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37-022 (5) 600 FLORENCE RD-24 MOIUNTAIN LAUEL PATH BP-2021-0019 GIS#: COMMONWEALTH OF MASSACHUSETTS Map: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: Bath reno BUILDING PERMIT Permit# I BP-2021-0019 Prosect# JS-2021-000023 Est.Cost: $10300.00 Fee: $31..00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor., License: Use Group: CLAUDIO GARRIDO 89458 Lot Size(sq.ft.): Owner: MACLEOD PEGGY L zonine: Applicant: CLAUDIO GARRIDO AT. 600 FLORENCE RD - 24 MOIUNTAIN LAUEL PATH Applicant Address: Phone: Insurance: 140 NASH HILL RD (413) 268-9052 HAYDENVILLEMA01039 ISSUED ON.7/8/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-RENO BATH 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 7/8/2020 0:00:00 $31.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner _- -- /NC/c ho PK` Dor lI Rw r Department use only ! City of Northampton Status of Permit: v /r . Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability ' Room 100 Water/Well Availability Go) Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans N oOther Specify 01 wN TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: _A Q This section to be completed by office 04 Ko uv''i� �,kuQ 1 aA Map 9 Lot Unit i t�Y�NC� N1� Zone Overlay District Elm St. District CB District SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record,: I 1(�,,�','A f\I�OAQOd 94 W,uAttvlAU4-4 P ate,, F1bfeock Name(Print1Current Mailing Address: l 111 S� Lot l q Telephone Signature } 2.2 Authorized Aaent: fV0 LA 03 Name(Print) Current Mailing Address: l `fir Signature r Telephone a/ 69 SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building ©V ,\ (a)Building Permit Fee � lJ(J 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 431 4. Mechanical(HVAC) 5. Fire Protection 6. Total =(1 +2 + 3+4+5) Q 0 � Check Number f-I / A q This Section For Official Use Only Building Permit Number: 6Yn'.1 LIP? IIsssued: Signature: i /� Z0z6 Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWN OR CONTRACTOR) r 3 13 4'647 - J-0-4S 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 _.. Frontage _- Setbacks Front Side L:= R:= L:= R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved a&in #of Parking Spaces —- Fill: volume&L.ocation �-------- A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW © YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES Q IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 01, DONT KNOW © YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: m^�F C. Do any signs exist on the property? YES © NO IF YES, describe size, type and location: l 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,ex ation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 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 E3 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[p] Other[M Brief Description of Proposed Renovate bathroom Work: / Alteration of existing bedroom Yes v No Adding new bedroom Yes V/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 I, as Owner of the subject prope hereby authorize to act on behalf, in all matters relative to authorized by this building permit pplication. Signahke of Date I, `-f" L�l/V �/ t/I �%�( �)- 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 —7 �) Signature of Owner/Ag Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Q G�3 License Number &2y ZAVq Address Expirati Date ?2 2 Sigff u Telephone 9. Registered Home Improvement Contractor: Not Appli blee ❑ C.� nLM(o 5 U Company Name Registration Nu ber 1yo 6L,,q�iL4 #("/z -5 1 � 1 Address Expiration Date Telephon 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....... PY No...... ❑ City of Northampton Massachusetts J G I H ; DEPARTMNT OF BUILDING INSPECTIONS y x 212 Main Street • Municipal Building Jti cD Northampton, Mil 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 reeistered contractors. Note.If the homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work: Est.Cost: Address of Work: Date of Permit Application: 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: 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: r 7 z w re Md-Jda le Date wner Name and Signature The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Apnticant Information Please Print Lecibly NameBusiness/ Peggy MacLeod ( Organization/Individual): Address:24 Mountain Laurel Path City/State/Zip:Florence, MA 01062' Phone#:413-530-6119 Are you an employer?Check the appropriate box: Type of project(required): I.❑I am a employer with employees(full and/or pan-time).' 7. New construction 2.kam a sole proprietor or partnership and have no employees working for me in 8. Q Remodeling . y capacity.[No workers'comp.insurance required.] 9. Demolition 3.[JI am a homeowner doing all work myself[No workers'comp.insurance required.]t ❑ 4.[:]l am a homeowner 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 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 501 am a general contractor and I have hired the subcontractors fisted on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption 14.Q Other orpo gh mption per MGL c. 152,§I(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 munber. ma 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. I do hereby certify under the pains and pe Jpe7 that the information provided a is true and correctSi ature: c� � Date: 2 Phone#: LOther only. Do not write in this area,to be completed by city or town official. n: Permit/License# ority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone#: City of Northampton SSS S/ Massachusetts c DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building Northampton, MA 01060 f ^ CSO 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: �4 /K0tkjj+C�V%(.GWY2.I ", 'Hoytr% �� (Please print house number and street name) Is to be disposed of at: va N(A �p(114c (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) -7J 2U Sighat4r&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.