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32A-017 (2) I WALNUT ST BP-2018-1057 GIS 4: COMMONWEALTH OF MASSACHUSETTS Map:Block:32A-017 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Categorv:Porch Repair BUILDING PERMIT Permit ft BP-2018-1057 Project JS-2018-001909 Est Cost, $89200.00 Fee:$100.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: PAUL GASS 077256 Lot Size(sa.ft.): 3441.24 Owner. LEVINE ELIOT B&MADGE C EVERS Zoning URC(100)/ Applicant: PAUL GASS AT: 11 WALNUT ST Applicant Address: Phone: Insurance: 58 SUMMER ST (413)387-9105 SOLE PROPRIETOR GREEN FIELDMA01301 ISSUED ON:4/18/2018 0:00:00 TO PERFORM THE FOLLOWING WORK:REMOVE AND REPLACE 2ND FLOOR PORCH BEAM, REMOVE AND REBUILD 1ST FLOOR PORCH STRUCTURE 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 It 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 4/18/20180:00:00 $100.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck-Building Commissioner File#BP-2018-1057 APPLICANT/CONTACT PERSON PAUL GASS ADDRESS/PHONE 58 SUMMER ST GREENFIELD (413)387-9105 PROPERTY LOCATION I 1 WALNUT ST MAP32APARCELO17 001 ZONE URC000V THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST E ED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid TvveofConstruction: REMOVE AND REPLACE 2ND FLOOR PORCH BEAM REMOVE AND REBUILD I ST FLOOR PORCH STRUCTURE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 077256 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Projecn 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 /nsolition Delay %SignatufFof Buniciffigl0f7f 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. t Versionl.7 Commercial Buildin Permit May 15,2000 Department use only `jo��e4j'3-587-1240 City of Northampton Status of Permit n� Building Department Curb CuUDriveway Permit AM ' IT212 Main Street Sewer(Septic Availability Room 100 Water/Well Availability Deur or nu;m;rvo;rsorthampton, MA O1060 Two Sets of Structural Plans Fax 413-587-1272 Ploi Plans Other Specify APPLICATION TO CONSTRUCT,REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION t -SITE INFORMATION 1.1 Property Address'. This section to be completed by office I , wNL uV,'- ,y( hi- Map /�t Lot 40 /7 Unit Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: SLi *+ Le,V1N� _ Name(Print) � /� Current Melling Address S C-l�7 vi LLL' �01(leNtrlU,f fMIR,01O Signature K Telephone Lif 2.2 Authorized Agent: ` p i t_ C-. 66+ L Name(Print) Current Mailing Address: SB S.Amha 8f' CO� :'9 Ill1(�. 0.13 / Signature Telephone ro SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bpermit applicant 1. Building ,� o (a) Building Permit Fee 0 I avy9 2 Electrical (b) Estimated Total Cost of Construction from 6 3, Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6, Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number Date Issued Sign Bu; mg mmissioner/Insp rof Builtlings Date �9//C9 T R , Versiont.7 Comm<mial Building Permit May 15,2000 SECTION4.CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition El Repairs El Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other Brief Description Enter a brief description here. Q,.,K vq fl WA ?"I; a i -RM((, 111u &0, Of Proposed Work: 'Ze"vies k4 vIW SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly11A-1 ElA-21:1A-3 El 1A ❑ A4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ _ 3A ❑ I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ _ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify. M Mixed Use ❑ Specify S Special Use ❑ Specify. COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group'. Proposed Use Group' Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34) SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1" 2^d 3rd 3rd m 4m Total Area (sf) Total Proposed New Construction(sf) Total Height(h) Total Height it 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public to Private ElZone Outside Flood Zone❑ Municipal EC On site disposal system❑ l � Versionl.7 Commercial Building Permit May 15,2000 S. NORTRAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building D ymnnent Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage (Int area minus bld5&pa-d parking) #of Parking Spaces Fill: Ivalume&Lacenon) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW ® YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW C) YES 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 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 PTS IF YES, then a Northampton Storm Water Management Permit from the DPW is required. � 4 Verswril.7 Commercial Building Permit May 15,2000 t SECTION 9.PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES.FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registran0 Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General -i-erral Contractor //'' ljlq$S Not Applicable ❑ Company Nam Responsible In rge of Construction Atltlress {/3 3P7-9laS Signa Telephone Version1.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes © No SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I. EL)of ' {LemJ&1^ /� as Owner of the subject property hereby authorize 1 ITL.. C. ICJ " to act on my behalfinall atte trve to work authorized by this building permit application. X Signature of Owner `J Date I gAVL C - u i J 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 under1,he pains and penalties of perjury. y. Na .