37-004 (13) 579 FLORENCE RD BP-2019-0056
CIS 4: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 37-004 CITY OF NORTHAMPTON
Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL-cc.1144/2�A)
Cate rr REPLACEMENT DOOR_ BUILDING PERMIT
Permit# BP-2019-0056
Proiect# JS-2019-000085
Est Cosh $2000.00
Fee,$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JDR BUILDERS 074105
Lot Size(sp. 11): 30056.40 Owner. DELUE ANNA M AKA ANNA M POWERS
zonine: Applicant: JDR BUILDERS
AT.- 579 FLORENCE RD
ApolicantAddress: Phone: Insurance:
P O BOX 4 (413) 665-7587 WC
NORTH HATFIELDMAD1066 ISSUED ON.7/16/20180:00:00
TO PERFORM THE FOLLOWING WORK REPLACE SLIDING GLASS DOORS
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:
FeeTyoe: Date Paid: Amount:
Building 7/16/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck-Building Commissioner
Deparanent use only
City of North mpt n Status of Permit
JUL j1
pep rtm nt Curb CWDmmway Permit
M1 ain treat Sewer/Septic Availability
II�! Room 1 0 Water/Well Availability
DEPNOR
F c ra 6 0060 Two Sets of Structural Plans
3-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONEPOR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION l (q-15,0
1.1 PrlrlloceAdtlmss: This section to be completed by officeoffice) 1gTss '�hiW
1_()124 J C C VA Map ii Lot I Unit
Zone Overlay District
Elm SL District Cle District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name(Pont) � /n/+J Cummt Mailing Address:
^
Anna , Y/ I Ou)C c'S Telephone i 3 58 S-QO t
Signature
2.2 Authorized Anent:
j -?--^'bul rr N C . � �x y d0,
Name(Pn Current Mailing Address:
3) `r- 79f?3
Signalur Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com latad hv ramorita licant
1. Building n �U/� (a)Building Permit Fee
2. Electrical / (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee / ' (/
4. Mechanical (HVAC) 4u J
5. Fire Protection
6, Total=(1 +2+3+4+5) Check Number 7
This Section For Official Use Only
Date
Building Permit Number: Issued:
Sign re'
Builtling Co ionerllnspeclor olBuildiigs Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. jhmnt
All Information Must M Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Thi,column to be find in by
Building Department
Lot Sin
Frontage
Setbacks
Side L:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage
(Lot area minus bldg&paved
,kin
#of Parkin S aces
Fill:
vommo&wwuon
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO ia DONT KNOW O 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 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 C.)
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 or is it part of a common plan
that will disturb over 1 acre? YES O NO A(_l
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK leheck all applicable)
New House Addition ❑ ReplacamenNSfiadows Alteration(s) ❑ Roofing ❑
Or Doons CL��I
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Sldini Othl
Brief Description of Proposed
Work: �� $1-7J7uG 6�4s5 bo-8--
Alteration of existing bedroom_Yes_L No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _Yes No
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 cont ie ion. nsions
e. Number of stories?
I. Method of heating? i s or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy liance form attached?
h. Type of construction
i. Is construction within 100 ft. etlands? Yes No. Is construction within 100 yr. floodplain_Yes No
j. Depth of basement or ar floor below finished grade
k. Will building conform o the new
and Zoning regulations? Yes No.
I. Septic Tank_ City Sewer_ Private well_ City water Supply
SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETEDWHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, N R A e) as Owner of the subject
property 7
hereby authorize `ua X ^ '� �— J YID1A- Q� 1!�L'
to act
�1on my behalf, in all matters relative to work authorized by this building permit application
ct� .
( A n4j ✓n l�rr...Pnd
Signature of Owner Date
1, f� - 1/' � 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 unfte pajgs penaltie erjury.
PnM Name �,V7 ) ( V
P9 -� '
ip
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
Not Apphi;a/brle ❑
Name of Uceme Holder: —1 Ky r`-�� C) L-1 J'U.45—
License Number
�O� f"I NDi 1-(r+r.��".�"fl. ✓"1 .4* OlU Q' S �_ `I_ Z.p
Address Expirolion Date
Signature Telephone
9 Registered Home lmprovemeM Contractor: Not Applicable ❑
Comparw Name Registration Number
Y,>-;C� (t C, vllkvt µ a- vtyS3 3- `i - 2-D
Address Expiration Date
Telephone �1 N--7Y
SECTION 70-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.__. No...... ❑
s—
City of Northampton
SS p
Massachusetts
D&PBSTNEIrT OF SrrZLDING INSPECTIONS ;t "
212 Nain Street • . icipal Build!., p CD
NorNe ton, NA 01060 hry. yjl^
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 most 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-exish'ng owneroccupied building containing
at least one but not mom than four dwelling units....or to structures which am adjacent to such residence or building'be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered
(
Type of Work: `f_"Cq" S ' G. J> t 4_ Est.Cost: `Z'17W
Address of Work:
Date of Permit Application: t-
I hereby certify that:
Registration is not required for the following mason(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.C.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:
`1 , 11, "l1; 51A2- 'wtLAN>�-_" lyj C- L4 9S is--
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
Massachusetts
t DEPdBT OF BDLLDMG S SPECTLOKS 2 �,
212 Main Street •Municipal euiltling
'.r ton, M 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:
S -M I- T wY[i+ K-�
(Please print house number and street name)
Is to be disposed of at:
\1,1 L' �.j ,
(Plea print name ffnd loc;rtiM of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
JatLtuo Inc � ��
(Company Name and Address)
1I
Signatu e f Permit Applicant or Owner Date
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 ofMassaehusetts
1 DepaHment of IndustrialAccidents
I Congress Street,Suite100
Boson, MA 02/14-4-20017
www.massgov/d(a
Workers'Compensation Insurance Affidavit:Builders!Contractors!Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING A11'11HORIT V.
Applicant Information � r��_�����a Ple e sPrint Le tibly
Name (Bminess/OrganizatioMndividuar: 3U t k.Ur-`s"� I IL ec -
Address: PO -1
City/State/Zip: 'a 1 VNO r"�Phone is: X7"7 �(-7
Are you an employer?Check the appropriate Ime Type of project(required):
I-L!J�-wdt
a employer with `ve_ employees(full and/or portions) Z ❑New construction
2.❑I on a sole proprietor or partnership and have no employees working for me in 8' :modeling
any capacity.(No workers'wmp v(vuence r,.addl
3.�Iam a homeownerdan II workm If Noworkers'com surare i d 9. Bedding n
ge myself [ pin' cregwre l'
4.❑1 amo homeowner and will be hiring contractors to conduct all work on my property Iwill IB❑ Building addition
ensure that all contactors either have workermcompensaaon insurance or are sole IL❑Electrical repairs or additions
pri,amli rs with no employees. 12.❑Plumbing repairs or additions
5 1 an a genal contactor and I have hired the aabcnnnactors listed on the attached shcet. 13.�Roof repairs
These sub-connactoa have employees and have workers'comp.insurance t
6❑Weare a saturation and i6 offices,have exercised their right ofexempion per MGL c 14. Other
152,§1(4),and we have no employees,[No workers wmp-insurance required I
•Any applicant that checks box Bl 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 most submit a new affidavit indicating such.
:Contactors that check this box must attached m additional sheet showing the home of the sub-contactors and state whether or not those entities have
employees. If the sub commissions have employees,they must provide their workers'comppolicy number.
I am an employer dud is providing worrken'compensation insurance for my employees Below is the policy andjob site
information
Insurance Company Name:
`QPf
Policy#or Self-ins.. Lie. WC U —t/ j� Expiration Date:
Job Site Address: \ / / / C�2-- 1 ��^ City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date}
Tailrace,secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify er thermal penalties ofperjury thin the information provided above is true and correct.
Sh t re' t ) 7 e Date' f 2—�
Phone#' �� Lf' -7la
Oficial use only. Do not write in this area,m be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#: