25-061 (2) 101 OLD FERRY RD BP-2018-0154
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25 -061 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERNIIT
Permit# BP-2018-0154
Project# JS-2018-000285
Est. Cost: $18500.00
Fee: $117.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: LIVELY BUILDERS 173606
Lot Size(sq. ft.): 13677.84 Owner: MINER RAYLENE
Zoning: Applicant: LIVELY BUILDERS
AT: 101 OLD FERRY RD
Applicant Address: Phone: Insurance:
60 K STREET (413) 834-0726
TURNERS FALLSMA01376 ISSUED ON:8/31/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:INST ALL NEW ASPHALT ROOF, INSTAL 4-5
FOOTINGS FOR PORCH
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 8/31/2017 0:00:00 $117.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
, Department use only
City f Northampton
Status of Permit
/..11.9; rr: c:1 Building Department Curb Cut/Driveway Permit
(41 it A.- 212 Main Street Sewer/Septic Availability
' 4 4- .f`'91, Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION b?- \E--15Lt Tioch
1.1 Prooertv Address: This section to be comp$eted"fiy office
I 01 old H R Z (V) Map d‘C-- Lot 0 Le I Unit
NO2- Tt-I4N1P-TONJ Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
fjc N r C..) le)
0 le ( )
Name(Print) ç Cu rent Mailing Address
X 7)41MeleA "17- 74-14,-7 0g- _5---(4 Telephone
Signature
2.2 Authorized Agent:
(,)OS 1-k,(4 1- 1vcc.. j go s+- I(/frefs [-cols
Name(Print Current Mailing Address:
9)) -
Signature Telephone
SECTI 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 Goo Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Numberiasi?0'7
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
8 134 f(7
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK icheck all analicable)
New House Addition Replacementthyl Wdows Alteration(s) EJ Roofing II(
Or Doors
Accessory Bldg. Demolition D New Signs [0] Decks [El Siding ED] Other[E ]
Brief Description of Proposed
' Vs-in
Work: Iy-1 rod:- 4,, - S C
"'4 1 .1\j (
Alteration of existing bedroom Yes —7 No Adding new bedroom Yes No r( c.
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 1,7/ Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached? NO
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? WO . C) L1C../ _czc C Fireplaces or Woodstoves Number of each r ly flae)
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction V 13
i. Is construction within 100 ft.of wetlands? Yes %.-7 No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conf m to the Building and Zoning regulations? \--7 Yes No.( -hj-
I. Septic Tank City Sewer 14/11 Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPUES FOR BUILDING PERMIT
I, (17,1 I a c_LI ux01._ , as Owner of the subject
property
hereby authorize -I)S r U 5_,L`-/
to act on my behalf, in all matters relative to work authorized by this building permit application.
'
Signature of of Owner Da e
Lk)S L—)V 1—\-f ,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.
JCSLivy
Print Name
ft
'3--
Signature of Owner/Agent " J Date
Section 4. ZONING AU 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: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage tyo
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Findin ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page d/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
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 0 NO (.1
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,ex - ation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder: JOS it-.1
LicenseNumberNumber
Address i Expiration Date
Signat e
Telephone
,• 1. L... • U.- 1.4.10 ' Not Applicable 0
—3C)S /736o4,
Company Nam s Registration Number
Li\A, Lj (3(A L olg-5 /6//s//
Address Expiration Dat
60 h 11 pl 0 1 3 1(L. Telephone 4-)
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 builcaylgermit.
Signed Affidavit Attached Yes No 0
City of Northampton
PY MAr.fYj:�.
.�) Massachusetts w?•
(d k
it S DEPARTMENT OF BUILDING INSPECTIONS y •,`
212 Main Street • Municipal BuildingJti.
: �z Northampton, MA 01060 rs�W.-1,3%"
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
performing work on such homes, a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building" be
done by rei istered contractors.
Note:If the homeowner has contracted with a corporation or LLC, that entity must be registered.
Type of Work: '-b�i.a-41��_ &xi�i ;�(.�5
Est.Cost: I 7;S CL,
Address of Work: 10 ) O 1c.) k'' f r �. (� 1.3
Date of Permit Application: g
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under$1,000.00
Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
2 - - -7 )05' G,(3 vec-,Lky 366,C,
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
-----,..„
s,
Massachusetts 4-, .V, C:,
4, ... ..,'
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1: '"A' 11 k C
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,11 iil DEPARTMENT OF BUILDING INSPECTIONS ;' *
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212 Main Street •Municipal Building 04: •t,
Northampton, MA 01060
Debris 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.
The debris from construction work being performed at:
io 1 Oic,) t ---errk,1 tXr
(Please print house number and street name)
Is to be disposed of at:
_
(Please print name and location olfaci)
Or will be disposed of in a dumpster onsite rented or leased from:
aLL.. .1„), s DukAps-Tif LO G ?CAIN D, 131 e Iv A fe os---)- 0 ii\J Mr-1
(Company Name and Address) ,
1
,
Cne) J //i ,,
Ccia. — —) 3 1-7
A._.- 6a,„ i I. _.1, i c>‹. -
Si turfe of Permit Ap li nt or Owner r ate
-
Y
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The Commonwealth of Massachusetts
Department of Industrial Accidents
lr
:÷.77,147---="m Office of Investigations
Si
600 Washington Street
Boston,MA 02111
; www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): Jo i�/ l
Address: ( U
City/State/Zip:-TL,(v-15 f lI 5 M4 , 6,3 7L Phone#: 4 i 3 4 -6-7.1-C
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with / 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7 ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑Building addition
[No workers' comp. insurance 5. 0 We area corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.[ Plumbing repairs or additions
myself. No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers'
comp. insurance required.] 13. Other 667"1 6
*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.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. Lief-
Policy
Insurance Company Name: L i i
Policy#or Self-ins.Lic.#: w C.a - 3 ►S -- ‘01---7 i'3 - O Expiration Date: t - O - 18
Job Site Address: I U I City/State/Zip: IVo r f q
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 nde the pains d penalties of perjury that the information provided above is true and correct.
Signature: In G� irDate: a -
Phone#: C/ -S J C>7.Z
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#:
O 9id
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