Loading...
17A-036 230N4JR'THMAPLE ST BP- 2010 -0078 GIs #: COMMONWEALTH OF MASSACHUSETTS M Wd31j k: I7A - 036 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category BUILDING PERMIT Permit # BP- 2010 -0078 Project # JS- 2010 - 000084 Est. Cost: $1196.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES Lot Size(sa. ft.): 15246.00 Owner: ZADWORNY JOHN P Zoning: URA(100) //RI/WSP Applicant: HOME DEPOT AT HOME SERVICES AT. 236 NORTH MAPLE ST Applicant Address: Phone: Insurance: 345 GREENWOOD ST (401) 935 -2633 O WORCESTERMA01607 ISSUED ON. 712212009 0:00:00 TO PERFORM THE FOLLOWING WORK--Windom 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 7/22/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo r Department use only City of Northampton Status of Permit: . Building Department Curti'Cut/priveway Permit' 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 Plot%Site Plans Other Specify 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 --A— Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record i N Name (PrintT Current Mailing Address: Telephone y Signature 2 Aut horized A ent: Name (P t) Current NTailing Address: - 1J.VJ_ A-A .0e_ Signature Telephone SEC ON 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed b ermit applicant 1. Building (a) Building Permit Fee 2 FlPrtrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 35 (J 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check Number`�� This Section For Official Use Onl Building Permit Number: Date Issued: Signature: �-"�— Q fz - L2 Building Commissioner /Inspector of Buildings te Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information 1 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 p arking) # of Parking Spaces A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT 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 0 DON'T KNOW 0 YES 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 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 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. t SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable New House ❑ Addition ❑ Replacement Wiryrtbws Alteration(s) Roofing Or Doors Ea Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding [0] Other [ol Brief Description of Proposed q ],,.— Work: p( 'Tr� / Alteration of existing bedroom Yes No Adding new bedroom Yes No � Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete the followin 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- 1. 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, Gee b��] ��� as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, 0 ,4 1& as Owner /Authorized Agent hereby dec ar at the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under t e ins and F ti s of perjury. Print All Signature of ner/ gent Date , SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction S u p ervisor : Not Applicable ❑ Name of License Holder 1 L L©o ^ License Number ,- z ,. Address Expiration Date Si ture Telephone 9. Registered Home Im Contra tor: Not Applicable ❑ t h 14h Company Name Registration N tuber Address Expiration Da ti Telephone 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 gprmit. Signed Affidavit Attached Yes....... EV 101, No...... ❑ 11.- Home Owner Exemption 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 Homeown 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 -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 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 Lativo Annotated, you may be liable fui peisuu(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 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his /her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he /she resides or intends 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 -year period shall not be considered a home owner." The building department for the City of Northampton wants person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation /footings (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location The Commonwealth of Massachusetts Department o f Industrial.4 ccidents -- Office of Investigations 600 Washington Street Boston, MA 02111 T s w1Nw. inass.gov /dia Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers Applicant Information Please Print LegibIN Name ( Business /Organization/Individual): Address: City /State / Zip: Phone #: F A re you an employer? Check: the appropriate box: Type of project (required): 1. ❑ I am a employer with _ 4. F I am a general contractor and I employees (full and/or part- time }. * have hired the sub - contractors 6. ❑New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling ship and have no employees These sub - contractors have 8. Demolition working for me in any capacity. employees acid have wuikers' [No workers' comp. insurance comp. insurance. $ 9. � Building addition required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3. 