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05-041 (3)
257 AUDUBON RD BP-2017-1241 GIS s: COMMONWEALTH OF MASSACHUSETTS Map:Block: 05-041 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 replaced BUILDING D( 1 ERMIT Permits BP-2017-1241 Project JS-2017-002080 Est. Cost: $7000.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: TODD D PEASE 101384 Lot Size(sq. ft.): 47044.80 Owner: MARINI TINA Zoning: RR(100)/ Applicant: TODD D PEASE AT: 257 AUDUBON RD Applicant Address: Phone: Insurance: 4 CROSS ST (413) 210-1476 BUCKLAN DMA01338 ISSUED ON:S/1/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 8 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 5/1/2017 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck-Building Commissioner NN Department use ordy;, ��- City of Northampton Status of Permit ' /1,-,./ �Cb Building Department Curb CuuDnveway Perms �y 212 Main Street Sewer/SepticAvailabi6ty `\�Y�2'`_ Room 100 Wate(/WelJArailabddy Northampton, MA 01060 Two Sets of Structural Plans Nv, phone 413-587-1240 Fax 413-587-1272 PlovSdePlans / Other:,90111 APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING V SECTION 1 -SITE INFORMATION ' /7— a cti 1.1 Property Address. ,7 / This section to be completed/� by office ,76 7 ,d, /)_ i Map 05 Lot '' `/ Unit /�( Wr/I.CCC---rrriii moi/ lLL Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: /� line\ Plikr , l a -) 404ilJen hA t-ea4srhtss Name( , Current Mailing Address: S- A , - v3 C-31 gage, elephone Signature 2.2 Authorized Anent: tand Peas-i. V cCoS ( S3-r- c4- (Lick LA eA� NA- Name(Print) Current Mailing Address: O"I fl V 11:1-4it— V13 -al o - /V7-6 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building ,...ti�y 7306 e0 (a)Building Permit Fee 2. Electrical T �`- (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 6.Fire Protection .r,9 410 6. Total= (1 +2+3+q+6) Check Number �w U This Section For Official Use Only I Building Permit Numb- - ! Date .0,9,- I Issued- Signature / Thou / Building Commissioner/Inspector of Buildingsg� Date AFe w �w, G(/e,.o cos �e Gs /e7uil1 J��,,{ 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: A: L: R: Rear Building Height Bldg.Square Footage Open Space Footage °o (Lot area minus bldg.&payed parking) a:of Parking Spaces Fill: (volume&Location) _. A. Has a Specie! Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DONT KNOW © YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O 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 O NO 0 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 O 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 O NO O 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 ❑ Replacemen endows Alteration(s) n Roofing 0 Or Doors J Accessory Bldg. ❑ Demolition ❑ New Signs ID] Decks [C Siding[D] Other(CD Brief Description of Proposed Work: ,$ (�C t.✓ ParAeia5).. no / t 'nitr r. [4 r� (Ni Alteration of existing bedroom Yes f No J Adding new bedroom Yes ✓ No Gi/nf rr�. Attached Narrative Renovating unfinished basement Yes le Plans Attached Roll -Sheet ea.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. 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, �t e. Ince • A t as Owner of the subject property TOM ' (� hereby authorize 1 OM 0 Pei {"cc to act on m alf,in all matters relative to work authorized by this building permit application. X CI.-- �N x 4 - zg . i7 Signature of weer (� Dale TORI Q Pei re , 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. Toru 0 Pcc s-c Print Name o.4/I a'g aa 17 Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction TSupervisor: /� I Not Applicable ❑ MOI Name of License Holder'. 1 sLl (easte as- (o1 I License Number V Gass sk-rec4- ,ckla {1 MQ ► Ia., Ja-0S Address 0/3a& Expiration Date af.-&A yr3 - aia iy?6 Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Peet s c . ,r,, s SCC V Z c Y i 9 )-111-\ Company Name Registration Number 1l cr-osr S -'ec7 r114 ' i AP an Address Expiration Date d13 a Telephone 413-di f/ /v') 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 Olt No 0 11. — Home Owner Exemption The current exemption for'homeowners"was extended to include Owner-occupied Dwellings 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 1083.5.1. Definition of homeowner:Person(5l 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 he 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 he required from time to time,during and upon enmp leti on 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 City of Northampton 212 Main Strcct, 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: a S1 nu ) uDon, P. L. c CA n- c t5 The debris will be transported by: 5- a ...✓< 3w 'nc The debris will be received by: WYNNe s}er Building permit number: Name of Permit Applicant Tc Qcvc / to al rrrAf C n Date Signature of Permit Applicant The Commonwealth of Massachusetts t_ .re= ,-,, Department of Industrial Accidents _;. — Office of Investigations 7 I rJ 1 Congress Street, Suite 100 E= Boston, MA 02114-2017 . www.neass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Bussincss:OrganivatiomJndivl dual): Address: City/State/Zip: Phone#: Are ou an employer? Check the appropriate box: Type of project(required): 1. I am a employer with 1 4. ❑ I am a general contractor and I employees(full and/or pan-time)." have hired the sub-contractors 6. ❑ New constriction 2.❑ t am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition workingfor me in anycapacity. employees and have workers' P y- 9. ❑Building addition [No workers' comp. insurance comp. insurance.- required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions officers have exercised their I LE Plumbing repairs or additions 3.❑ I am a homeowner doing all work myself. [No workers' comp. right of exemption per MGL I2— Roof repairs insurance required.] c. 152,§1(4),and we have no — employees. [No workers' l3.❑ Other comp. insurance required.] 'Any applicant hat checks box*I must also fill out the section below showing their workers compensation policy information. `I lom:owners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. BJonnactors that check this box must attached an additional sheet howine 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'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: v9at tn. &tn..,A Policy#or Self-ins. Lic. M: a AGI) L✓6 �. pp ,,II _ _ Expiration Date: 3 II/cit /,Zo le Job Site Address: as-i Aso fl v1 eA City/State/Zip: Le L/r.J 1'..5 . 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 51 300.00 and/or one-year imprisonment, as well as civil penalties in the form ofa STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cernf/p under the pains and penalties of perjury that the information provided above is true and correct Signature: ab'e't Date: V/2s/dci 'f Phone 4: '1/b - ea/0 - /tf'j4 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#: