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17C-107 DUVAL CONSTRUCTION 53- 7202/2118 15 2 THEODORE A. DUVAL D/B/A 49 WORTHEN STREET DATE i U a 7--1 [� WEST SPRINGFIELD, MA 01089 c� DATE I PAY TO �.(y}l} `(l&\ k,) Q.et\ M �j,JJ c ' IAI } i . l ) $ - z THE ORDER OF / ^ O United Bank nr MEMO e 7 U t�/i�C1Y1 -- - - - -� - - -- - -- 1 : 2LL 20271: '?--7-9-8-4 0L52 ratuE DUVAL CONSTRUCTION 53- 7202/2118 151 THEODORE A. DUVAL D/B/A 49 WORTHEN STREET WEST SPRINGFIELD, MA 01089 DATE 0 - 7 - i b PAY TO CS mmo) ,� cal d > Q 53aCt,tA N^S I $ 100 .D s / T EORDEROF r! ` '/�dt� hu noil ,�cd eLI lafl S --- `"` - J, , ARS �. United Bank MEMO �'--)+fA Owci- .. .i&nY)l Fee I 2LL872027�� 7 7984 5 59 7v OLSL n SLUE - • THE COMMONWEALTH OF MASSACHUSETTS OFFICE OF CONSUMER AFFAIRS AND For OCABR Use Only. BUSINESS REGULATION Registration No: y , y � 10 Park Plaza, Suite 5170 C . Boston , MA 02116 Effective Date: t ' " Application for Registration as a Home Improvement 111 Contractor or Sub - Contractor Expiration Date: (MGL c. 142A; 780 CMR 110R6) 1. NAME OF APPLICANT: Wel ()U. 1 1 (MUST BEEITHERAN INDIVIDUAL, CORPORATION ,LLC,LLP, TRUST, OROTEERLEGAL ENTITY) 2. NUMBER OF EMPLOYEES:. 0 3. APPLICANT TYPE: /INDIVIDUAL _ CORPORATION PARTNERSHIP _ TRUST (CHECK ONE — MUST BE SAME LEGAL ENTITY AS THE ENTITY IDENTIFIED IN #1) 4 . SOCIALSECURITYNO.: () vi -' bc.Z - l ( FEDERAL TAX ID NO.: O U lac) b H 5. APPLICANT PHONE #:0 1,-c)Th _ t 1(L APPLICANT EMAIL ADDRESS: \ tb 1S'{ C.1'(A1 ALL Lc 6. MAILING ADDRESS: 1 2 7ri h�1f1 V C e ."! � C� Y1L'� (ri N i) (3 (4 STREET CITY STATE ZIP 7. PERMANENT ADDRESS: 12j y 1 11 [ IV �or�.rzr�G (t J Of t)C'3 STREET CITY STATE ZIP PLEASE NOTE THAT A P.O. BOX IS NOT ACCEPTABLE FOR PERMANENT ADDRESS. YOU MUST LIST A STREET ADDRESS 8. IF i'HP: APPPLCCANT IS A CORPORATION OR A PARTNERSHIP, PLEASE PROVIDE THE NAME, ADDRESS, SOCIAL SECURITY # AND TITLE OF THE INDIVIDUAL WHO WILL BE RESPONSIBLE FOR'1'HE CORPORATION'S THE TRUST'S OR THE PARTNERSHIP'S WORK (Please review the Instructions before answering this question): LAST FIRST SOCIAL SECURITY # TITLE 9. IF APPLICANT IS DOING BUSINESS UNDER A D/B/A, PLEASE STATE THAT D/B/A, AND ATTACH A COPY OF THE FICTICIOUS NAME CERTIFICATE FILED WITH THE CITY OR TOWN CLERK: DBANAME: bca V0 ` ( v n \ C \ ) : ) a n 10. LIST ALL PARTNERS, TRUSTEES, OFFICERS, DIRECTORS, AND MAJOR OWNERS (10% OR GREATER OF OWNERSHIP) OF AN APPLICANT PARTNERSHIP OR CORPORATION, BELOW. USE ADDITIONAL PAPER IF NECESSARY AND INCLUDE NEEDED PAPERWORK (SEE INSTRUCTIONS). PLEASE INDICATE BY AN "X" IN THE LAST COLUMN THOSE INDIVIDUALS WHO REQUIRE AN APPLICATION FOR ADDITIONAL REGISTRATION I.D. CARDS. USE ADDITIONAL SHEETS IF NECESSARY. FULL NAME TITLE % OWNER ADDRESS SUPP. CARD __ ap E1 X - f - . 03/16/98 10:58:40 AM 1 � C. � � � . RESIDENTIAL PROPERTY RECORD CARD CITY OF NORTHAMPTON, MASSACHUSETTS EFFECTIVE DATE OF VALUE: DECEMBER 31, 1993 7 PARCEL ID: 17C- 107 -001 81 HIGH ST Living Units: 1 Class: 101 Card #: 1 of: 1 CURRENT OWNER /ADDRESS LAND DATA: Zoning: URB Neighborhood ID: 5.00 TYPE SIZE INFLUENCE FACTOR(s) LAND VALUE LAK JUDITH . PRIML SITE 10,500 SF '4,240 SF ASSESSMENT INFORMATION: 81 HIGH ST SF FLORENCE MA 01062 AC PRIOR CURRENT AC AC LAND 34,000 44,200 • AC BUILDING 97,500 111,000 AC TOTAL 131,500 155,200 AC WRA ESTIMATE 150,813 Deed Book: 3888 TC'AL ACREAGE: 0.241 TOTAL LAND VALUE: 44,200 COST ESTIMATE 129,800 • Deed Page: 113 MARKET ESTIMATE 1.55,200 Deed Date: ASSESSMENT BASED ON: MKT APPRCH ADDITION DATA Partial Completion /New Construction: Y Lower Level First Floor Second Floor Third Floor Area Value SALES DATA: Date Type Price Validity Opn Frm Prch 240 5,500 9202 LAND & BLDG 50,000 A Enc Frm Prch 119 4,300 Bsmnt Unfsh Frame Bay 28 1,400 DWELLING DATA: Style: CVNTL Story Height: 1.5 Attic: NONE DWELLING COMPUTATIONS: 18 Basement: FULL 7 Total Bedrooms: 3 Base Price: 88,010 Total Fixtures: 7 Plumbing Adjustment: 1,560 Full Baths: 2 Heat /Cent A/C Adj.: 0 Half Baths: 0 Basement Adjustment: 0 Year Built: 1900 Exterior Trim: 0 18 18 Basement Garage (# Cars) 0 Finished Bsmt Living Area: 0 17 EFP Exterior Walls: FRAME Bsmt Recreation Area: 0 Unfinished Area: 0 Unfinished Area: 0 Ground Floor Area: 996 Basement Garage 0 Total Living Area: 1771 Fireplaces: 0 Finished Basement Living Area: 0 Additions: 11,200 Basement Recreation Area: 0 SUBTOTAL 100,770 — Masonry Fireplace Stacks /Openings: 0 / 0 Grade Factor (X) 1.10 8 1 Metal Fireplace Stacks: 0 C & D Factor (X) 1.00 F=B/B Heat /Central A /C: BASIC Replacement Cost New: 110,850 7 Heating System: HOT WATER Percent Good: 75 Fuel Type: GAS Market Adjustment: 0 ' 4 14 Quality Grade: C+ RCNLD Residence: 83,100 Cond /Desirability /Utility: GD OUTBUILDING DATA: PERMIT DATA Type Qty Yr Sizel Size2 Grd Cond Value Date # Purpose Price 6 28 Garage 1 30 1 336 C F 2,480 14 NOTES:' 20 Total OBY Value: 2,500 1 Hr 20 6 Pk ft Et ,.. .,- 0 - 1 -'. 4 1 _ _________. —....._....... . co12.2 aka fiN Lk TO Ei-)1 173 V iet„ 4 1. . . ' 0 - N2 I. a • (on 02,(2, pret i , ) . 1 tiou3e „a-v-IC ,-; 1, t..e...tri v t'tib.: 7 1 e li 2 0016 �,� 3,..ctii-4, Lak_ /Tcd.Duval f ., KEY � fZ�vEw�Y ��,`� 4.3 f i • Derck N < > i 31 y 7 ' 18 g E FP U 1. 8 18 v 119 7 - 8 1 c i9) 3 4 14 ( J (1.1 T -...`-I 1 F Q 6 ° f1 6 28 1 rl 1 14 14 20 0 FP 21 (2 6 f R,OXT w 1 1 HIGH STREET A... . • 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 pic_essxe_quires 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 -------------- pcit-s -in- conjunction.. to the- building.permitissued,_ 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 of Industrial Accidents =:=fit=0 Office of Investigations ®1= a � � 600 Washington Street Boston, MA 02111 �� . www.mass gov /dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individuar): 11‘. QC) CPI 00. DU\ /oz'' Address: \ go IAVQ- 4. J City /State/Zip: 0 C no,nCE fl1 W n Phone. #: (I '' D1-) 1 k- i11 Are you an employer? Check the appropriate box: Type of project (required): / 1. D I am a employer with 4. I am a general contractor and I 6 [New construction . employees (full and/or part- time).* have hired the sub- contractors 2. [� I am a sole proprietor or partner- listed on the attached sheet 7. ❑ Remodeling ✓ ship and have. no P- nployees These sub - contractors have g. 0 Demolition working for me in capacity. employees and have workers' 9. 0 Budd { E5 { addition [No workers' comp. insurance comp' 10.0 Electrical repairs I required.] 5. 