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38B-127 (4) }Dep _7_11-1 use only ' si r , -!•�� City of Northampton .;.1 _ D Building Department ..,� .. '� M Cur CDnveay �,.'•_.s d �„ ..LC3 i".K1k 9x ti r".: F'� 1,i. �k}•��.7? ss-,'# -` .fiZ,aZ�jy, ( 212 Main Street Se /SepdcAailabtfit}c f .�x.,�ti• � 4~r,, � *`..i`�� z a � ,,{3�yt{"s Room 100 APR 6 Wa r/WellAvadabil'rty 'rx* a s4 � �� F�, - J � 2020 ty RM Northampton, s# Northampton, MA 01060 Tw SetsoStructucalP[an � b�xm,�3 '� _= ,r � ,� y^'F :� G� *+5�., c��+ E 'i.� �t e� 7' �1 � �`^�,tx 9w I&,5•z�.as �� . � phone 413-587-1240,, - I?lo Site Plansas_�•. RU[t D1nrr,INCPECTIONS ' I f FIAVAp,O . � y s ✓ 100 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A.ONE OR TWO FAMILY DWELLING ;'SECTION t.-SNT:E INFORMATION : "r' } Thrs section to;be,completed byroffca[-a 44 1.1 Property Address: k k t a a L ni t _j er z.oFle -� t t 4OverlayBrsirieta •�a-q ts,53`-} � y $'�. 7r .w'9' �ag •,. z _ P Elm St<Distnct �.:� a x- CB DFstr[ct 3?�°._' r N F SECTION 2:-PROPERTY OWNERSHIP/AUTHORIZED AGENT'.: 2.1 Owner of Record: I-C)aun neLI P U n -1 04,•, -SSoGk Su^ q 0 e)torr,h Namerint) Current Mailing Address: J74 �-�-� Telephone Sig ature 2.2 Authorized Agent: I der P-�• x bot�al, �lore�-�c�c � C>►U<<� Name(Print Current Mailing Address: �k13-5�y- 522 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 _ r. This Section:F'o'e-0fficial:Use OnI . Permit-Number:��aU ` �©l.Y� . Issue g. ed: Buildin : Signature: Building Commissionedlnspector of Buildings Date l� EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF.PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing Or Doors FI Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks Siding [0] Other[p] Brief tion of Proposed osed A Work: p p �Uii�x ��GK C�Jr Yid ✓ - Alteration of existing bedroom Yes No Adding new bedroom Yes Nd� Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa.If New i Use and or add t on.to_ex[stir q hot s nq,comRl'ete ttie'fa]fovinn : 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 IOQ trl n� ` f.i"rT k ��hn � � as Owner of the subject property hereby authorize ��-[T I %emt-,'l SI �V e�MCCl'7 to act be If, in all matters relative to work authorized by this building permit application. ____ 5 Z 3 -z,12o Sign ure of Owner. Date I, l�J�� cel 'll�-r'Y► lQ V WE 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. Print Name { Signature of Owner/Agent Date _ City of Northampton ,• _ . 515,,x.: ) Massachusetts r' DEPARTI4ENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Lti 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("BIC"). 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 rhas contracted with a corporation or LLC, that entity must be registered Type of Work: lU t t Est. Cost: Address of Work: 14() C p(ung�'jti,�� Q rG✓�c,-� / ) Date of Permit Application: 3— 3u.— .9oa v I hereby certify that: Registration is not required for the following reason(-): _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: a 11cU V,&,xn414r —Th C. f055y3 Date Contract6r 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 a. DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building 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: yC� cc)I�x�•l�x.�,� ITcr-. (Please print house number and street name) Is to be disposed of at: �R-UiftA N-O-Qoi'(J� (4c \C) �\ba (Ple ` e print n� e and loc on of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature of er it licant or wner 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. r Commonwealth of Massachusetts ®1 Division of Professional Licensure Board of Building Regulations and Standards Const`�pictlVSbpervisor IJ CS-077279 E�Tires:06/21/2020 STEVEN A SIL-VERMAN ^ _ 268 FOMER 140_4D SOUTHAMPTOIV�VIA �40I,s 3305 T Commissioner cii%��Len �r� 2L.GCs-fiUGciL ' Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvementi:Contractor Registration Type: Corporation VALLEY HOME IMPROVEMENT INC z C Registration: 105543 P.O.BOX 60627 �r Expiration: 07/16/2020 FLORENCE,MA 01062 ;, 1 .; 'J- Update Address and Return Card. 1 A 2OM-05/17 �intirtcvecc5s¢CG�cy�.��¢�-1¢r/�ulell� . Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration validfor individual use only TYPE,.Corporation before the expiration date. If found return to: Re gistrationN Expiration Office of Consumer Affairs and Business Regulation AK� 07/16/2020 One Ashburton Place-Suite 1301 VALLEYHOMEPNMeER[G%VEWJkCI�If1C Boston,MA 02108 � ,. STEVEN A.SILVERMAN-.q 340 RIVERSIDED � .�•• � �� "` NORTHAMPTON,MA 01062 Undersecretary Not valid without signature The Commonwealth of Massachusetts x Department oflndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-20-17 www mass.govldia `Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNUTTING AUTHORITY. Applicant information 11 Please Print Legibly Name (Business/Organization/Individual): (� l'�U C- SYYZ X2,e-o-,12 nn re 14 --Tr1 c Address: 'x-10 ��ve✓s��lt �n�rr r�. o. &Xc (ao(o21 City/State/Zip:T1 ot-encL kR C.>10(o2 Phone#: 4 t-6-GSN--1 S2Z Are you an employer?Check the appropriate box: Type of project(required): LE)I am a employer with I t3 employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in g. IN Remodeling any capacity.fNoworkers'comp.insurance required.l 3.[:]l am a homeowner doingall work myself. t 9• ❑Demolition' y [No workers'comp.insurance required.] 4.❑I am a homcowncr and will be hiring contractors to conduct all work on my property. I will 10❑Building addition 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 r additions 5.❑I am a general contractor and T have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs Ton hese sub-ctractors have employee,andhave workers'comp.insurance. G.❑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.INo workers'comp.insurance required.l *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 state whether or not those entities have employees. Tf 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 thepolicy and job site information. Insurance Company Name: -AY-be `k- 7,y-)C- U,-O-n c l- (---1,rU�o Policy#or Self-ins.Lic.#: 00500 3 V 2 \S Expiration Date: o? Job Site Address:- LU C-61Y -1 l/� 1t City/State/Zip:_�C�(rttia'J 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 certify un r the pains andpe aJttes ofplp,.Ar hat the information provided above is true and correct Signature: Date: /o�o -)oao Phone#: LA SsLt--I CJ2 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 nspector6.Other Contact Person: Phone#: