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24C-086 (2) Departm .TT use se onl y 'f! l City of Northampton Y_ Status of Permit: Building Department �_ Curb Cut/Driveway Permit_ t ` 212 Main Street rt � Sewer/Septic Availability Room 100 WaterlWell Availability Northampton, MA 0106618 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1242?07j, Plot/Site Plans n` Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR; RENOVATE pR,,DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Map a;i'OC- Loty EC/ Unit Zone Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: m o`r�j�,,�f�kd'Y\, 5a r + , ��� 1 ��-j=,�, % ��j: .� 1 li i 'BUVNhs�r��� Name(Pant) T T Current Mailing Address: �7 Signature Telephone i � 3 k 1 '� 2.2 Authorized Agent: Goo V\ Name(Pr" 01 /�7 Current Mailing Address: C- 413 Signature Telephone SECTION 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 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: 0-,10 - 03 Date Issued: Signature: Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [0] Other[CQ Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No 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 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 1, , 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 a 1-/`h' C, as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application ai a true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. cin 0 • o Print Name J _z 10 SigrKture of Owner/Agent Dat Massachusetts �c{� y r� DEPARTMWT OF BUILDING INSPECTIONS , 212 Main Street • Municipal Building Northampton, MA 01060 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 registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work: R `Lt; , trace+r IV4�,",OQ1 r Est.Cost: Address of Work: 0.5,0 Date of Permit Application: oZ 0 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: 3 z acs k As*,,&Axd 4wg¢, / 70 ' e.11 ate I 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 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 Sire I Frontage Setbacks Front Side L:- iJ R: L: R: Rear Building Height Bldg.Square Footage 2t4� Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO (�( DON'T KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW 0 YES IF YES: enter Book Page and/or Docl.ment # B. Does the site contain a brook, body of water or wetlands? NOOr DON'T KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained ® , 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 ® NO (T�/ IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading,ex vation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q 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 ❑ Name of License Holder: License Number c Address n / Expira on Dat, Signature elephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number 910 9r 1?-e-tl bill (D 7; 'z( 1 ,3(-) / ;;L C) Address Expiratfon Dates Telephone l3 -1/1 "R 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...... ❑ ... ..z ., _.., ..........t. ...,.. Massachusetts w DEPARTMENT OF BUILDING INSPECTIONS ?< 212 Main Street •Municipal Building Northampton, MA 01060 ss`6tti` 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: ( � - XI ff)a55ac.0 rl �+- (Please print house number and street name) Is to be disposed of at: Rr o KA-L � Ll,i'v, 04 (Pleasef print name afnd location of facility) Or will be disposed of in a dumpster onsite rented or leased from: kyand eatw(Company Nam Address) �zq 0�'� 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 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please PrintfLeeibl`y1 Name (Business/Organization/Individual): &0C=N '��,po,0ndh P e,Aey "t-y\ l 6666 Address: l 0g City/State/Zip: -f Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.[]I am a employer with employees(full and/or part-time).* 7. C]New construction 2.®1 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.C]1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Building addition 4❑1 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 11.❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions ❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance: p 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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. 1 do hereby certify der the p ' sand enaltielof perjury hat the information provided above is true znd correct. Signature: Date: 3R- Phone#• `-r l �5 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#: µ Roof Ree,,€ r;at 19 ?1 Massasoit Street North ampton,MA t rI a€ .191, Bun er hill i a, l 1,€. ,t?al- coot March 14,21120 �.;NL``X wili i`„'m' nve all tllf' `i 'sl C', i ei`;;#;lilt silly ;les from roof(A 19-21 and re e, ,mlorce as h � }'4t e �.:� I' I` � eathing as -�� Lbt�St. # . <r!, ),. tram thF3pi }i i.� ill E'Cpl's. 3s�tet, 1dsG1il, �ja.2UCII s , 'XII 111k) ak 0C" k 1 : r/c t t r to 11i1 € #tt jtt€-e ��w3 itt< �xt:e llaa>r gars}{gip "',1f "I f,3 t in o €s";n'fi <A k. ':�t��"dl€�it5, it!,. �. E .iE{ } � " ro F�n/gutte RESTORiMON ff j "A Li3Ll'lL'I`t',tlWood" rt ,.. �l VaiCIt.tl#i13aiE(ti1F3 DSII? +. r tot# rt3l�it, I 301 Al` -.t��€,c includingtrash removal Is,01.. . ,-zll tll�to be W� t o post l tas,time and l at ri tl-e i itltllta° , :st cif �3(l;000 to b p aid 1 J3 a :, .,, g sit up, 1/3 at !';;y 'ood alld ice and snow fabric, I /fi at tl si h ofs►tinglin , Alla 11Ca 7 "