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37-022 (2) 600 FLORENCE RD- 15 MOUNTAIN LAUREL PATH BP-2020-1148 GIS#: COMMONWEALTH OF MASSACHUSETTS Ma_p:Block:37-022 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: window replaced BUILDING PERMIT Permit# BP-2020-1148 Project# JS-2020-001930 Est.Cost: $250.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(ssq. ft.): Owner. HIRSCHMAN PETER S& zonine: Applicant. HIRSCHMAN PETER S & AT. 600 FLORENCE RD - 15 MOUNTAIN LAUREL PATH Applicant Address: Phone: Insurance: 600 FLORENCE RD #15 () 584-8884 0 FLORENCEMA01062 ISSUED ON.512612020 0:00:00 TO PERFORM THE FOLLOWING WORK.-NEW REPLACEMENT WINDOW 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 Si(_,nahire: FeeType: Date Paid: Amount: Building 5/26/2020 0:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner CNS,qjaW v Department use only City of Northamptokli? Status of Permit: Building Department < CUT-6 Cut/Driveway Permit ' 212 Main Street <097 Sewer/Septic Availability Room 100 VVaterlWell Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272PiotlSite Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 9.1 Property Address: This section to be completed by office �l 15 Mountain Laurel Path, Florence, MA 01062 Map Z Lot V 22-- unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Peter Hir chman 1 \fountain Laurel Path,Florence,MA 01062 Name(Print Current Mailing Address: —�` Telephone Slgn lure 2.2 Authorized Agent: jName(Print) 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 250.(x) (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=0 +2+3+4+5) 250.00 Check Number This Section For Official Use Only Building Permit Number: 6aU � teF11`ued: l Signature: S ZZ'i u,Gy Building Commissioner/inspector of Buildings Date �qtevarn,, ._�> @ i' a�ofl , Com EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable, New House ❑ addition ❑ Replacement vii'pdows Alteration(s) E] Roofing E] Or Doors l� Accessory Bldg. ❑ Demolition ❑ New Signs [CA Decks [Q Siding[01 Other[oj Brief Work Description of Proposed �ptu(4 . 4e } d v\ r` G w ' I" Alteration of existing bedroom `fes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.If N.. .ho=y d Or ,+.,:ft.—.t^ t t; CC;-="­.0.. Its,..� u l..!! lltl V• VV Vltl VI■ V bAl�i!!lV VMJ!!1V• ll.. VlIV l.l!!V. 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. Proposer)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? K 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 I, ,as Owner of the subject property hereby authorize to act on my behalf,in all matters relative to work authorized by ti its bUildiFiy peri lit apNli�atio��. Signature of Owner Date I, �e+k' �rr-'Ck' vhr`a vim-- 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 Signaturc of 0v:ncrl/1.4crtt Date The Commonweakh of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dta Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. ADDlicant Information L i i Please Print Legibly Name(Business/Organization%lndividual): PC TQ f �}1 r S C�v►Al ct v\ Address: (..e",W ��c( City/State/Zip: [ O Z Phone k — Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full andlor part-time)." 7. ❑New construction 2f]l am a sole proprietor or partnership and have no employees working for me in g_ ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.[J1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 10❑Building addition 4.01 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 11.0 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 repairsThese sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGI,c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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. Belem,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 tinder MGL c. 152,§25A is a criminal violation punishable by a fine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. do hereby certif un airs and penalties of perjury that the information provided altnv is true and correct i_enahue_: v V Da �IV one#: Official use only. Do not write in this area,to be completed by city or to-nm official u City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: �� City of Northampton f Massachusetts v A DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building ,$ Northampton, MA 01060 gaF. OR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two- year period shall not be considered a home owner." The building department for the City of Northampton wants any person(s)who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages; which include foundationifootings (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection The building department requires these inspections before the work is concealed, failure to secure these inspecti4naran result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in con j!inctjpn to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made l0-\.C', understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date �,hht Atri Address of work location SOk�n '1l� C�Ut�� Y City of Northampton t Massachusetts DEPARTMENT OF BUILDING INSPECTIONS ala 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: (Please print house number and street name) T Is to be disposed of at: (-F5Wse print nanle and lodatibn of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) wo"ignature of Permit Applican 5�0wnertate 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.