0 We are a corporation and its ❑ � p irs or additions 3.0 I -am a Homeowner- doing- all -work-- - - - - -- __s ers_tave e_zcis d it —1-1-.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 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 the policy and job 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 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 fine of up to $250.00 a day against the violator: 13e advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains art , rii1 ofperjury that the infornsation provided _above_istrue_and.correct -_ _ Signature: ` f �D Date. • • _ . ---/u _ 0i Phone #: 1 a 1 1 IIC, . Official rue only. Do nit write in this diet; to be completed by city or town ofeiaL City or Town: Permit/License # 1 Issuing Authority (circle one): - Iz Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical .Ins .ector 5. Plumbing Ins .ector _ _ _ 6. Other - . Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable Name of License Holder : e � � 1 � \/Z ql I License Number l 3 Sfh h n A /K "c) orkQY) M roll 0)0&,), 3_a©_ /a Address ) Expiration Date l ► Vc ,. cl s -- a7) quo Signature Telephone 9..Rectistered.HomelmproveMent Contractor , x Not Applicable ❑ /pi'/ j c°.q+,cin t o�C hG CompNnv Name Registration Number Address Expiration Date 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 permit. Signed Affidavit Attached Yes ❑ No ❑ The_currentexemption for "homeowner?' 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 1083.5.1. 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 -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 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 loft amp 4r I iriances; a e . • • - • ; . - , ,. ,1 • - • > : .r- al- Laws- Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks trgt Siding [0] Other [0] Brief Description of Proposed de/siat Work: 5 Vv ti at( rc O C 11aa c `r /,s Iat Fr) t'"L� I abo r1c s�. Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet ea. New house and yr addition o' "existing hOUStnn,:26oirriplete the following: t a. Use of building : One Family ✓ Two Family Other b. Number of rooms in each family unit: a Number of Bathrooms .� c. Is there a garage attached? KZ 121 i d. Proposed Square footage of new construction. A rny , ', gc� } Dimensions ? cI r c k e. Number of stories? _ o� ` f. Method of heating? �{ c3 / kp{- Loa r Fireplaces or Woodstoves 1'W 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 V'No j. Depth of basement or cellar floor below finished grade k. Will building conform to the tl'uidand Zoning regulations? V Yes No . I. Septic Tank . City Sewer p ty Private well City water Supply ‘/ SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT U1511 - 14 LAW., , as Owner of the subject property ^� hereby authorize `T O' D _ t > Ll\/i .L to act on my behalf, in all matters relative to work authorized by this building permit application. tp — � ©1O Sign of Owner Date I, -- f - f\ Q00 lYitC4 'iAVQ. , 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. ■ LC o bYLQ A. J. )UuVC1 Print Name •TR)D-64,0-q 16 --44---/0 Signature of Owner /Agent Date , ' , ' R ,' Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Eiisting Proposed Required by Zoning This column to be filled in by Building Department X Lot Size 0.2 a►ert,5 mm Frontage �,_.,.� 4) M_ Setbacks Front /:., 1 Side L -.3 .__ L. _. R. _ _ _w .� Rea Building Height _ v Bldg. Square Footage % „, tn Open Space Footage m ,,._ % (Lot area minus bldg & paved parking) # of Parking Spaces _- -- -.._ - -< Fill: i l I (volume & Location) ..._:.�__. -- ....._ _. ` A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO A DONT KNOW 0 YES 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 i I Pagel and /or Document # "_••_.. B. Does the site contain a brook, body of water or wetlands? NO X44 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES (3 NO to IF YES, describe size, type and location: D: ` - ,Are iere an rObiTs chah es to or a iWihs o s� ns inten" ec bi'ffies ro ert ? YES 0 NO YP P g g P P Y 0, IF YES, describe size, type and location: tr _ 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 's IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • y • IF ' , t 4 tr , ` �� t' City of Northampton Status o1 1 iltit 1 Building\Department C!rs pC 12 Main Street er(S j ai Gym `'.. ecsm 100 e iiM1 it , F j , Wil - Northampton, MA 01060 Sets` tiff` phone 413- 587 -1240 Fax 413 - 587 -1272 Pf© a 6]x31 s 11 5 4 z 74ri 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 $' '1"+1 A 1_ C Map Lot Unit O r vx J I ` , Zone Overlay District ,v, Elm St District CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Curr nt Mailing Address: Telephone t 3 — 5$ Signat 2.2 orized Agent: Tr —_p D u"AI— 13 ` i�.sa M Acv E Name (Print) Current Mailing Address: 1.413. Q.1t -9 1t(-, Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only comRleted by permit applicant 1. Building o" (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 6. Total = (1 + 2 + 3 + 4 + 5) Check Number J�.J This Section For Official Use Only Date Building Permit Number. Issued: Signature: Building Commissioner /Inspector of Buildings Date 1 File # BP- 2011 -0382 APPLICANT /CONTACT PERSON THEODORE A DUVAL ADDRESS/PHONE 13 STILSON AVE #2 FLORENCE (413) 217 -4116 PROPERTY LOCATION 81 HIGH ST MAP 17C PARCEL 107 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out/ 1 0 — I S ? Fee Paid v 5d - 2c) Typeof Construction: CONSTRUCT DECK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 96086 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF9RMATION PRESENTED: Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay l� z,P Signs a of Buildin Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission, Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information. 6 BP- 2011 -0382 COMMONWEALTH OF MASSACHUSETTS ;r CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP- 2011 -0382 Project # JS- 2011- 000640 Est. Cost: $2500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THEODORE A DUVAL 96086 Lot Size(sq. ft.): 10497.96 Owner: LAK JUDITH Zoning: URB(100)/ Applicant: THEODORE A DUVAL AT: 81 HIGH ST Applicant Address: Phone: Insurance: 13 STILSON AVE #2 (413) 217 -4116 FLORENCEMA01062 ISSUED ON:10/28/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: CONSTRUCT DECK 79 SQ FT 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 10/28/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner