction 2.g I am a sole proprietor or partner- listed on the attached sheet. 7. NI Remodeling ship and have no employees These sub-contractors have 8. .4 Demolition working for me in any capacity. employees and have workers' [No workers' camp. insurance comp.insurance? 9. Building addition required.] 5. [] We are a corporation and its 10y Electrical repairs or additions 3.0 tam a homeowner doing an work officers have exercised their 11.,4 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.] 'Arry applicant that checks box NI must also flu out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors 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, lithe sub-contractors have employees,they must provide their workers'comppolicy 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.d: v 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 certify under theppains a d pe res o erjury that the information provided above is true and correct Signature: elks/ d i -C._. . Date- i///4 Phoned. 4/13- 83ti-.38551 Official use only. Do not write in this area,to be completed by city or town official, City or Town: __Perntit/License/4 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: Phoned: P rr- " on o`�1\� c- Portion 02 0.. 3r• � —Poor \c) roorvc I to a. \oa�nroo M . Ivo) sk‘fk,slect— in 3\op e- ✓: 3Z i neewaSJ 12X4 p ro1'osed shower/poi ktr000" 'ZO 171 sink T;;f�1�,�1 n7l�otec� 1cLuivi N./ , I dam t Z3 / , AIPA ga6/ l 'Cast 4J/a CleaAopen (J5 Z�u 3 Co