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17D-017 (2) 4 � r � ff t\ �t ■ I. 4 sflA4Pi. s j QI'xt x f NI�Z#Ilampthn 1 = *=t eaglek t V�4/ y:. /, d assac nsctfs maw ._-_-311:___. 'm_'� DEPARTMENT OP BUILDING I.NSPECTIONS 212 Main Street • Municipal Building ' Northampton, Mass. 01060 �,~ •'�� WORKER'S COMPENSATION INSURANCE AleE.WAVIT L A/c L -5 0 Al' .iii / ! -i %4 cS. ,7 T V/Z-/..i i /7" 77Z. L. .Gi-' ‘ /= 2cs; -'? /--, ._,5 ''`f L (licensee/permittee) with a principal place of business/residence at: 3 `'to lei /2. -4 5 i .b / }r2 /i//z / x/Oe_/`f�'r.7.,, ,-- 0/u; xv (p hone #) 9 SZ2 (street /city!s ^to zip) : Ci do hereby certify, under the pains and penalties of perjury, that: (X) 1 am an employer providing the following worker's compensation coverage for my employees working on this job: (Insurance Company) (Policy Number) (Expiration Date) ( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following worker's compensation policies: (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company /Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Pohicy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional sheet if necessary to include information pertaining to all .ors) ( ) I am a sole proprietor and have no one working for me. ( ) 1 am a home owner performing all the work myself. NOTE: please be aware that vihilo homeowners who employ persona to do n a%n* a - construction or repair work on a dwelling of not more than the units in which the homeowner resides or on the grounds appurtenant thereto are not wally oonsidered to be employ under the worker's compensation Act (GL152,,1(5)), application by a homeowner for € lice or permit may evidence the legal atPhss of an employer under the Works Compensation A. I ur d innd tia a copy of this stat.,r--, may ba forwarded to the Deportment of Iue1utrial Accidents' Q.foe of Insurance for th® coverage verification and that failure to secure coverage wades section 25A of MQL 152 can lead to the imposition of c iminai penalties consisting of a fin, of up to $1,500.0.0 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a fine of $1OO.O0 a day agaixt me.. Signed this J clay of / `' • 'J : ,r 6 "/ 0 For dal use only 4 t Number / , l: / �,� / ,� Lot # Signature of I;� / teense . /Permittee l - • • \1 audt 14.0.7,t1mett1 4 hihitt' Z l i-4 1 `I'S Boma.' ol Building Reguktiiitis toil ' its S O1 Licorw. Lit onse- CS 60300 P.,:stritted to. 1G NELSON A SNIFFLETT 340 RIVERSIDE DR P8X60627 FLORENCE, MA 01062 Aniatioii 922 4 ,001k1i,,,,a, T rtt 3435 iikord or Building Reigniatio'cis and Standar:its License or registration '1 alid tor indix idol use on k HOME IMPROVEMENT CONTRACTOR beim expiration d e 11 found return to Registration: 105543 13ottrd or Building Regulations arld StItadardS One Place Rut Expiration: 7;17)2010 Tr# 270246 Ashburton 1301 Boston, 711a. 02108 Type Pf VALLEY Hat.:E IVPROVEMENT iNC Neson Shittlett 1.i. / • .34-0 Ra„-ert jl Northam4,ton xittniniNerititir Not v 4dTOout signature SECTION 8 - CONSTRUCTION SERVICES j .1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : Nelson Shifflett._._ - - _— _ -_ 06 Valley Home Improvement, Inc. Louise Number 340 Riverside Dri_v_e. Northampton, n .0106 9/22//0 Address I ( rat on Date 584 -7522 ` gnature Telephone 1 v i ,r' ,9„,Registered H. e Improvement Contractor: Not Appkcab e ❑ Valley Home Improvement, Inc- . -____ 105543 Company Name Rcgistr ,lion Number 340 Riverside Drive 7/17/10 Address I Lxo ration Date Northampton, MA 01060 Feoptrone -7522 SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 1._ Workers Compensation Insurance affidavit must be completed and submitted with tf s application. Failure to provide his af`:idavit 1 will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes 1K No n 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner-occupied Dwellings of one (1) or rwoi2) 1amdic 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 t: °ltich 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 \ person V4'110 copstructs more than one 1€oini in a tn 0 - w+ t tit:: irsfi ita , col. ire consiaelVt: a i ?_e Such "homeowner" shall submit to the Building Official, on a form acceptable to the 'Building. Official, that tip she shall he responsible for all such work performed under the building permit.. As acting Construction Supervisor tour presence on the job site will be required from time to tinge, 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 t mpiuyers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated. you ltaav be liable for person(s) you i tin to 'perform work for you LOOJOi this 1'icnoit. The enders €2neil "homeowner" certifies and assumes responsibility for compliance with the Slate Bodddino Code, City of Northampton (Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature tscpPrE N,o` PRO='C) Cdr n1( E. .. w n •� ..LS.Ftttcz�t t t 5 :�4;LCEdzic:tt4 "� t - iIz;w7., A Rerc,tt 'xteR . New Si r y Y r Lithe! i 4 GA it NOW ho use and or 3dditiotn to C cisting hai srnc comp ete_the ng. it4id/ itArk)°(( wCRT1011(i Oitt�� AUbI 4P,IZ i7C1f 'TO CC CO E16.1ED V;i1W S ` i:r OVVNE r lf r i`. C(m T Atx°�...`Tcrp 0 trs FOP BUR 'ING pt'r^,t41 _ v , 'to. Nelson Shi±t1ett, Valley Home Inprovement, Inc. Ne1son_USLi t1ett,,. ,Honee_ Iraprov_ernentt,...Inc; Nelson Sti4±1ett V , Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage _ Setbacks Front d G �, Side 1 R: Y L: I;AL/_M Rear ! 