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16B-006 (2) _: BRII��rE BP- 2010 -0543 GIs: COMMONWEALTH OF MASSACHUSETTS I 6 - 006 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0543 Project H JS- 2010 - 000762 Est. Cost: $4500.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: KEVIN NETTO CONSTRUCTION INC 001317 Lot Size(sq. ft.): 12980.88 Owner: KELLEY PHILLIP R & ALICE M Zoning: URA(100) / /RI Applicant: KEVIN NETTO CONSTRUCTION INC AT. 110 BRIDGE RD Applicant Address: Phone: Insurance: 90 Southampton Rd (413) 527 -3168 Workers Compensation WESTHAMPTONMA01027 ISSUED ON :1111812009 0:00:00 TO PERFORM THE FOLLOWING WORK :INSTALL REPLACEMENT WINDOWS & DOOR POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector t'nderground: 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 11/18/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo Department,use only City of Northampton Status of Permit: Building Department curb Cut(DrnrewayPermit 212 Main Street Sewer /Septic Availability. Room 100 Water/Well Availability Northampton, MA 01060 Two sets of structural Plans phone 413- 587 -1240 Fax 413- 587 -1272 Plotlsite Plans . 4 Other Specify �✓� APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be completed by office 1.1 Property Address Map tot Unit Zone Overlay District EIm St District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record �X J\- Name (Print) Current Mailing Add s - "•'l off, Telephone S ignatu ig 2.2 Authorized Agent: S y—xm • N'p— Name (Print) Current Mailing Address: ��Da Sighature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Fee r 2. Electrical (b) Estimated Total Cost of Construction from (6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection .._ _.. _6, T otal =�1 + 2_ �_3 +4t + 5 -- - y Check Number 13 f This Section For Official Use Onl _ Date.. Building Permit Number. Issued: Signature: Building Commissionert nl' specto� o t 5ullaings Date 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:1-1 Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg & paved parking) of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for/on the site? NO Vy DON KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON KNOW 0 YES 0 IF YES: enter Book Page. and/or Document # B. Does the site contain a brook, body of water or wetlands? NO <y DON KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 Date Issued: C. Do any signs exist on the property? YES NO t<;N 0 Xy IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES NO IF YES, describe size, type and location: E. Will the construction activity di-qturh (Hearing, grading Pycavation. or filling) over I acre or is it part of a common plan that will disturb over I acre? YES 0 NO 07 � %01 IF YES, then — aNartKa�mtoh Storm — Wit — er Ma — nagerff 6rit Permit from the DPW is required. SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable► New House Addition Replacement Windows Alteretion(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [C7] Decks Siding [tom] Other [C j Brief Description of Proposed \ Work: \Qm " 'Q� c mac. i�� } ��c �(`eA�G2!c VTX Alteration of existing bedroom Yes IL No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes V No Plans Attached Roll - Sheet 6a. If`Newhouse and or addition to existing housing, complete the following: a. Use of building: One Family Two Family Other I 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 WHIN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDINGPERMIT I, 4 V \CSL \`i��[ as Owner of the subject property ` ,\ hereby authorize N � - RV\'n to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date as Owner /Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best o mi cfno dge a6'T6 elief. Signed under the pains and penalties of perjury. Print am L \\ - \'� Signa ure of Owner /Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction _ Supervisor : y� Not Applicable ❑ Name of License Holder : � \'n �_ 1 VC dnY\ License Number Address Expiration Date I ignature Telephone 9. Registered Home_ improvement Contractor: Not Applicable ❑ Company Name Registration Number Address 1 Expiration Date Telephones azI 3��a 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....... 114 No...,.. ❑ 11. - Home ° Owner Exempti ©n 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 farm structures. A person who constructs more than one home in a two -vear 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 shall 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 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 Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature 77ie Commonwealth of _ 1assachuseas Department of In dustrial _4 ccidents r" `.a Office of Inzesriga.'ions i� 600 Washingron Street Boston, _VL4 0 111 www.massgvv /dia Workers' Compensation Insurance.Affidavit. Builders /Contractors/EIectricians /Plumbers Applicant Information Please Print Legibly -Name ( 3LSiness' Or �aaizari on /Indivi�aIj : �y��..��C��ex u��.'� Address. 'Q�Q ��.t•�c -fir �� City/State-'Zip: `1 Phone y \3 - bN% Are you an employer? Chest the appropriate box: Type of project (required): 4. I am a general contractor and Z 1 _ ® I am a employer with _ 6. ❑ New construction I employees (full and/or part-time).* have hired the sub - contractors 1, atta 7. n R emode ,,,Q f r! T _- _ listed on the attached shte� � -- 4 �. ;_, � n:. � a sore proprietor or par�er- ship an — A have no _..., leyees These sub-contractors have r 8_ r emo ,�uuon I worm for me in any capacity. employees and have workers' 9. Building addition [No workers' co . msta .=e comp. inrirance.+ required ] 5. ❑ We are a corporation and its 10.❑ Ele :cal repairs or additions :. ❑ I am a homeowner doing all work oEcers have exercised, their 11.❑ Plumbing repairs or additions myself [N o work.°rs' coup. rift of exemption per MGL 12. Q Roof repairs insuran required.] t c. 1:2, § 1(4), and we have no employees- [No workers' 13.19 OtTlcr 3� coma. insurance require] -' "i4.Yf3 v� pox z'r. - IIIILSi arso out tIIe SGnoII Oeiow saowma 7JOt1.�. 5' Compen=on.pOUCy MfMM3A1i T Eomeow n s who sunrdz this amdavit mmcanns they are doing aU wmt and then bite outside contractors must submit a new affidavit indicating such. tContractors that check this box mum arachd an additional sheet saowwin-e the name of the sub- conn:actots and sire wnetber ornot those rarities nave =npiovees_ ff the sublonn actors -nave crapiove -s, they angst provide ties wmi. comp. policy nnaiec I am an employer that is providing workers' compensation insurance for my employees Below is the policy and joh site in Insurance Company Name- Policy # or Self - ins. Lic. �C,C.�$ C�`�`1�1a.C��4 Expiration Date: Job sire ,address: WZ5 City/SWn/zip _- ktrach a copy of the workers' comp Lion policy declaration pace (showing the policy number and expiration date)_ Failu to s= ire coverage as required under Section 25'rA of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1-500.00 and/or one -year =nsonrment, as well as crnl penalties in the form of - a STOP WORK ORDER and a 61 - of up to 5250.00 a day a-minst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DL4 for iressance coverage verIncanon. I do ' er 'y certify ur �� Oil enalties ofpe: -jury thar the information provided above is true and correct Phone vffccuu use only. Do not write m tits area, tb be completed by ezty or town of}iciaL ' Cit or ?own: - _-- .- .------- __ -. - -- - - -- -- - - -- — Permi#lLicense Iss Authority (circle one): 1. Board of Health 2. Building Department ?. CiMTown Clerk 4. ;Electrical Inspector 5. PIumbing Inspector 6. Other Contact Person: Phone