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18C-019 ..•a • . ... Versionl.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 CONTRACT, APPLIES FOR BUILDING PERMIT 1, d . / ® , as Owner of the subject property hereby authorize act on my beh,rin all matters relativ o work thorized by this building permit application. . _. .. ,_. ... Signature of Owner Date • f't. 06, t,( b S , as Owner/ uthorize • 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 parns_and penalties of pequ. Print Na AAA14 4Y0 Signatur. .f Owner /Agent Date It SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : �. . . � . . L J �c� �.,..... 1(L � . J ... t 1 D License Number JOtt -16160- c5r) 1)e it) 144 16Z Address Expira o n D Signatur Telephone SECTION 13 = WORKERS' COMPENSATION INSURANCE AFFIDAVITI(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 0 A C 1 I 3 (? 6 3- 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 ENCLOSED SPACE) 9.1 Registered Architect: 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 Signature Telephone Expiration Date Name _.. __ . ._. ..__ .. ......... _ .... __ _.. , _._._ Area of Res __,._ ..__. ._.... .._ _. .. ponsibility Address Number Signature Telephone Expiration Date 9.3 General Contractor Not Applicable ❑ Company Name: Responsible In Charge of Construction Address Signature Telephone • Version1.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side 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 Q DONT KNOW 0 YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book ` Page and /or Document #', B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW (3 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Date Issued C. Do any signs exist on the property? YES (3 NO 0 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 0 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. -a Versionl.7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ ditions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofin Change of Use ❑ Other ❑ Brief Description Enter a brief description here. j - f ( p 1 U 1' U-1/ CA, rite Q--' Of Proposed Work: Q , 1113 r I J11-81 -6-Le SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑ A -4 ❑ A -5 ❑ 1B ❑ B Business ❑ , 2A ❑ E Educational ❑ 2B - 1 ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ � 3B ❑ M Mercantile ❑ 4 ❑ R Residential R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S -2 ❑ 5B ! ❑ • U Utility ❑ Specify: 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: Existing Hazard Index 780 CMR 34). ,._ _, .,,, _, ,,,.m_ _ , .,_ ,,__ 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) 1 st 1 st 2nd 2" d 3ro 3� 4 th __ . 4 th (sf) p Total Area (s Total Proposed New Construction _ 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 ❑ Private ❑ Zone Outside Flood ZoneD Municipal ❑ On site disposal system • -r Versionl.7 Commercial Building Permit May 15, 2000 Department use only City of Northampton Status' off Permit Building Department Curb Cut/Dnveway Permit { 212 Main Street Sewer /SeptiiAvailabtlity Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413 - 587 -1240 Fax 413- 587 -1272 Piot/SitePtans= Other Specify" APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR,QCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWE!..LNG SECTION 1 SITE INFORMATION 1.1 Property Address: This sectio® ;be d by office '.1'5 /...� / �/� & Map Lot Unit G �/ l l DJ Zone Overlay District A oce)iii. 4144 Pktro ( EIm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT tive.A 2.1 Owner of Record FI_.. j f '.'�" Cam/ .... ,...�..... Name (Print) Current Mailing A dress. y irk' F j l '._ ... 42161 —J.7 69 Signature V '!' Telephone 2.2 Authorized Agent: Name (Print) Current Mailing Addre Signature r, , �1 Telephone E 7 7:_"^tr " � c 1 " J !!! tt 111 SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of •► Construction from (6) ir►:�'��,_ „_ 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 +2 +3 +4 +5) Check Number /i ( ej' 35 This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date I Y a_y BP- 2011 -0516 GIs #: COMMONWEALTH OF MASSACHUSETTS :100';.019 '' 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 -0516 Project # JS- 2011- 000844 Est. Cost: $5600.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HAWKINS ROOFING Lot Size(sq. ft.): 8145.72 Owner: RYAN TRACEY A Zoning: SR(100)/ Applicant: HAWKINS ROOFING AT: 289 HATFIELD ST Applicant Address: Phone: Insurance: P 0 BOX 107 (413) 774 -6834 SOUTH DEERFIELDMA01373ISSUED ON:12/7/2010 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 12/7/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License License: CS 89442 Restricted to: 00 GERARD J RONAN PO BOX 675 EASTHAMPTON, MA 01027 ` may/` Expiration: 3/19/2012 ( 'ummissiuner Tr#: 18580 • gg ee .se t SE :Z' Q .emac Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Mf Boston, Massachusetts 02116 Hoxne Improvement Contractor Registration Regishation: 160584 Type: Private Corporation Expiration: 8172012 Tr* 201019 YANKEE HOME IMPROVEMENT INC GERARD ROWAN 82 INDUSTRIAL DRIVE - NORTHAMPTON, MA 01060 __ - - - -- _ - -- Update Address and return card- Mark reason for change. 0 Address 0 Reskeerai Emp&oyraent 0 Lost Card DPS -CAI w 50 34-44/0/14101216 Mont* 17700 YANKE3 ACORD,. CERTIFICATE OF LIABILITY INSURANCE NM 1/201 0 PRODUCER THIS CERTIFICATE 1S WEED AS A MATTER OF INFORMATION King & Cushman. Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIRCATE King & Finn Streets _ALTER TH *S CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 447 Northampton, MA 01081 INSURERS AFFORDING COQ NAIL 0 mums — sISURERA: Cotofly MINIM= Company Yankee Home Improvement POURER lk 82 Industrial Dr. Ste 2 Northampton, MA 01060 INSURER POUREROe INSURER M COVERAGES THE POL1c 5 OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE NAMED ABOVE FOR THE POLICY PERIOD INOICATELL NOTINr[HSTANTANG MY REQUIREMENT. TERN OR CONDITION OF ANY CONTRACT OR OTEER DOCUMENT MATH RESPECT TO WHICH THIS °E MBRCKTE MAYBE TERMED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE PDXES DESCRIBED HERBN 19 SUBJECT TO ALL THE TERMS. EXCLUSIONS AND coNorriona OF sum POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BERN REDUCED BY PAID CLAIMS. LIR TYPE OFMSURAMCE POUCYIUWa DPCISMICINEDIRIMOOEVI WOW users A OENI9tAL UMW"( 147995 08114/10 08114/11 EACH OCOMRENCE $1.000.000 X Mammy& AoIBRAI. LiuoaRM Ar s50,000 1 O M M B MADE r i OCCUR M E D EIIP�ABp one p ) :5,000 Psoxrwwl.sAovmum $1,900.000 user o&AacaEGATE s2,000.000 GENL/ AGGREGATE MST PRODUCTS- COMMOPAGG $2,000,000 � PYn n AUTOROWLE WARM cameo stem $ ANY AUTO (Es aolidenty r ALL OWNED AUTOS IMIURY SCHEDULED AUTOS (Pi Num) ** O AUTOS BODILY INJURY NOKONII�ED AUTOS e $ DA/MME • – OMAN UAMJTY AUTO ONLY -EAA Da f $ R ANY AUTO OTHER THAN EA M C $ AUTO ONLY: ATMI $ ExCENNUN EMIR.LAUNSAY EACH OCCURRENCE $ -1 OCCUR n CLANS NAM AGGREGATE $ DEDUCTIBLE S RETENTION $ $ WORMED, COMPOISATION EMPLOYER! LIAMM AND J 1 g ANY FROPRETORIPARTNERIMECUTIVE ET_EW HACCIDENT $ OFFICERMEMBER INCLUDED? EL CIS ME • EA EUPI.OYEk :gr ow w eft S P ROVISTDN9 4Now EL OMENS - POLICY UST I $ OMER DESCMPnoe OF OPERATION u acs,' noes rvateusuexcuiseote meow rreoressmart speau PROVRaoN: - CERTIFICATE HOLDER CANCEUATION mown 'nrra" MEADOW essomen Po1C IE$OE CA+a:ee.» BERME THE EIIPmAT1ON DATil MAIEOF. TM MUM IMAM MIL ENTINVOlt TOMIL 111 DAYS MITTEN NaTIC@ TO THRO W/1MATE HOW ER NANBD TO TM idleC MIT FAILURE TOM SO (MALL WOW NO OMANI= OR MAW OFANY UPON THE Olelelerle, 118AGSIT9 MANDAMUS. M ACORD 25 (2001/08)1 of 2 .9183 NAP 0 ACORD CORPORATION 1988 cTOname: - - - -> cro£aznum CERTIFICATE OF INSURANCE 1010512x' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. MPORTANT: If the Certificate holder is an ADDITIONAL INSURED, the poiicy(Ies) must be endorsed. If SUBROGATION I S WAIVED, subject to the terms and conditions of the policy, certain policies may require and endorsement. A statement • this certificate does not confer rights to the certificate holder in lieu of such endorsement PRODUCER Kennedy & Associates 1349 Allen St Springfield, MA 1118 COMP HIES AFFORDING INSURANCE COMPANY A GRANITE STATE INSURANCE COMPANY INSURED Yankee Home Improvements 82 Industrial Ave Unit 2 Northampton, MA 010800000 COVERAGES. THIS IS TO CERTIFY THAT THE POLICIES OF. INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOT WITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. co - LTR TYPE OF INSURANCE POLICY RUINER POLICY EFFECTIVE DATE POLICY EXPIRATION DATE A WORMERS CXMM'ENSATION AND EMPLOYERS' LtABLRY oars —i THE PROPRIETOR/ ( PARTNERS/EXECUTIVE OFFICERS ARE INCL o EXCL ❑ 9943619 10/02/2010 10/02/2011 STATUTORY LRAITS °TREK CoverAIN APple. to MA Oper llon.OrIy. EACH ACCDENT $ 100,000 DISEASE POLICY LIMIT $ 500,000 _DISEASE-EACH EMPLOYEE $ 100,000 DESCRIPTION OF OPERA71ONSNEHICLESISPECIAL ITEMS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE OLSCRIBED POLICES BE CANCEU.EO BED THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WIH1E THE POLICY PRRVI81ON8. AUTHORIZED REPRESENTATIVE • 1 YANKEE HOME IMPROVEMENT, INC. All home improvement contractors and subcontractors MA# 160584 CT# 0673924 CSL# 089442 engaged in home improvement contracting, unless specifi- 82 INDUSTRIAL DRIVE, NORTHAMPTON MA 01060 cally exempt from registration by Provisions of Chapter 142A 1 - 877 88YANKEE 1 - 889 - 2653 of the general laws, must be registered with the 413 - 341 - 5259 Commonwealth of Massachusetts. Inquiries about registra- tion and status should be made to the Director, Home Improvement Contract Registration, One Ashburton Place, Submitted / y�'� /l Room 1301, Boston, MA 02108 (617) 727 -8598 .4 il c ft:4 To: i J 0 Pb I tS .1d r ' 4.,1 / ll �� l�- .� _,, ( 2) �2 SC ,. t ' PHONE, � �� ! -3572 DATE S I y i 1 CELL PHONE (f 4 ,6 ' ?'i 72_ . We he submit specifications and estimates for work to be performed materials to be used: .- ' a-' ° X4.1 ✓L,Yf S".2(.4 f (�rt�car AaA ( . der , • s £� /� A 4 s . (- / /4 p , J w f _ ' .1 .1 . A It _ i t 1)05C; (V z L o S '� /u p er&i17x_ a_ , i - v ' f7 / ?.{, 01 e ll Q-r H ' j, e'.It.G�, �[.�`v, /7.r , - Z 5 s '�'.� ,v cc i �: � — / /.� / ,0ide�° 1/_ 4- a Scf o-e `ovve . ` .s1k ti C�JRraK�oCHw�' I m in the work or order t4materfhls befd third day following the signing of this Agreement, unless he ''n. Contractor will begin the work on or about h / / / / / ( date). Barring delay caused by circumstances beyond Contractor's control, the work will be completed by nit (date). The Owner hereby acknowledges and that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor including, but ed to strikes, Acts of God, shortages of mater - als, accidents, and aN other delays beyond its control, shall not be considered as violations of this Agreement. t i WARRANTY I t I i,iff/ The Contractor warrants that the work fumished hereunder shall be free from defects in materials and workmanship for a period of / %7 t 7 following ple tion and shall comply with the requirements of this Agreement In the event any defect in workmanship or materials, or damage caused by the Contractor, its subcontractors, employees or agents, is discovered after completion of any job, including cleanup, the Contractor shah, at its own expense, forthwith remedy, repair, correct, replace, or cause to be remedied, repaired or replaced, such dam- age or such defect in materials and workmanship. The foregoing warranties shall survive anv inspection performed in connection with the agreed -upon work. We Propose hereby to fumish material and labor - complete in accordance with above specifications, for the sum of: , 6� L,� IL .CA s Tics. ��� O ? �;.V,L ;d . ° rU2 ' ° h oc , �,dotrars ($ ) 2 i'4 . ). Payment to de as follows: Cam' %($ , , , , �© ) upon signing contract YANKEE HOME IMPROVEMENT, INC. G c ° Name of Contractor/Designated Registrant 10 % ($ �" t , ) upon completion of i 4h tZ lire.. 82 INDUSTRIAL DRIVE Street Address ` l t ..' % ($ , 3 i Z i ' ) upon completion of C1,1?-4/.. NORTHAMPTON. MA 01060 413 -341 -5259 City/State Phone 1 C;' % ($ 12.'i gi vC ) shalt be made forthwith upon 160584 completion of work under this contract. Registration No. �/ Notice: No agreement for home improvement contracting work shall require a down N: e • I - - / dl l ' Ail' �\ . payment (advance deposit) of more than one -third of the total contract price or the total amount of all deposits or payments which the contractor must make, in advance, Authorized Si. nature //�,, to order and/or otherwise obtain delivery of special order materials and equipment, - whichever amount is greater, Acceptance of Proposal 1 have read both aides of this document and accept the prices, specifications and conditions stated. 1 understand that upon signing, this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above. You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the Seller, which may be his main office or branch thereof, provided you notify the Seller in writing at his main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. Please refer to the Notice of Cancellation that accompanies this contract; con- tents of which are referred to above and incorporated herein by reference. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. / j .0 (5 3 t�Ol� Signature - e � Date Signature Date 1 The Commonwealth of Massachusetts _,— Department of Industrial Accidents lr _ " Office of Investigations - ■ 600 Washington Street Boston, MA 02111 1 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Lezibly Name ( Business /Organization/Individual): t LiecE E .� f(7��r1/O F{�N T - ES Q 20 c7A- OA/ Address: 62 .?'Nch. T --/ 2Z City /State /Zip: A, -,NAT —,l, /1A . i n Phone #: f i - 3 Vi 525 j Are yAu an employer? Check the appropriate box: Type of project (required): 1. ar I am a employer with 8 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. t 7. ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.0 Other *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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: GElctlj e #'iCt cU . Policy # or Self -ins. Lic. #: £ I'f ,3 b / 1 Expiration Date: /Q 721 2e / / Job Site Address: 22AT /14-r‘,&-.6„6 3"i eez T cit /State /Zip:deryk fi' u, , elo6a 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 the pains and penalties of perjtuy that the information provided above is true and correct. ✓ Si mature : Date: "700e Phone #: 'J/5 -- . 'i / 52c, II Official use only. Do not write in this area, to be completed by city or town official r 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 : 6ERA 4D Rey,,, a Al C- 5 2,7 4 42 Do / License Number g2 L /7? #_041,5 /A L- Dl'. A.1��'r •irifrreo J .3/i gi 2 c 2. Address Expiration Date 4 7 3Li-f - .5 2S 1 nature Telephone 9. Registered Home Improvement Contractor. Not Applicable ❑ �A K6 de.4far !rer9k6cJc�kle•AS 1 i Gr g �` Company Name / 1 Registration Number X32 N.r7-a5 ; elf L og : ih /4 1 , h 0 6/ ? f /2. Address Expiration Date -----Z4--------------- Telephone J O- 3 .1.1 - 5 Z t 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 ❑ 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 under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code. City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (chgck all applicable) New House ❑ Addition Replacemenalindows Alteration(s) [J Roofing n Or Doors Ppl Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [[] Siding [❑] Other [❑] Brief Description of Proposed Work: - R LA LL 1/1 Dex .:,5 id Di x.16 Alteration of existing bedroom Yes )C No Adding new bedroom Yes )X No Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roll - Sheet 6a. If New house and or addition to existino: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 1, f` N/ 5 _, as Owner of the subject property hereby authorize A+vKCC !-�rsHE . �.M�w'�� � ��� T 6E2/IR') R i,9iv to act on my behal , in all matters relative to work authorized by this building permit application. CA/ oav reit c_ -,-- 5/24124 // Signature of Owner Date I, / A0- 1 .- lye : HE PJ T -- iE ef) PC's RAJ , 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. G A/zl7 '&2A/ow Print Name of Owner /Agent Date 1 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 DONT KNOW 1!� YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES Q IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DONT 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 to or additions of signs intended for the property ? YES 0 NC 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 O NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. lo x • 1 i Department use only _ i , _ WED City of Northampton Status of Permit: Building Department •Curb CI( riveway Permit 212 Main Street Sewer/SeptfaAvadability Ng 2 t 4 6 1 A i . Room 100 Water/Well Av at y i , N( hampton, MA 01060 Two Sets Structural Plans _�.�;- w"• 41 587 -1240 Fax 413 -587 -1272 01.-", P.k�tlSite Plans s t►,.. --v— - Vther 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 22 f-i - i ri&L.17 57: Map Lot Unit A c//a - T'u4 r.(p 72..,A4 ; M el ; 00 r Cj c, c'a Zone Overlay District Elm St. District CB District 1 SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: . D SE'GA L 28 `? /-{4 7 / C- 1– D -; f-,e T Name (Print) Current Mailing Address: 4/3 3// -3515 OA/ Cc✓N' 77Z At CT Telephone Signature 2.2 Authorized Aaent: N c 2.1, r DLJ,; , f q G Di 'i 4' ag d p ! i 1lar - 6 • �dvaki lte?- i- ,44iipi xi, Af04 c:7/c9 6G? Name (Print) Current Mailing Addre s: 'f /3 -- :4i -3576 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building ` -% 1 .7`r,i7; -n/ (a) Building Permit Fee 4 f2 4,,-, 2. Electrical (b) Estimated Total Cost of Construction from (6) 2.2, t . Lld 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) f" 22 , d,. 'j . "-"`' Check Number ,! . 3/ 0? erz9 This Section For Official Use Only Date Building Permit Number: - Issued: Signature: Building Commissioner /Inspector of Buildings Date a 289 HATFIELD ST BP- 2011 -0984 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18C - 019 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: replacement windows /siding BUILDING PERMIT Permit # BP- 2011 -0984 Project # JS- 2011- 001607 Est. Cost: $22184.00 Fee: $100.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: YANKEE HOME IMPROVEMENT INC 89442 Lot Size(sq. ft.): 8145.72 Owner: SEGAL ENID Zoning: SR(100)/ Applicant: YANKEE HOME IMPROVEMENT INC AT: 289 HATFIELD ST Applicant Address: Phone: Insurance: 82 INDUSTRIAL DR, UNIT 2 (413) 584 -8318 WC NORTHAMPTONMA01060 ISSUED ON:5/27/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS & SIDING 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 5/27/2011 0:00:00 $100.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner