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38D-045 (2)
."--/ 5_1 r7A A t/ 5 tA rlari 9? • tom (7,9 -0p,g1c . asfooxy ane ..7/7 7varewh ,e ermet 1 4/Pr2/7...49 zolz5 fruf •s'd° d etaPoevieVo i I The C'onzrnonwealth of Massachusetts Department of Industrial Accidents Office of Investigations r ! 600 Washington Street Boston, MA 02111 www.rnass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /EIectricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): L,j 20ZY 20Z i1/ — / Address: /// p", =0 F1.r /;"`U City /State /Zip: .4 '.GO 5, "wt ei/v 53 Phone #: 41/'3 ._ 1175-0 Are you an employer? Check the appropriate box: Type of project (required): 1. [1 I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors 6. El New construction 2. N., I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling These sub - contractors have ship and have no employees 8. [1] Demolition f me m any capacity. employees and have workers' working y p t y 9. ❑ Building addition [No workers' comp. insurance comp. insurance.t re uired. 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 9 ] officers have exercised their 3.11 I am a homeowner doing all work 11. 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. ❑ 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 At 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 lip 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 perjury that the information provided above is true and correct. Signature: G/LvI. !Q y Date: 7 c Phone #: 1 // ' 3 • y - t/ 7 S U Official use only. Do not write in this area, to he 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 #: HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his /her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he /she resides or intends to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two -year period shall not be considered a home owner." The building department for the City of Northampton wants person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation /footings (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ 1- Name of License Holder : / ,Lt7t 1/J tj, Oy 6 1 License Number /! 14//9 r� 5.T PD d x /?o .CSC eg.)5, 4'.* d /0 5 2.,4i 5 Z/ d Address Expiration Da e f /4k2) y/ ''1 -5F1 -975Z) Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ y �f ‘..e.v5rlw6/7of ! " 4e6 Company Name Registration Number ore" 53 ST, pe) 03GGx /7L42 l ' ,es94 4► q '� /io 2 o L o Address 4 /j3 Expiration D e Telephone 95V- 7 5" 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 g No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (l) 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 fu, peisuii(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 Annotatcd. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing 1 Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [E Siding [D] Other [D) Brief Description of Proposed Work: 6EG0U giEstJR.0 /7-/vP ACAs 'C Z/Yio c zip a I7/ a3/911/1 Alteration of existing bedroom Yes No Adding new bedroom Yes k"No Attached Narrative Renovating unfinished basement Yes L 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 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 RD& ea7 /f , as Owner of the subject property hereby authorize 2-i /LAy .T y✓4 .T "5 to act on y behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 412V ¶ e-4 5c/?' , 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. A 2y T S VTZCNN Print Name g C" ly fir.- i - 7 /i 9/» Signature of Owner/Agent Date tte atif 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 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 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book ; Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 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 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. t -,,.------\\ 1 ' E S tiLi Depa yse City of Northampton Status o Per it:' Building Department �, . Cu (�ii.tJ[Oiv way Perm '` 212 Main Street Sewer /S eptic Avail '' ;'> Room 100 IV e : .f =.tr t,�+� _ Northampton, MA 01060 T at P] phone 413 - 587 -1240 Fax 413 - 587 -1272 4- ,i wp U tt lans Other Spec APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office a+4/ /1/1IQLDA/ ,9(. ' Map Lot Unit 4 /n4 e,/b60 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: -e>/ti'Ig-J7ti /// , my 4.?/D60 Name (Print) Current Mailing ddress: ` 'Y /3 _ 5��1— 6� 7 Z �,'i , L. - Telephone Signature 2.2 Authorized Agent: L4 AA 4i J' y4 c,// Pd 691,X /,A0 lJ 6 5,mR 6 05'3 Name (Print) Current Mailing Address: ti/3 v 549 — y 7 � Signature G% � Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building $ 4•ei r0 e, (a) Building Permit Fee 2 Electrical ' dr 4)0 (b) Estimated Total Cost of Construction from (6) 3. Plumbing ill ‘C,0 Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) ' /(aj © D 4 Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2010 -0074 APPLICANT /CONTACT PERSON LARRY YENTCH ADDRESS /PHONE P 0 BOX 120 LEEDS (413) 584 -4750 PROPERTY LOCATION 24 HARLOW AVE MAP 38D PARCEL 045 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT F e Paid 'lding Permit Filled out_ /� ► ee Paid Ian' 6 t Typeof Construction:_Remodel bath New Construction Non Structural interior renovations Addition to Existin 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 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. 24 HARLOW AVE BP- 2010-0074 GIS #: COMMONWEALTH OF MASSACHUSETTS Tvlap:Block: 38D - 045 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit # BP- 2010 -0074 Project # JS- 2010 - 000080 Est. Cost: $10000.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: LARRY YENTCH Lot Size(sq. ft.): 4181.76 Owner: KEEFE ROBERT & JANICE A Zoning: URB(100)% Applicant: LARRY YENTCH A '1' :_2_4_H_A R__L OW AVE Applicant Address: Phone: insurance: P 0 BOX 120 (413) 584 - 4750 LEEDSMA01053 ISSUED ON :7/22/2009 0 :00 :00 TO PERFORM THE FOLLOWING WORK :Remodel 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: .P l Footings: Rough: e C -15 ? / 'Sough: ` ° 6 House # Foundation: T ., P.. hAs Driveway Final: Final• ( 1 — ��'' Final: � � � �� r 1f / Rough Frame: OK -m q / 1 ; Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: o lc- a I Qq THIS PERMIT MAY BE REVOKED BY THE CI Y OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGUL NS. Certificate of Occupancy Signature: �a FeeType: Date Paid: Amount: Building 7/22/2009 0:00:00 $60.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo