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11A-062 (3) 9 LEONARD ST BP-2020-0300 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: I IA-062 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Deck BUILDING PERMIT Permit# BP-2020-0300 Project# JS-2020-000498 Est. Cost: $13500.00 Fee: $88.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MARK SARAFIN 053434 Lot Size(sq. ft.): 72745.20 Owner: O'NEIL SUSAN Zoning: URA(100)/ Applicant. MARK SARAFIN AT: 9 LEONARD ST Applicant Address: Phone: Insurance: 85 RUSSELLVILLE (413) 563-9256 () Workers Compensation SOUTHAMPTON MAO 1073 ISSUED ON: TO PERFORM THE FOLLOWING WORK.-REMOVE 12X12 DECK AND REPLACE WITH 14X12 DECK 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 9/13/2019 0:00:00 $88.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2020-0300 APPLICANT/CONTACT PERSON MARK SARAFIN ADDRESS/PHONE 85 RUSSELLVILLE SOUTHAMPTON (413)563-9256() PROPERTY LOCATION 9 LEONARD ST MAP I IA PARCEL 062 001 ZONE URA000)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST EN SE� REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid ineof Construction:_REMOVE 12X12 DECK AND REPL WEVITH 14X12 DECK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 053434 3 sets of Plans/Plot Plan THE OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF RMATION PRESENTED: Approved 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 Demolition Delay 5�x -/2-2419 Signature of Buil mg Official 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. City of Northampton Status of Permit: Department use only i` Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability ' Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-12 F—z-t I s APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOV TE OR D LISH A ONE O TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION L?tftj60t kRCt0Jb8 CO pleted by office NORTH 1.1 Property Address: 0N,MA 01060 C1 �� 2 5 Map Lot \ ^ nit Zone Overlay District Elm St. District CB District SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: nn a' ke, 9 Lf�a� 5 �,e� + leeA 014 Name(Print) Current Mailing Address: vI OS t Telephone Signature 2.2 Authorized Agent: wit k 5�afz�aF��-. o� Q,rss-e l l U,y e. Ceti Sww-4c'w 0;0.1 . �M�P► Name(Pri t) Current Mailing Address: Signature Telephone SECTION 3- ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building �`• b (a) Building Permit Fee 2. Electrical v (b) Estimated Total Cost of Construction from (6 3. Plumbing Building Permit Fee 4. Mechanical HVAC 5. Fire Protection 6. Total =0 +2+3+4+5) / �d � Check Number This Section For Official Use Only Building Permit Nu er: Date Issued: Signature: 9- Building Commissioner/Inspector of Buildings Date A r1 v��.� 1 9-A L _ V\10 EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 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 .Ul- 4C�C e Frontage Setbacks Front50 Side L:�_R: 1q0 L:q_R: /4 0 Rear c266 4— ani 00 Building Height ($1 t7�1 Bldg.Square Footage q1� 3 % �3 1V aJ Open Space Footage 1� % (Lot area minus bldg&paved 1 parking) #of Parking Spaces Fill: D (volume&Location) � A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO ® DON'T KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DON'T KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO � DON'T KNOW ® YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , Date Issued: C. Do any signs exist on the property? YES ® NO Xy IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © 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 ® NO 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 ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors (] Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding Other[o] Brief Des�}ption of Proposed � � �.� �"c' ��a� "�,�,� I S�-G 12 Work: ew10U'_ la A\'d l� tL q"V6Ce W� S Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes J No Plans Attached Roll -Sheet 6a. 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 constructio'7--Dimensions / e. Number of stories? f. Method of heating? F' places or Woodstoves Number of each g. Energy Conservation Compliance. Masgcheck Energy Compliance form attached? h. Type of construction �� i. Is construction within 100 ft. of wetl s? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cella or 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, �JU�C�.n V, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, V V `\'`\2. e_ 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. M V t/ \\Pr'Z)IL 51A YZ%A F\ y� Print Name L//'� �� q ldlq Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable El/� Name of License Holder: \A4AL 3 Q `!� License Number CIL, SOL, MA Addr ss ,' _ �I��-� Expiration Date f I 3 �Slp Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Lo Address Expiration Date Telephone 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....... No...... ❑ v� v= v� a�v� vaavrra� vvra Massachusetts DEPARTMENT OF BUILDING INSPECTIONSr 212 Main Street •Municipal Building —r 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: L-•n&<7 �J-S- (Please print house number and street name) Is to be disposed of at: (Pleas6 print name d locatio o facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature of 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 of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Wovkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lep_ibly Name (Business/Organization/Individual): Address: SSS City/State/Zi ,�,4a,•n '!>n VAly - Q ol'7j Phone#: 919`903-10.5'& Are you an employer?Check the appropriate box: Type of project(required): 1 gI am a employer with 0C employees(full and/or part-time).* 7. ❑New construction 2.[7 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.[j 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[]Roof r airs These sub-contractors have employees and have workers'comp.insurance? 6.❑We are a corporation and its officers have exercised their right of exemption per MGL C. 14.[:]Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I 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. :Contractors 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. If the sub-contractors have employees,they must provide their workers'comp.policy number. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ATM Policy#or Self-ins.Lic.#: u)r1,,_, 66 " a?019 Expiration Date: 1 ' —a O Job Site Address: "l LeAG vz© 5-- City/State/Zip: lee o-, VYA,.A d 105-3 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to 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 certi u r t e ai an�dp�al f perjury that the information provided above is true and correct. Sip-nature: , Date: Phone#: 4 S- 151,03 - 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#: ebb --- o!, VA puc=� I I C 40 �VJS ----- --_ �PPV�ro J � -TO14 V-4O�Y� Le i P n