___....._ . Sigrillure 1AOwner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Sabena sor. Net Applicable ❑ Name of License HaltlirCS - o-7-7a56 License Numbe Address 59 J.+N-Maz Expiration Data ' Gam rva . 0130 �{Is-3i7-�lOS izc - 1665'%2 Signature Telephone �7YvIa"01) - 6( l o SECTION 13-WORKERS'CO SATION INSURANCE AFFIDAVIT(M.G.L.c.152,y 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affdavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes No 0 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: 1 t,l W Lt U�� A The debris will be transported by: _ llv\l'OlU5i Ow FIgtz The debris will be received by: C_ 1 L-no Building permit number: Name of Permit Applicant Date Signature of Permit Applicant PIS The Commonwealth of Massachusetts _ Department of IndustrialAccidents I Congress Street, Suite 100 Boston,MA 0III4-2017 / www.mass.gov/dia Workers' Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERADTTING AUTHORITY. Applicant Information /' Please Print Legibly Business/Organizatiofn' Name: ht/L COE Address: 59 City/State/Zip: G� . M . 0I O 1 Phone#: J{/ 3 — 9$7— 4 IOf .Are you an employer?Check the appropriate box: Business Type(required): L❑ 1 am a employer with employees(full and/ 5, ❑Retail � orpart-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.rW 1 am a sole proprietor or partnership and have no 71 ❑Office and/or Sales trial.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] S- ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §I(4),and we have l0.❑Manufacturing no employees. [No workers' comp.insurance required]* 4.❑ We are a non-profit or�r�ganization,staffed by volunteers, 11.E]HealthCare ,,Ad with no employees. [.No workers' comp.insurance req.] 12.fj]' Other V " 04 'Hoy applicarn that checks box KI must also fill out the section below sM1on'ing Ih.'rworkers'cnmpcnsa0ov polity infarmanon. "k the corporate officers have exempted themselves,bot[he corporation his onicr employees,a workers'compensation poncy is mgaued and.nch an organisation should check box#I. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip. Policy#or Self-ins-Lie# Expiration Date: 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby car ' un,. the/Jpain(,s$^d pen ties ofperjury that the information provided above is true and carred. Signature: GCi(/"(" C. qDate: 0 Phone 4. � 3- 3t�7 / i0S Oficial use only. Do not write in this area, to be completed by city or town officio[ City or Town: Permit/lI kense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: wwumazs-gov/die t Information and Instructions Massachusetts General Laws chapter 152 requires all e nplcyers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...e�ery Terson in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,patmership, asounion,corporation or other legal oddly,or any two or more of the foregoing engaged in a joint enterprise,and inch ding the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do main mance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall rot because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or ioeal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or in construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither th.:commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work i all acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the can'ractmg authority." Applicants Please fill out the workers' compensation affidavit con plot:ly,by checking the boxes that apply to your situation and,if necessary,supply your insurance company's name,address and phone number along with a certificate of insurance. Limited Liability Companies(LLC)or Limited Liabilitf Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required.Be advised that this affidavit may be submitted ro the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being rex rice-ad,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are regnred c obtain a workers' compensation policy,please call the Department at the number listed below. Self-marred cc onto dies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legi)ly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of I rvestigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that must submit multiple perp it/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary). A copy of the affidat it that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid of fida,dt is on file for future permits or Poetess. A new affidavit must be filled out each year.where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture(i.e.a dog license or permit to bnm 1 noes etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of It dustrial Accidents 1 Cc ngtess Street Boston,MA 02114-2017 Tel. #617-727-4900 ,ext. 7406 or 1-877-MASSAFE Fax# 61"'-727-7749 wwu.mass.gc v/dia Form Ta, l .d 02-23-15 -r JJIL Al I , � Q / S�ht.oc#tori J 1� ate. .�,.�! N'f. la'•* .;jR'L�l' I I� I , 4n1 i I i I t r e xe its IQ ,. I � y, s u t t