0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. o work' right of exemption per MGL y � workers' comp. 12.0 Roof repairs insurance 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 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 number. I am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy andjob 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 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 form of a STOP WORK ORDER and a tine of tip to ,$2.50 00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigatio of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: Of use only. Do not write in this area, to be completed by city or town official City or Town: Permit /License # 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 #: ' . . ^ �~� The ConmononwwroJth ° c&usrt1s Depurbrem1ofIndustria/Aocidmr1s �V ice nf/xvcx/' o/innx 600 IV. Boston, MA 82111 wmwx,nos.gon/ozu Workers' Compensation Insurance Affidavit: Btiildex Applicant Information Please Print Lej!ibly Name (Business/Organization/Individual): Address 6 to Are yo" an employer? Check the appropriate box: Type of project (required):, m a employer with I am a general contractor and I 1. Yl 4. f 6. FJ New construction employees (fitill and/or part-time).* have hired the sub-contractors 2T1 I am a sole proprietor or partner- listed on the attached sheet. 7. FJ Remodeling ship and have no employees These sub-contractors have working for me in any capacity. e . mployees and have workers' 8. F] Demolition [No workers' comp. insurance comp. insurance.t' 9. E] Building addition required.] 5. Ej We are a corporation and its 10.El Electrical repairs or additions 3. F I arn a homeowner doing all work officers have exercised their ILE] Plumbing repairs or additions myself [No workers' co mp. right of exemption per MGL 12.[:] Roof repaq's insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.[�-<er comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' cvm»oosa000vouurinfonm*ovu. / Homeowners who subrnit this affidavit indicating they are doing all work and the hire outside contractors must submit ^ new affiuxwit indicating such. lContractors 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. u the sub-contractors have employees, mo must provide their workers' comp- polity number. ^°''^"'^ employer that "p,,,^°^" workers' compensat /r^unonoo}ormyemployees. Below othxpo/ifyanu}o»site information Insurance Company Name: fro Policy # or Self-ins. Lic. #: Expiration Date:_ J S Add `^`y,a`^",Zyv: Attach a copy of the workers' compensation p.li—I 1 -1 - -tion page (showing the policy number and expiration date). Failure ro secure coverage ax required under Section 25Ao[MGLc. 152 can lead tothe imposition of criminal penalties ofu ' fine tip to $:1 and/or impri sonmen of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Idoherebycerti un r ep la4p nalties ofperjury that the information provided above is true and correct. Si ature: =A 41,, Official use onl Do not write in this area, to be compTeted - b y cit or town officiaL City or Town: Perrnit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: -- - - rn - 1 ° o C. In •� O C7 (` � d � r Z3 �� v m M M 4J m -J p- v� �" U > Otiou v ° a tt W _ . w o .n y J1. = = 1> ; � 0 0 CO m v O C O' a W .:. .` d� c Z W z W ♦♦ 2 '• � F-- `� W a Z p[ U 0 Q m (o g co gol►X UtVRoVXMENT CONVUCr I►�►sE D: Sold,, ftmthed.and Installed Sraec4 Name: flostott . Hate-. ZA j - 0' 4 1 T�3Y? At. .saviCes.I�: . `:d(it/s T1te limbeskylot At- 1•Ipme,Servic:eg ' 3452x•ii�vtiod S,ucet, 2, Worcesrrs .01607 Branch Number: 31 Tolt[ a ; (�p01,1►575[1;;ax.(508)75r8823 Fedeial'CD 97064$dit - " �'$X, 1M 664 39; ItT Copt L"'16427 [ is IP'5f,5 i<skggt d rt'Cost aaepr RAC t+ 11$$3 Installation Address: .,'.11• :1 : � = n CIS'. 5rate.. „ Zip PurChaser(s): Vk'4&?koot`- Aa se: Cell Pkose! Horne Address {If different fraui Lnscellntion Address). city SU�te ziP E tartkl Address {eo tei eiyapraject cotnmunicatipps.Ai�d :Home : Slepat updatea�. ❑ I DO NOT wish to receive "W marketing tmsile seam The Home taenctt, I t _o : Und ecaigaed ("Cuatomier'y, the Ownas of the Ise ikt� .above,insiallation'addcess. agrees co hvy, no an T er rv;ces Inc. {°eke )dome:Dkpet) agrees to delitis;a�ttngo.fps :jltp. jnyta#ou (`igsn "),of all materials described, on the below and on the refa=md Spec Sheet{s), ail of w+h}rh •are ate .iobp.,:Oft C4ntragt ltY this refersAoe. along with Any applicable State Sdppl is r and Paymerts'Sutnmary MWhed hereto Jny.0 o : Okdeis (c6lleCtivBly, 'Contract"); lob ii: tw.+.� aeaeKaat -. p V p i 4 �jl r� fu+$ Siding indnwa 'Insulation `/.l 6)9 �tY1L'�f I�OOr$ 0 F]Itoofng ClSiding Windows InauiWon []C3[nters) Covers OFntry 11 V — R40&g Siding []'11Pindowa {� Irixutation : . []Gutters ;Covers []Entry Groors C'} Rooting iaine' fl :'h"u>akL}+S Q`1�+laF}qu y , ,,,a, � .'' ... i � •• +::`.1;i' pQutteis /•cbvers''T7pt+z�.' : ; „ «�,, ;'''z ' ; v� ?.� raw ,,,F �';� ,�.; � ; �r: n4iaFzo4m25Yrtkmicofcoatrietwroawttdae ;IQpeiSeat4ino(Ud . ebot,.; Mslne Potch.sars Hwy sat depo* more than um4fifrd of the CdrmrsctAaaouut .. j Cuatornar Agroos that, immediately upon completion of the work f6r•each PrC44cl, Cuktamer will exec+,te a CotiipLrtipai eetti5ucaae (one for each product as defined by an individual Spec Sheet) acid pay arty belani�e due.' As ipp]ic�a'le;' eiah' Cush► r - Lin W'this Contract agrees to be jointly and severally obligated sud liable beseutidei.. : The lloine. Depot reserves the right to issue a Change Order qc. terminate this Contract or. any individual Prodl t(B) included h erein, at its discretion, if The Home Depot or its authorized smice provid& de terinlnet;'dW it :t:anpat•perfo=inuts obligatia dua to It strgarnMI problem with the horn:, environmenwl hazards atuh A$ mold, asbestos of lead poi 4d'ee+i'sati ty',conerrtis, pricing emors,or because work required to complete the job was not included in. the 'ConGuv41. r '' ... . Pa ymgt SQf0mAEy: The Payment Summan # . 3 . C. tJ 1A`44; ed' "' ' part o this. 0=ra t. sets, the focal Contract amount ind.psytnenu requaed' for the depgsits',aAd 5rynl payanows byR�oduct Ie1.. . J . NoTrerL'r�i Cflsz'o R You are entitled to s completely flkkd -in copy of the Caafteadtat the•time;.yatt!alip-. Dnaot sign it COMM" taste: there is out Complett:on ertillcate for Back tlsied'Prodret as d by: vidp l•'Spear S beforo'woek o,a.tht+t Product is complete. In the event of terminaGou of this Contratt, Customer agrees to Pay The. )FtaX,* Depgr the cams of unterUls, labor, expenses third services provided by The Rome Decor or Authorized Service Provider t ttA date of ter sdutlon, pins aanuyy other Amannis set forth in this Agreement or owed indict• applicable taw. IM HCrWL DE OT MAY WITHROIZ Al►1[OUNTS OWED TO TIIE HOME DEPOT FROM THE 00;15S19" PA,YMM OR OTIM PANS MADE, WITHOUT LIMITING THE ROME DEPOT'S OTHER R1ENSOJES FOR ABCOVERY CIR SUCH AMOUNT& has a and A t i don: Customer agrees and understands that thus Agreemtmt is the entire ag eement between Cuooaner And he Home epos with regard w the Products and Installation services and sup des all prior discussions and agrtt>zrents, either oral or written, reiatjrlg to said products and Installatim This Agretwout cannot assigned or amendod except by a writing signed by Customer acid The Home Depot. Customer acknowledges andagrees that Cuctonw has read, undetmAii, voluntarily accepts the terms of and has received a copy of this AgreemenL Ac y t.- Submitted [omer's 5ignar Date Sales clansuttant's modure Date x Telephone Nor. Customer's Signature Date Sales Consultant License No, C&N,C LLATION CUSTONMIt MAY CANCEL THIS (� applicable) AGREEIMINT WrMOUT PENAL"T"Y Out 0RUGATION BY DELIVERING WRITTEN NOTICE TO TITE HOME DEPOT BY MIDNIGHT ON THE 'Y`Hl>ttD BUSXNIESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACTIED RE"TO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PItESCR.iBED BY LAW IN CUSTOMER'S STATE. , NOTICE: ADDITIONAL TERMS AND CONDITIONS AU STATrw ON THL REvua aft Af{D Aim PA$YOlr no COrtr$ACT "o-ft C-sc Wtvte—ArenehFae Yellow- Custom" Pink — SakgsC mute*