4 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 ✓ DON'T KNOW YES IF YES, date issued: W YES: Was the pmit recorded at the Registry of Deeds? Z er NO DON'T KNOW YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO, DON'T KNOW 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 t r d ins of signs intended for the property ?YES No d / ins YES, describe size, type and location: R •` . , . . Department use only City of Northampton i Status of Permit: r 4 ,, B u i l'E,i n g Department Curb Cut/Driveway Permit . 21'2 Main Street Sewer/Septic Availability o 100 om Vtlater/Well Availability NO hampton, MA 01060 Two Sets of Structural Plans L , phone 413-587.1240 Fax 413-587-1272 Plot/Site Plans__ , - Other ' APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1 1.1 Property_Address: This section to be completecii)y office li49-2.-4fit0t4i—A_VC Map _ Lot Unit ( — _ 1 _ I 11/1..t Ctfrnle_ii A 4 Dt- Zone Overlay District _ Eirn St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT _ 1 2.1., ner of Record: ---. . ikl) roi 4- a /94,9' 41goi...5 __,S_Aw if Nilain^ rin •••• Current M 'ling AC.:4-sA 5 I Telephone Signature 2.2 Authorized Agent: Nelson Shifflett Valley Home Improvement, Inc__ P.O. Box 60627, Florence,_ MA. 01062 rtanic (Print) Currer.: Malling iliddress: 4,„ vild / d 584 :Signature i Teiephole SECTION 3 - ESTIMATED CONSTRUCTION COST L ,„,, Item ' Estimated Cost (Dollars) to be Oriiiy completed by pe r m it aholicam Oticiai Use . _ . _ . Buiiding (a) Buildwg Permit Fee 5(2 0 . --I 2. F'eci.tical (b) Estimated Total Cost of ■S Construction from (6) 1 _i ,...._ 3, 9..Erbing Building Permit Fee .. _____.... 4. Mechanical (I i 13, I:iii Pri,tectin,i 1 6. Troia. iii=i: (1 + 2 + 3 + 4 4- 1)) 1 , se; 0 (..i Cheek riumbtir - 7 - T- 23irli it ,....,_ _ 1 This Section For Official Use Only Buileirg Permit Number: i _ Date issued: ' Signaturc: Buildirg CorornissionerlInspoctor of Buildings. DatF, _ . , File # BP- 2011 -0221 APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P 0 Box 60627 FLORENCE (413) 584 -7522 PROPERTY LOCATION 1 VE 61/0/(Ar bre' MAP 17D PARCEL 017 001 ZONE URB(100) //WP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid / �7 36Q/ 1/4.4t3,0 Typeof Construction: REMODEL KITCHEN & BATH New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 060300 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Signature of Building fficial 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. • 4 STRAW AVE , , 4 BP-2011-0221 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D - 017 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 -0221 Project # JS- 2011- 000382 Est. Cost: $50000.00 Fee: $300.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 060300 Lot Size(sq. ft.): 19994.04 Owner: SIROLS DANIEL & JANA Zoning: URB(100) //WP Applicant: VALLEY HOME IMPROVEMENT INC AT: 62 STRAW AVE Applicant Address: Phone: Insurance: P O Box 60627 (413) 584 -7522 Workers Compensation FLORENCEMA01062 ISSUED ON:9/14/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN & BATH 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 9/14/2010 0:00:00 $300.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner 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 iermits 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, o c J T "lt t PA n m (S (L.6'L 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 Date 4 • 1 Address of work location j2 STMT^' ,pnr F The Commonwealth of Massachusetts Department of Industrial Accidents �l Office oflnvestigations • W =o - 1 - 600 Washington Street f Boston, MA 02111 � �. . 1 www.mass gov /dia . -Workers' Compensation Insurance Affidavit Builders/ Contractors /Electricians/PIumbers Applicant Information . Please Print LegibIy 7 1--Name ( Business /Organiiati I ndiv i dual):. k 01 } l'A (3 (Z - U - 2 -- Address: (25 5 ?rkk "' fr..' z = (..i r..:. : City /State/Zip: - Phone. #: Are you an employer? Check the appropriate box: • Type of project (required): // 1.0 I am a employer with 4. 0 I am a general contractor and I 6. 0 New construction employees (full and/or part-time).* have hired the sub- contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet 7. D Remodeling These sub - contractors have. ii - ship and have no e '..^ iloyees 8. eao on • working for me in any capacity. employees and have workers' ; 9 Building don [No workers' comb. insurance _ :comp. r,Frran # -:.. . equired.j 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3. OF, I am a homeowner doing all work officers have xercised their . 11.0 P1a king repairs or additions n yself [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-1 • - *Any applicant that checks box # must also fill out the section below showing their workers' .compensation policy information_ t Homeowners who submit this affcdavit:indicating they are doing all wort and then hire outside contractors must submit a new affidavit indicating owl, 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 required' tinder. Section`25A' 'of MGL c. 152 can lead to the imposition of cnmina1 penalties of a fine up to 51,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK -ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Itivestisaiions of the DIA for ms a coverage verifcatton _ ... , . f .. P fdo hereby certify u 4 ep and penalties of penury that the Information rovided.above_rslrue aadcoriect_ / bate: 0 6 1 '12 1 ` Phone it: ! Official use only Do not write o c -, ' �i this to be completed by city or town o�c %o► 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 #: • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone H Rdgltrd,klio�te Irtliro�reiiitpnGotcot" SEISLaigli. Not Applicable ❑ Company 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 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 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 Lo ¢nin Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing El f Or Doors O Accessory Bldg. ❑ Demolition New Signs [C3] Decks [CJ Siding [0] Other [CO Brief Description of Proposed Work: (2]r ( 112 i- SF{E1 Alteration of existing bedroom Yes `� No Adding new bedroom Yes ' No Attached Narrative Renovating unfinished basement Yes V No Plans Attached Roll - Sheet 6a If + :h e d or'adchtionto a istii ar �usTna:R.comDl the llowi a: a. Use of building : One Family V 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 . 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 , 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 ,FD t %f M 26 , as Owner /Authorized Agent hereby declare that th 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. r (�i�tC N1, tkiv1tSIL Print Name Signature of Owner /Age' 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 1 ---7"-----' N " „, _„„: Y Frontage 1 I' Setbacks Front 3 1 r J Side L R: L: ? R Rear , _-- Building Height i 4 r i Bldg. Square Footage F" 1'1 % = I Open Space Footage % (Lot area minus bldg &paved # _ 1 I , — . parking) 1 # of Parking Spaces L } -- Fill: 1 1 (volume & Location) i 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:t t IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book 1 i Pagel € and /or Document # 'Y !" B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q ,Date Issued C. Do any signs exist on the property? YES 0 NO a IF YES, describe size, type and location: t D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 12( IF YES, describe size, type and location: / _ E. Will the construction activity disturb (clearing, grading, ex ation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton viit*.f.' Building Department _ := 21ZMain Street = gym i 4 kq Room 100 APIA 2 /N9rtiAampton, MA 01060 phone 417 -1240 Fax 413- 587 -1272 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 (2 6 S / Map . Lot _ Unit F1- of Nt-". (NAP.. O t C -� done Overlay District Erin St District ' CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: E tT M. M46f - t z S s Ir v ok I e F Name (Print) Current Mailing Address: r _ , Telephone Signature 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building C (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) CS Check Number ! _ Vs>6 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date - F . File # BP- 2010 -0940 APPLICANT /CONTACT PERSON AMBROZ EDYTHE M & BARBARA W GRAVES ADDRESS/PHONE 125 STRAW AVE FLORENCE PROPERTY LOCATION 125 STRAW AVE MAP 17D PARCEL 017 001 ZONE URB(100) //WP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out P i _ Fee Paid /✓/ Typeof Construction: REMOVE 12 X 12 SHED New Construction Non Structural interior renovations Addition to Existing, Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 /,410 Signature of Building 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. . . ‘42,5 STRAW AVE BP- 2010 -0940 GIS #: COMMONWEALTH OF MASSACHUSETTS -1014,14100k: 17D- 017 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- 2010 -0940 Project # JS- 2010 - 001399 Est. Cost: $0.00 Fee: $20.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 19994.04 Owner: AMBROZ EDYTHE M & BARBARA W GRAVES Zoning: URB(100) //WP Applicant: AMBROZ EDYTHE M & BARBARA W GRAVES AT: 125 STRAW AVE Applicant Address: Phone: Insurance: 125 STRAW AVE (413) 586 -1086 0 FLORENCEMA01062 ISSUED ON:5/3/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: REMOVE 12 X 12 SHED 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 5/3/2010 0:00:00 $20.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo R.C oofi ng Lt. 6 Line St. Southampton, Ma. 01073 Estimate Date Phone (413) 527-4775 Fax (413) 527 -8469 4/26/2010 Name / Address Job Location Edy Ambroz 125 Straw Ave. 125 Straw Ave. Florence, Ma. 01062 Florence, Ma. 01062 (413) 586-1806 Terms Rep Estimate valid for 30 days Dave Job Description Total Remove existing roofs. 4,800.00 k Furnish & install aluminum drip edge, pipe flashings, chimney fleshings and step flashings. 4�<' * Furnish & install new lead counter fleshings. c _ J P. Furnish & install CertainTeed Winterguard ice & water barrier along eaves and ZG ' f valleys. /.J/ Furnish & install synthetic underlayment over existing deck. p 1�i /;� Furnish & install 30 year CertainTeed Woodscape Series shingle. Td �J (A Furnish & install CertainTeed approved ridge vent. - Furnish & install 1/2" fiberboard insulation on flat roof section. �E Furnish & install .045 re- inforced rubber roof system, mechanically attached on flat roof section. A0 exterior roofing related debris to be removed by R.C.I. Roofing. - All work to be performed according to manufacturers' specifications. 5 -year RCI Roofing workmanship warranty included. /# 30 year CertainTeed material warranty included. /l` All related permits will be obtained by R.C.I. Roofing. Add $2.50 per square foot for wood decking replacement if needed. J f? 0 p.[Za cis (Jo - F WE LOOK FORWARD TO DOING BUSINESS WITH YOU. Total $4 4S Yo 0 0 TERMS OF PAYMENT 5% Deposit Balance upon completion Customer Signature / Registration # 126235 Construction License # 074334 Insured by Reynolds, 13arnes & Hebb, Inc. 413- 447 -7376 Date Q(� 4 • I 111) 16 - N1.1■S,ICIIII•CII• - Di:1).1111MM( ul i t It4■Arti ul BillId111:1 RC•2.11i,111 and ' d.irik ‘,.. C r)(1. tructK.sr ''' License. GS 74334 Restricted to: 00 MARK T DEL)SLE ,. 33 FIRST AVE EASTHAMPTON, MA 01027 E xpirat ion. 5/3/2012 r iiter T.r.. 26357 , ("/ om monawari4 1 i 74,, • ',,,, I. i 1 eiJet6 Office of Consumer Affairs & Business liegulation 1 HOME IMPROVEMENT CONTRACTOR Registration: 126235 Expiration: 5/6/2012 Tr# 293949 Type: Partnership R.C.I. ROOFING MARK DELISLE 6 LINE ST SOUTHAMPTON, MA 01073 Undersecretary \ The Commonwealth of Massachusetts Department of Industrial Accidents . ' `"_—' Office of Investigations .. I 600 Washington Street ` " % Boston, MA 02111 � -i' �,1 r =' � www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers Applicant Information QQ Please Print Legibly Warne ( Eau, iness /Organization /individual): R 0_, C l OQ,c 1 ,Cl \,? Address: .4) L `(\ e.. -.- . city/State/zip: �,� �, -t� Phone #: y�3 �`t j Are you an employer? Check the appropriate box: Type of project (required): I . ,,,,4/, am a employer with 2.o 4 • ❑ 1 am a general contractor and 1 employees (full and /or part - time).* have hired the sub contractors 6 . ❑ New construction ,. ( I am a sole proprietor or partner listed on the attached sheet. 7. Iii Remodeling y ship and have no employees These sub - contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' INo v rkers' comp. insurance comp. insurance.: 9. ❑ Building addition required. ❑ 5 We are a corporation and its 10.0 Electrical repairs or additions 3. 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' com p right of exemption per MGL 12. oof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] 'Any applicant chat checks box #1 must also till out the section below showing their workers' compensation policy information. { lomcowncrs N1 ho submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. •Contractor 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. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Co,npany Name: aCx,.e.. wb, _ \'y L Qr.,-S.+.a.A h S . Policy # or Sell-ins. Lic. ; : AJkAjC_ LLk 5$ 01 35 ( Expiration Date: / 0 - 5' - 2,0 1 0 Job Site Address: i S .5 \ .At.. City /State /Zip: ctorcan.kic. .. 014 2., .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 tine up to $1.00.00 and/or one -year imprisonment, as welt as civil penalties in the form ofa STOP WORK ORDER and a fine of up to $250.0( 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. 1 do hereby certify under the ins and penalties of perjury that the information provided above is true and correct. Signature: ___ _ Date: 5-1 1` t 0 Phone #: ( {j _ Official 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 #: t y • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ • Name of License Holder: Mayh 'Del i s 1 e . '7 ?XI 33'+ License Number `' • . O s ... V. • 5- 03 -i10 Address - Expiration Date (13) 52(1- Signature / / Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ ft e.i. 1ofnq 126235 Company Name Registration Number ( � 4.::t Sir, 5 - D6 -!0 Haareaa -� Expiration Date kl ampTOn Ma. Ol673 Telephoncel1 ?75 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 4 2' .. No ❑ 11. — Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied Dwellints of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who docs 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. :)r 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 he advised that with reference to Chaptcr 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 attael . tit • • V • A SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable) New House E Addition Replacement Windows Alteration(s) ❑ Roofing El Or Doors Cl . . Accessory Bldg. U Demolition ❑ . New Signs [0] Decks . [q . Siding ID) Other(pJ' " • Brief Description of Proposed } Work: _ a � tanhe1{ � 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 following: a. Use of budding : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? '-' ' • • '1. 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 . 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 WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, C Q� as Owner of the subject property Max); r R.I. ereby authorize t_ !' l l )e t RIP QT I l• g,. ROOT1 n to act on my behalf, in all matters r ative to work authorized by this ui ding permit application. 9 Att. gohed I r -1 Sig'nati1ti of Owner Date I , J4y � D P.I t S1 f°. 'AS aU tlnY IleA ao t , as Owner /Authorized Agent hereby declare that the statements and information on the foregoing lication are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. M a ali I Print Name - Signature of Owner /Agent Date ■ s 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 L■)t Size Frontage I I Setbacks Front i , Side L:' R:' L:I R: i I f Rear . L __ _. BJilding Height _, B'dg. Square Footage % f ' Open Space Footage % (L)tarca minus bldg & paved 1 parking) # :if Parking Spaces _ Fill: (vnlume & Location) ! t i 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; I and /or Document # 1 B. Does the site contain a brook, body of water or wetlands? NO © DONT KNOW O YES O 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 O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO O IF YES, describe size, type and location: E. WiII 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 Q NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. L, 1 City of Northampton Statuis of ' , Building Department artment + ea a n 212 Main Street J Room 100 wet- v Northampton, MA 01060 .+, t ; • phone 413- 587 -1240 Fax 413- 587 -1272 Plot /hbt�lb ", =r x T Other • - is 4t. ,t 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 2,S S o-J Map ' Lot Unit C o r Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 1� +may 10 co =Z. Z.S S re.z 0-q e_. d I M Name (Pa'n1) Current Mailing Address: a tta 4)e.61 -71) h .5 (1$- 1 g 0 (A Telephone Signature 2.2 Authorized Agent: Malik rne• • 16 - oc.fin43 - . a • _ •• VT) Name (Print) Current Mailing ' • • resit: Q 1 0 �--- (1i3) 521- 1T15 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 1.1 ,F rki 4 �® . o 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) ' � C� , OC. Check Number %9 5 1,, This Section For Official Use Only Date Bo 1ding Permit Number. Issued: Signature: Building Commissioner/Inspector of Buildings Date • t • � r 125 ST A p* BP- 2010 -1033 GIS #: COMMONWEALTH OF MASSACHUSETTS • `1oc 17D -017 4 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- 2010 -1033 Project # JS- 2010- 001524 Est. Cost: $5280.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sq. ft.): 19994.04 Owner: AMBROZ EDYTHE M & BARBARA W GRAVES Zoning: URB(100) //WP Applicant: RCI ROOFING AT: 125 STRAW AVE Applicant Address: Phone: Insurance: 6 LINE ST (413) 527 -4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON:5/19/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: STRIP & SHINGLE ROOF 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 5/19/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo VALLEY RESTORATION SERVICES INC INSURED: Barbara Graves Policy No : Claim Number : Our File No. : Action Description Quantity /Unit Structure Restoration 1st Fir Bedroom 11' 1" x 10' 7" x 7' 3" Offset 1 9' 8" x 5' 7" x 7' 3" Seal & Paint Wall(s) 454.29 SF Special Move & Reset Contents, Cover 2.00 HR & Protect 2nd Fir Landing 14' 6" x 9' 0" x 7' 5" Hallway Offset 9' 1" x 4' 6" x 7' 5" Special Repair Plaster Wall(s) 1.00 LS Seal & Paint Wall(s) 483.49 SF Special Move & Reset Contents, Cover 2.00 HR & Protect Master Bedroom 12' 3" x 11' 8" x 7' 5" Offset 9' 3" x 4' 8" x 7' 5" Special Repair Plaster Ceiling 1.00 LS Special Window Trim Repair 1.00 LS Seal & Paint Ceiling 186.16 SF Special Move & Reset Contents, Cover 2.00 HR & Protect Stain & Seal Window Trim to Match 1.00 EA 2nd Fir Bathroom Special Vanity Repair 1.00 LS Basement Special Install /Reset Basement Window 1.00 ES / Trim General Conditions Special Post Construction Clean Up 12.00 HR Special Debris Hauling & Dumping Fees 1.00 LS Special Permits & Fees 1.00 EA Special Set of Plans for Town Inspector 1.00 EA Building Repair Estimate Pagg 3 of 4 1/10/2011 COPYRIGHT 1987 -2010 SJV 1 VALLEY RESTORATION SERVICES INC INSURED: Barbara Graves Policy No : Claim Number : Our File No. Action Description Quantity /Unit Structure Restoration Rear Porch 34' 0" x 8' 4" x 8' 0" Offset 1 10' 0" x 8' 4" x 8' 0" Replace Soffit Trim 1 X 12 Match 70.00 LF Replace Spc. Crown Molding / Custom 1.00 LS Cut to Match Replace Custom Box in Beam 1 x 12 136.00 LF Replace Trim 1 X 6 Under Beam 68.00 LF Replace Molding to Match Soffit 20.00 LF Replace Ceiling Wood Fir Tongue & 366.52 SF Groove 1 x 4 Replace Molding to Match Existing Ceiling 122.00 LF Replace Blown Wall Insul 140.00 SF Replace Siding Cedar Shingle Red 185.00 SF Replace Siding Cedar Bevel 6 56.00 SF Replace 30 Lb Felt 528.00 SQ Replace Corner Board Trim 1 X 6 21.00 LF Special Reset & Attach Staircase 1.00 LS Replace Trim 1 X 12 10.00 LF Replace Membrane Roof Single Ply 7.00 SQ Seal & Paint Ceiling 366.52 SF Seal & Paint Decking 366.52 SF Seal & Paint Hand Rail(s) & Balistars 1.00 LS Seal & Paint Posts 9.00 EA Seal & Paint Staircase 1.00 EA Seal & Paint Cedar Siding to Match 165.00 SF Seal & Paint Cedar Bevel Siding to Match 46.00 SF Seal & Paint Molding & Trim 772.00 LF Replace Ceiling Fixture Avg. Qual. 1.00 EA Special Repair /Reset Ornate Door 1.00 EA Exterior Special Repair /Reset Storm Door 1.00 EA NOTE NOTE 1.00 Replaced Posts, Molding & Trim Work will be Duplicated from the Exisiting Front Porch. 1st Fir Bedroom 11' 1" x 10' 7" x 7' 3" Offset 1 9' 8" x 5' 7" x 7' 3" Special Repair Plaster Ceiling 1.00 LS Special Repair Plaster Wall(s) 1.00 LS Seal & Paint Ceiling 171.19 SF Building Repair Estimate Pa9e 2 of 4 1/10/2011 COPYRIGHT 1987 -2010 SJV VALLEY RESTORATION SERVICES INC 6 PARKWOOD DR WILBRAHAM, MA 01095 413- 599 -1888 - 413- 599 -1813 Insured : Barbara Graves Address : 125 Straw Ave Date Of Loss : 1/10/2011 Florence, MA 01060 Adjuster : Michael Breton Insd. Phone # : (413)582 -9197 Inspt. Date : 12/28/2010 Action Description Quantity /Unit Structure Restoration Rear Porch 34' 0" x 8' 4" x 8' 0" Offset 1 10' 0" x 8' 4" x 8' 0" Special Demo Remaining Decking 1.00 LS Remove Concrete Block 8x10x16 as 1.00 LS Needed Replace Concrete Block 8x10x16 1.00 MN Replace Floor Joists 2x8x8 16 In O/C 160.00 SF Replace Floor Joist Hanger 2 X 8 16.00 EA Replace Sill(s) Treated 2 X 8 36.00 LF Replace Floor Wood Fir Tongue & 160.00 SF Groove 1 X 4 Replace Posts 6 X 6, Custom 1x6 9.00 EA Replace Custom Post Base & Gap 18.00 EA Replace Outside Corner Molding for 9 36.00 EA Posts Replace Custom Handrails & Balisters 84.00 LF Replace Ceiling Beams 4 X 8 68.00 LF Replace Ledger Board for Ceiling 2x 8 36.00 LF Replace Ceiling Joists 2x8x12 16 In O/C 26.00 EA Replace Joist Hangers on Ledgers 26.00 EA Replace Ledger Board for Rafters 2x8 24.00 LF Replace Rafters 2x8 16 Inches On Center 528.00 SF Replace Roof Sheathing kfri T&G 1x8 528.00 SF Replace Fascia 1 X 6 70.00 LF Replace Eve Trim 70.00 LF Replace Crown Molding 3 5/8 to Match 70.00 LF Building Repair Estimate Pagp 1 of 4 1/10/2011 COPYRIGHT 1987 -2010 SJV Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall" enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub - contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retumed to the city or town that the application for the permit or license is being requested, not the Department of • Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self - insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. • Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit /license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy pf the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. _ The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone -and fax number The Commonwealth of Massachusetts • Department of Industrial Accidents Office of Investigations 600 Washington Street • Boston, MA. 02111 Tel. # 617- 727 -4900 ext 406 or 1 -$77 MASSAFE Revised 11 -22 -06 Fax # 617- 727 -7749 www.mass.gov /dia The Commonwealth of Massachusetts Department of Industrial Accidents ►- Office of Investigations to -g 600 Washington Street 9 Boston, MA 02111 www.massgov /dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): if l k y Res' 2 7 Address: (0 T l'40 (1 / 4e City /State/Zip: 4J/ /4't eft jfg.. O /0f C; Phone. #: 7' 5 7 l g ca Are you an employer? Check the appropriate box: Type of project (required): / 1. E}" I am a employer er with A 4. 0 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. enloyees These sub - contractors have. .g. 0 Demolition working for me in any capacity. employees and have workers' P aci $ 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required:] 5. 0 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. [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: RAC ha e 4 Ye'1 (- ,TJL/S ✓f'd •�' 4 64 c y Policy # or Self-ins. Lic. #: � '?' D t v Expiration Date: /0 — Zp // Job Site Address: / 2 C --ra u'' AV L City /State /Zip: • fl�f4l1C'i free ,. 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 aiming 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. Be 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 u der pains and pen perjury that the information provided above is true and correct Signature: / / / Date: .- - 17 . . Phone #: / 3 5 j ` g.0.18 Official 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 N Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : :TO /+A s L K i j 5 3 9 5 2 License Number 6 PA-le 4WOe2J 4Ra ae 12/1) [a/ cc' /74- 3 1 3 / 20/ 2. Address C.J /S— Expiration ate c74" /4 yr s11 /S .08 Sig r e Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ U a le geii 40 vG,11 ovt v t eS t / .7'dli A tV i h j' ) q S q Company N ai ve Registration Number PCP boon) DP tie 10 i1br ,ha01 , ofors d 3/i`i�aO /3 dress Expiration Da Telephone C O 5' i I P 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 El 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 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 finder 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (heck all applicable) New House n Addition ❑ Replacement Windows Alteration(s) n Roofing Q-' Or Doors 0 1 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [la- Siding [0] Other [IT' Brief Description of Proposed p ,, �//9/� ? . ?d .s'-�„ Work: tse (3o t a-6 OX I ST t\) Q 0k6.14 O x ✓ Alteration of existing bedroom Yes ` 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 following: 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 . 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 I, / b') TI-t C ill 4m /3/?I.)Z , as Owner of the subject property p lP t CC hereby authorize \jail 1€ -f gc-s - r it�)� , J , rV t c ( 70/s) AeE L` to act on my behalf, in - a ers k .tive to work authorized by this building permit application. Signature of Owner ' Date I, �Oh V\ r I b tIt tf ci„/ l../ 4- or 4., *teiv∎ 5ervl e S , as Owner /Authorized Agent hereby declare that the statements and informati n on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. —JD ft )'t'/3e Print Name 1 ii /'9 , -- - G!/ Signature of • er /Agent 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: 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 0 DON'T KNOW er YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW YES Q IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q 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 (cI aring, grading, excav -tion, 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. , , 7 , r t'Y j ,E. .t t w ., f ' Department use only % sty of Northampton Status of Permit: 1 , A'ding Department Curb Cut/Driveway Permit 1 , 2 Main Street Sewer /Septic Availability - oom 100 Water/Well Availability oses - a pton, MA 01060 Two Sets of Structural Plans - 413 - 587 - 1240 Fax 413 - 587 - 1272 Plot/Site Plans OfSst* '' 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 1 .z 5 .S 141.) L Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: C VTHe tr. Am8Roz 125 St /ZAt,..> .!- (i6 Name (Print) L Current Mailing Address: 4 E3) 5 2 g1g7 Telephone Signature 2.2 Authorized Age Va,1 ley �2Q,TRei n fl .Sei vi c2S b /°R �` Lr/`j/ ©I' ivr 01 4444.. l44} Name (Print) / �/ ►�, Curr ent Mailing Address: d„®4S 4,,x1 - /,f y, 3 S y 9- /Bldg S igns Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building ' 90 eV, OD (a) Building Permit Fee 2. Electrical 471 2 co. (DO (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) )0 c2 q 6 . Do _ Check Number 3,3 0 Y 0 This Section For Official Use Only Date Building Permit Number: . Issued: Signature: Building Commissioner /Inspector of Buildings Date , File # BP- 2011 -0901 APPLICANT /CONTACT PERSON VALLEY RESTORATION SERVICES INC ADDRESS/PHONE 6 PARKWOOD DR WILBRAHAM (413) 599 -1888 PROPERTY LOCATION 125 STRAW AVE MAP 17D PARCEL 017 001 ZONE URB(100) //WP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid c9 `t" `, Typeof Construction: REBUILD PORCH (SAME FOOTPRINT) New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 093952 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN F9.WVIATION 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 Signature of Building 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. • 1 A '"� teryet. J V/ /( B P -2 901 11- 125 STRAW AVE pelt O O GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D - 017 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2011 -0901 Project # JS- 2011- 001471 Est. Cost: $29050.00 Fee: $174.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY RESTORATION SERVICES INC 093952 Lot Size(sq. ft.): 19994.04 Owner: AMBROZ EDYTHE M & BARBARA W GRAVES Zoning: URB(100) //WP Applicant: VALLEY RESTORATION SERVICES INC AT: 125 STRAW AVE Applicant Address: Phone: Insurance: 6 PARKWOOD DR (413) 599 -1888 WC WI LB RAHAMMA01095 ISSUED ON: 5/4/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:REBUILD PORCH (SAME FOOTPRINT) POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Buildin nspector Underground: Service: Meter: ting44 Rough: Rough: House # Fou s at n: Drivew in I: Final: Final: — Rou. Fr e: Gas: Fi e De I ar ment I c Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: \ Final: THIS PERMIT MAY BE REVO !. BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 5/4/2011 0:00:00 $174.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner k------ 5))141c-, .1",5 '5)1 b)Na. SOL-9 g z i-4 /JAA VUt Qt. 1 ( c „ i ! / cl.Ifi 0 A 0 1 ' 9 ) 5Q(1 1 714 1 ii -aid ,21/ JOq alti I.R0Q-H tiro:1_5 A 1 1\1 g 1 j - 5 / 1 L ` f 1 jY \ I t , ' '. 2 X: I b V k .1'1 ', tt..tr�(� 3b t�' � 1100 ' "2. ,0 � x,11 ) < 10 \ vo olv fi x\51'tk ;. 6 ' 'Illilliik ` l o c ,\IZ-) \ CV ' t2; 14" ‘ . I r7 p � a I - [oo �i RECEIVED Edythe M. Ambroz 125 Straw Avenue JS JUL 12 2011 Florence MA 01 062 413- 586 -1086 DEPT. OF BUILDING INSPECTIONS NORTHAMPTON, MA 01060 July 12, 2011 City of Northampton Building Inspector's Office Project: Rear Porch Renovations 125 Straw Avenue, Florence Dear Inspector: Last December a large tree fell on our rear porch, requiring extensive rebuilding. Valley Restoration Services, Inc. was scheduled to begin the work this spring, and applied for a permit. However, they were unable to begin the work, because the owner was in a disabling accident. Mike Caryofilles is performing the work, and we request the transfer of the permit to his name. Please call with any questions. Sincerely, i I A Edy A The Commonwealth of Massachusetts h • Department of Industrial Accidents Office of Investigations • 011011. r 6 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/Individual): / �� f � ��/ 72rziA//�'S Address: 57 /Licit 1 Xd City /State /Zip: (c.' ./1 to Or z- 3 Phone #: �/ (_`a -- / Ss z Z—e^l z c# Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ 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 employees These sub - contractors have 8. ❑ Demolition for me in any capacity. employees and have workers' working Y P ty. 9. ❑ Building addition [No workers' comp. insurance comp. insurance.# required.] 5• ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have their Plumbing repairs or additions 3. ❑ I am a homeowner doing all work ave exerc r 11. ❑ myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §I(4), and we have no employees. [No workers' 13. ❑ 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 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 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 coverage verification. I do hereby certify under t pain dpenalties of perjury that the information provided above is true and correct Signature: 0 f 7// � Date: J )t, � /2- -2- b l Phone #: 4 1/3 S 5 .-70 Official 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 #: Version1.7 Commercial Building Permit May 15, 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) • Independent Structural Engineering Structural Peer Review Required • Yes 0 No 0 SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN . OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, _ _ , _ .__�_ ....... - _ _ _ ..__ _.. _ .._. , as Owner of the subject property hereby authorize '_......._..... ___ __._ ____ _ _._---- act on my behalf, in all matters relative to work authorized by this building permit application. _ „_ __ __________ . _ Signature of Owner Date __ _____w_ _ _ ._ , I, '._ / (/j L ...`2_ t4- .L�LLt E'er _ _... , 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 wins and p of penury. . - Print Name _ __. __._._____... _______ _.__.. �� �._,....-- t „/Y / Z 26/ / ____ ..._ _ _..._ _.. _______ _ _._._ Signature of Owner /Agent Date SECTION 12 - CONSTRUCTION: SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder ,... C ` !._Gs t'_/ . . .... ..P .(G . - e`er - - N_ ---w -- License Number Address s- /) o C } Q fc 1 /�G1 C% 12.`3 C Expiration Date gf ��� � ✓ ( �_ C) ` .� S"Sl v `3 - z ?- / Si ature Telephone SECTION 13 - 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 0 No irl l /535 ' or Version1.7 Commercial Building Permit May 15, 2000 SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES FOR BUILDINGS - AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF EI!iSLOSEDSPACE) 9.1 Registered Architect: .. ___ __ M" '"' I Not Applicable Name (Registrant): - ___ , Registration Number • Address.__ _ .. _.._,.._.... __...._.._.__...._._.....,_... Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number . Signature Telephone Expiration Date . Name Area of Responsibility Address Registration Number F Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number I Signature Telephone Expiration Date 9.3 General Contractor .A.iC L._ a... i_e4/ ,5....._.w_.._... ______ ____ _ Not Applicable ❑ Company Name: • Responsible In Charge of Construction Address_ 57 0.9()/t ,.., XeQ / 1 ezi - , ! Signature Telephone • Version1.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON. ZONING Existing Proposed Required by Zoning This column tote filled in by Building Department _ Lot Size _ .^ Frontage Setbacks Front Side L: R Rear ? e rji 4 -,,4,t Building Height j 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 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 1 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 0 NO $) IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES (3 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 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 1 Version1.7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 . CUBIC FEET OF ENCLOSED SPACE ' 1 Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑ t Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing 0 Change of Use ❑ Other ,. i ._.- Brief Description ..�.._.�. ; _�_._ �' r -. Dm pt on `Enter a brief description here. Of Proposed Work: SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A I ❑ A-4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ' r ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ = ' 3A ❑ 1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential 71 R -1 I R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S -1 ❑ S -2 ❑ 5B ❑ U Utility ❑ Specify: y,__ M Mixed Use ❑ Specify S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE Existing Use Group: , __ _______ . Proposed Use Group: _ __ _ _ Existing Hazard Index 780 CMR 34): ;,..„ _ Proposed Hazard Index 780 CMR 34): _ ,, ._ ._ _ „..._ SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE'USE ONLY Floor Area per Floor (sf) 1st 1st 2nd ___. �.____. _ 2 nd 4t _. _ _ _ 4 �'. _M Total Area (sf) Total Proposed New Construction (sf),_ Total Height (ft) ___ ... Total Height ft 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public A Private ❑ Zone ___ ___ Outside Flood Zone❑ Municipal j On site disposal system C 0,,, I Te-L61 - ei g._ Version1.7 Commercial Buildin_ Permit Ma 15, 2000 7 Depart t irseionl .§ 4 V $ AWE W RECEIVES i 4 L City of Northampton Sta n i ' t ,_ � �� ' Building Department _ ' ertrt' :: '` JUL ,: 212 Main Street i §ewer�.Se Alfa•tri A . Room 100 ater i rari. , , i _ __ 1 OFNA M°INSPECTIONS Northampton,; MA 01060 ® . ,, t ,tl �` E 1 3- 587 -1240 Fax 413- 587 -1272 it fr tf Mans 1 _ , 0 t ' APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 SITE INFORMATION 1.1 Property Address: This section to be completed by office j ... Z 5- 5-4 e w 4-0-e j" /firopte:. _ Map Lot Unit Zone Overlay District _. — W _ Elm St "District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED. AGENT 2.1 Owner of Record: . .. Name (Print) f bf U(4 es Current Mailing Address _.. __ , _ _ _... _ / ? Signature Telephone 2.2 Authorized Agent: ( ) ,ll,��r C , ter _ _ Name Print > C/ / /es Curren Marlin Address ) , �4 0 ( —L .? 5 Signature __ 1 f t /�_ � Telephone 9 n t j5 s /C� SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building V -+� 5 C7 ` (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 It 13 `{ s This Section! For Official Use Only Building Permit Number Date Issued Signatur =. ,V %, 7 /1-// Buil. ommissioner /Inspector of Buildings Date Fleet(' _ID .ec),f.t.e...e/r (.........) 125 STRAW AVE BP- 2012 -0032 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D - 017 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2012 -0032 Project # JS- 2011- 001471 Est. Cost: $29000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MICHAEL CARYOFILLES 71393 Lot Size(sq. ft.): 19994.04 Owner: AMBROZ EDYTHE M & BARBARA W GRAVES Zoning: URB(100) //WP Applicant: MICHAEL CARYOFILLES AT: 125 STRAW AVE Applicant Address: Phone: Insurance: PO BOX 886 (413) 655 -8510 () PITTSFIELDMA01202 ISSUED ON:7/12/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: REBUILD PORCH (SAME FOOTPRINT) 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 7/12/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner , • /rip :_ JUL - 5 2011 DEPT. OF BUILDING INSPECTIONS NORTHAMPTON, MA 01060 Restoration Valley Restoration Services, Inc. 6 Parkwood Dr Wilbraham, MA 01095 (413) 599 -1888 Fax (413) 599 -1813 TAX ID 20- 2173391 Louis Hasbrouck Department of Building Inspections 212 Main St, Rm 100 Northampton, MA 01060 -3189 Dear Mr. Hasbrouck, Regarding the attached permit, Valley Restoration will not be performing any building repair work and would like to apply for a permit fee reimbursement. Sincerely, Flo Kibbe 125 STRAW AVE BP- 2011 -0901 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D - 017 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2011 -0901 Project # JS- 2011- 001471 Est. Cost: $29050.00 Fee: $174.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY RESTORATION SERVICES INC 093952 Lot Size(sq. ft.): 19994.04 Owner: AMBROZ EDYTHE M & BARBARA W GRAVES Zoning: URB(100) //WP Applicant: VALLEY RESTORATION SERVICES INC AT: 125 STRAW AVE Applicant Address: Phone: Insurance: 6 PARKWOOD DR (413) 599 -1888 WC W ILBRAHAMMA01095 ISSUED ON :5/4/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: REBUILD PORCH (SAME FOOTPRINT) 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. 4 4 et040 Certificate of Occupancy Signature: 1. 4414 ,. t. FeeType: Date Paid: Amount: Building 5/4/2011 0:00:00 $174.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner