11A-067 4 VILLONE DR BP-2011-0680
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GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Bloc 11A - 067 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit # BP-2011-0680
Project # JS- 2011- 001112
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sQ. ft.): 26266.68 Owner: SIEGEL STEVEN H & BARBARA H
Zoning: URA(100)/ Applicant: SIEGEL STEVEN H & BARBARA H
AT. 4 VILLONE DR
Applicant Address: Phone: Insurance:
4 VILLONE DR (413) 341 -3828 O
LEEDSMA01053 ISSUED ON :211412011 0:00:00
TO PERFORM THE FOLLOWING WORK :WOODSTOVE
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 2/14/20110:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
r �
R
ity of Northampton
uilding Department
F18B ,� 2Q�� 212 Main Street
Room 100
►� hampton, MA 01060 k
- 87 -1240 Fax 413 - 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address
This section to be completed by office
Unit
Zone Overlay" istri
tcMY$t Distr7et District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
Name (P n Current M ailing Address:
( (4, la ) 3 5 7 ,
Telephone
Si nature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3:- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
com leted by ermit 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
=bj4 0Q
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Onl
Building Permit Number: te
r.
Issu
Signatu :
Building Commissioner/Inspector of Buildings Date
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all ab)licable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors 17
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding [0] Other [Oj
Brief Description of Proposed
Work: r vn t �v� ZiJ�y S �o�lC G>u Y eGy I r. h om P
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa ° .�f��r�it;�lr►�i�acirl3�� ,. ��n ... ' �IS°l� �Q�`f��,�aoril
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. Masschec k 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 ''?a - OWNER AUTHORMATIOR: TO BE COMPLETED iWHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR. BUILDING PERMIT
as Owner of the subject
property
hereby authorize
to If ' all matt relative to work authorized by this building permit application.
2 Lk I t
Signature V Owner Date
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.
Pri a
gnature of Owner /Agent Date
i ?
. The Commonwealth of Massachusetts
Department of Industrial Accidents -
Office of Investigations
600 Washington Street
Boston, MA 02111
M www.mass gov/dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Le bly
Name ( Business /orgmizatiowhdividual):
Address: LA J i l l oO n r- 1
City /State/Zip: W 3_ Phone. #: Q X
F Are you an employer ?.Check the appropriate bog: Type of project (required):.
1. ❑ I am a employer with 4.. I am a general contractor and I
employees (full and/or part-time). * have hired the sub- contractors 6. F1 New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
ship and have no loyees These sub - contractors have. .8. Demolition
working for me in any capacity. employees_and Kaye wot=ers'
9 - BI)Adir, addition
UsTt# WOrkeiS' Comp: InStn3nee - -. CoIDP. mcrTranr•� #._.. - �__
. � ed 5 We are a corporation and its 10 0 Electncal repairs or additions
r
equn . j officers haveGercised their 11. Plumb' 3. I am a homeowner doing all work . • ❑ mg repairs or additions
myself o workers' co right of exemption Per MGL
[N comp 12:0Roofrepairs
insurance required] t c. 152, § 1(.4)', and we have no
1 Othcr vyc[
�P to yam- (N
- 3,
_ . o workers '
pomp- msut:ance required}.
*Any applicant that checks box #d= inust.aiso fill out the section below showing theirw)rkers' compensation policy information:
t Homeowners who submit this affidavit.indimting they are doing all work and the hire outside contractors mist submit ' a new affidavit indicating such
:Contractors that check this box must attached an additional sheet showing the name of fire sub= contractors and state whether arnotthose-entitis 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: Ciiy/StafelZtp:
Attach a copy of the workers' :compensation policy declaraiion page'(showing the p9licy number and ex date).
Failure, for secure coverage; as requftied un(Iit Sir tdoa 25A'ofMGL�e. 152 eari leadto the imposrti n o penalties of a
fine up to $1,500.00 and/or one -year imprisonment; as well, as civil penalties is the form ofa STOP WORK -ORDER and tine
of up to $250.00 a -day against the violator. Be advised that a copy of this statement maybe forwarded to t O.ffi of
Investtt�ahons of the t)IA- for insurance` coveras<e verification _;
I do hereby c _ ` _nder the and en ' s of- perjury that the informatinn provided above usrire'andcnrrect
Si ture:
Phone #: CI-L t 31 1 3 y
Offccirri use only. Do not write in this area, lb be comp by try or Town officer[
.City or Town: PermftUcense #
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 #: