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42-035 rA��—� ' "" ' BP- 2010 -0948 GIs #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 ?ERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0948 Project # JS- 2010- 001407 Est. Cost: $875.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JAMES DAWSON 002701 Lot Size(sq. ft.): 30361.32 Owner: FRADKIN DAVID L & JOAN ROBB Zoning: SR(100) //WSP II Applicant JAMES DAWSON AT. 735 WESTHAMPTON RD Applicant Address: Phone: Insurance: P O BOX 121 (413) 296 -4710 (� CHESTERFIELDMA01012 ISSUED ON :412812010 0:00:00 TO PERFORM THE FOLLOWING WORK.- REPAIR VALLEYS & AROUND CHIMNEY 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 4/28/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo City of Northampton s , Building Department 212 Main Street Room 100 Northampton, MA 01060 AP hpn 4 9 -1240 Fax 413 - 587 -1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - S.ITE'!INFORMATION __ 1.1 Property Address This section to be completed by office t - Map Lot Unit Zone _ Overlay Distinct tip ,E1rW --St Dlstr1¢t CB District .SECTION! 2 - PROPERTY "OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: _ - - Cunt M a il ing F 10� y� o 10 o o L Name (Print) � g Telephone Signature 2.2 Authorized Auenj A d Z Name (Print) Current Mailing Address: nature TelipAone --- SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Fee 7S' 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 3 � " v v 5. Fire Protection 6. Total = 0 + 2 + 3 + 4 + 5) Check Number This Section For Official Use Onl Date Building Permit Number: Issued: Signature: Buildng Commissionerllnspectorof Buildings - Date A 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:L—J R:L--? L:L------J R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg & paved pairking) of Parking Sp aces Fill: L (volume & Location) A. Has a Special Permit /Variance /Finding eve een issued for/on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the R gistry of Dee 7 NO _0 DON7 KNOW YE 0 IF YES: enter Book Pagel and/or Document #�' B. Does the site contain a brook, body f water or wetlands? NO DON7 KNOW 0 YES 0 IF YES, has a permit been or ne d to be obtained from the Conserva *on Commission? Needs to be obtained Q Obtained 0 Date ued: C. Do any signs exist on the prop;" rty7 YES NO IF YES, describe size, type =and location: - fo f1fii ? Y 0 NO 0 —_7 IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO 0 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 O 1 �K Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [O] Other [L7] Brief Description of Proposed Work: /Z an 122 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a t jr i a> t i' ai �I rcr a i n e + i ► �� e : 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 foo f new construction. Dim ons e. Number of stories? f. Method of heating? replaces or Woodstoves Number of each g. Energy Conservation Compliance. check Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlan Yes No. Is construction ' hin 100 yr. floodplain Yes No j. Depth of basement or cellar fl elow finished grade nfo k. Will building co a 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 J (� IJ �� 1��Z V1 as Owner of the subject property hereby authorize w to act on my behaVin all ers relative to work authorized by this building permit application. e fry Signature of Owner rA1 Date I, 'J✓3 m t/$ 0/961 J 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 SKJnature of Owner /Agent Date SECTION 8 - CONSTRUCTION SERVICES I 8.1 Licensed Construction Superv �y _ ) Not Applicable ❑ Name of License Holder : �'VY �'' i� I / J ��`—' 2! 0 License Number ` Address Expiration Date Q&!� &�� ( gnature Telephone BRdeistered Flatn "Iiraveriieib'tcfa .. ;.:K ....;= Not Applicable l Company Name Registration Number Address Expiration Date Telephone //� ' < SE CTION 10- WORKER 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....... ❑ No...... ❑ WNW n 'E The—current—exemption for "homeo±ners" was xtended to mclude_ occupied Dwellines 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 farm structures. A person who constructs more than one home in a two -vear period shall not be c onsidered a homeowner Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official that he /she shall be responsible for all such work performed under the building pe rmit. 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 person(s) 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 Laws-Annotated. o - amp on r riance ; a e Homeowner Signature A The Commonwealth of Massachusetts Department oflndustrial Accidents ' Office of Investigations a �L� 600 Washington Street 11 Boston, MA 02111 www.mass gov/dia - Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb.ers APPUcant Information Please Print L �'bl Name ( Business /Orgmization/Individual): _ //ham Cib� /G1J L1/ l cx Address: fG City /State/Zip: C ke5 - fet,,L- j e, 2Z A01 Phone. #: 2 d Are you an employer?. Check the appropriate box: Type of project (required): 1.0 I am a employer with 4.. Ej I am a general contractor and I employees (full and/or part-time). * have hired the sub - contractors 6. 0 New construction 2.9 I am a sole proprietor or partner- listed on the attached sheet. 7. (] Remodeling ship' and have a employees These sub - contractors have. .8. Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp. insuance comp...ins nce .t required:] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I -am- a -homeo-waer - -dein i;-all] w - - -- officers have ers d their — -1 1?Iu nub' repairs . er-1F -�- mg -ep ' or additions myself [No workers' comp. right of exemption per MGL 12.� repairs insuran required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.]. 'Any applicant -that checks box #.1 must also fin out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit.indicating they are doing an work and then hire outside cotntrxtors must subinit anew affidavit indicating such. tContrwwrs that check this box must.attached an additional shect sbowing the name of the sub_ contractors and state whether or not those entities have employees. if the subcontractors have employees, they must .pnmde 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 in ormation. 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 Section - 25A ofMGL c. 152 can lead to the imposition of criminal penalties ofa fine up to $1,500.00 and/or one impris 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. 15e advised that a copy of this statement maybe forwarded to the Office of Investieations of the DIA for f sus ance coveraee verification I do herebY,certify under the pains and penalties ofpedury.that the informdtionprovided_ahove ittrue�azrdcarrect -T Signature: i /.t /41 Tate• 4 7 Phone #: �r� i �' ��/ G) Offuial use only. Do not wrrte in flits area, to be completed y eily 0r town orzr L __City or Town: PermitUcense # Issuing Authority (circle one): - =f. Board of Health 2. Building Department 3. City/T Clerk .4. Electrica Inspector 5. Plumbing Inspector 6. Other - y Contact Person: Phone #-