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07-014 395 NORTH FARMS RD BP- 2011 -1069 GIs #: COMMONWEALTH OF MASSACHUSETTS Mav:Bloc 07 - 014 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: windows replaced BUILDING PERMIT Permit # BP- 2011 -1069 Project # JS- 2011- 001721 Est. Cost: $3600.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PELLA PRODUCTS, INC 091496 Lot Size(sq. ft.): Owner: MACKLER FREDERIC S & SUSAN Zoning: Applicant: PELLA PRODUCTS, INC AT. 395 NORTH FARMS RD Applicant Address: Phone: Insurance: 155 MAIN ST (413) 772 -0153 WC GREENFIELDMA01301 ISSUED ON. 6117120110:00:00 TO PERFORM THE FOLLOWING WORK.- INSTALL 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 Signature: FeeType: Date Paid: Amount: Building 6/17/20110:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner f ` City of Northampton RE I Building Department 212 Main Street Room 100 7 ZDI, orthampton, MA 01060 pho e 4 3 -587 -1240 Fax 413 -587 -1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING �.. s5:• as �� 1.1 Property Address 3c(5 I�o� �rh �c�l mS - +D n, a 0 to (02 2.1 Owner of Record 3 l_5' A Name (Print) Current Mailing Address: � sign ur Telephone 2.2 Authoriz Agent: - T LA- 1DRoz)y CTS Name (Print) Current Mailing Address: A o l 3 p 1 � � ) W3 - 7',1 -0 53 Signature Telephone Item Estimated Cost (Dollars) to be a 2z': completed by ermit applicant ` " '' " t x ' y a! 1. Building £ >< t r y 300 C) Q x 2. Electrical v 3. Plumbing f 4. Mechanical (HVAC) zk� ZA SN< 5. Fire Protection 6. Total= (1 +2 +3 +4 +5) �Q� •Q� ,:; x a.. "S i - �3tSfiI�ii�et�� r 5tg�at,�•rt3 � sw � �� � � � � ,� r 4L I 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 L� 0 Building Height C� Bldg. Square Footage Open Space Footage % (Lot area minus bldg & paved p arkin g) # of Parking Spaces Fill: volume & Location A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO ® DONT KNOW YES IF YES, date issued:1 — I IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO (D DONT KNOW Q YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® 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 Or 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 ® NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. W T 11 ENO New House ❑ Addition [❑ Replacement�dows Alteration(s) Roofing ❑ Or Doors. Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [O] Other [ED] Brief Descr' do f, Props d Work: f l} L) ] 1 q Qn !/1 / J t t Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes No �� C, t Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 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 C! I 1 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 . 1. Septic Tank City Sewer Private well City water Supply gg 5 Zr' gtr— Mack as Owner of the subject property hereby authorize 6 V to act on my be all relative to work authorized by this building permit application. Signat er J Date 0k ?C LL rP(2 -o L) Vc.TS 1 N L , 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. .y W OQ k 8 Print Name &j G ! tt Signature of Owner[Agent Date z 'a 8.1 Licensed Construction Supervisor Not Applicable ❑ �a�� �t a c ���0 Name of License Holder 1 License Number 155 i " J nee ng'QA8 X13 Address Expiration Date aj i7��)09, Lt t2> - 7 Signat a Telephone o Not Applicable ❑ Pile Pa-c) C S ,1t 1t-1Z2� 9 Company Name Registration Number �11 I �� Ma`t ` C- i -en�� 1 r\ (A 13c� Address _ C, Expiratior Date Telephone "l f J 7 -01 v 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...... ❑ The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner Person (s) who own a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or faun structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official that he/she sh211 be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for persons) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature A The Coznntonwealth of Massaehztsetts Department of ItidrtstrialAceidents '- Office of Investigations 600 Washin ton Street 4 j .0osion, iv A 62111 www.mass.govIdia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Platnbe 's Applicant Information r Please Print Lef4ibly Name ( Business / Organization /Individual): Address: ` P9 J t f fCf( ,;G City /State /Zip: K - l !/�Ic°rf f tc M_ M, ; lei -;?y/ Pho 4: _ ZX�Z GAS j Are you an employer? Check the appropriate box: Type of project (required): 1. [3_ I am a employer with d. E] I am a eaneral contractor and 1 6 ❑ New construction employees (full and /or part - time).* have hired the sub - contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. T ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ poinolition working or me in an c _aci employees and:have g Y a _P tT 9, ❑ Building addition [No workers' comp. insurance comp. isurance: required.] 5. F1 We are a corporation and its 10 ❑ Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work officers have exercised their 11 ElPlum, bing epa' rs or myself o workers' cam right of exemption per'MGL, ❑ Roof rep ' `s' Y [ p. 12, insurance required.] t C. 152, §1(4), and wc, employees. [loo•vrorkers' 13:: Other comp, insurancereciuired:] - - 12 er s *Arty applicant that checks box #1 must also fill out the section below showing their vork� rs' compensal%on policy inforirlation. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit ri new affidavit indicating such. .Contractors that check this box must attached an additional sheet showin -ihe rzame`Ofthe sir contractors artdstat�vwheth "r or not those enGlies7i#ve � employees. If the sub - contractors have employees, they must provide their ,workers' comp. poliiV rtumhc . I azn an employer that is providing workers' cotnpert.catinrt insurance for my employees. e1ow is Ill e pokey and jpb site information. Insurance Company Name: �i'� c %' Z «p i Policy # or Self- ins. d (_) Lic. #: r ' (� �1 < Q j / y _ Expiration Date: .lob Site Address: 9 1 oy4) VZ( - n - ls (�o� City /State /Z,i'p:Mu V rxam An Attach a copy of the workers' compensation policy declaration page (showing the polic number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to;the imposition of criminal penalties of a fine up to $1,500.00 and /or one -year imprisonment, as well as civil penalties in the farm of a STOP FORK ORDER and a fine of up to $250.00 a day against the violator. Be advised. that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance cov v erifi c ation. I do hereby cer ' under the pain and penalties of perjure that the information provided above is true an d correct. S i _-nature: Date: ` YX Phone #: � 1 - / :Z U 153 Official use only. Do not write in this area, to be completed by city or town c fficial C ity or Town: Permit /License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City /Town Clerk 4. :Electrical Inspector -5.1 Plumbing Inspector 6. Other Contact Person: Phone #: