23D-151 1■ . „
,P
Pann
. l MASSACHUSETTS ANKXRIT PAID $
WORKERS COMPENSATION and :
Fam y WORK
Record SPecialist , INMALS DATE
f
''"'°** EMPLOYERS LIABILITY APPLICATION undermiter
g New Business El Rewrite Of ,
Trial Application 0 Binder No.
1 Paicessor
Policy Now, ,„,,
Paytrlan: E.* se%p.Datg , EN/ration D Asalversa_ ry Rating Date
i
Agents Name:
atirt1.5 t &a/Y/1 Ag : I e -
f , Percent
Secondary Agent Agent No.: Percentage:
I NAMED INSURED i
p (11-Individual 0 02-Partnership* 0 03-Corporation 0 05-Limited Partnership* 0 05-Joint Venture
0 I 0-Umited Liability Co_ 0 Other (Describe) *Indicate Names of all Co-Partners
First Named Insurect or business) Name k (individual or business)
7a- mot
No. & Street . PO Box No. 8, Street: PO Box
/260 eafiv *eel-
Cit : State: 4 City: State: Zip
--4. Alifeid ftliti 6/330 Ilil
County of Assignment
Occupation: 62, Occupation:
Home Phone # ( &t 3 3q5" Home Phone* { )
Business Phone # (1/3) 20 Vi Business Phone # ( )
FEIN # (Mandatory): 67 .5 blai FEN1 I # ( Mandatory):
I
Billing Name and Address if different
Name: - RV A fi'vAle
Address: ZOO e ' li -I _. i a.___ - 0 tr 1 0/671, - f
EMPLOYERS LIABIUTY INSURANCE: Part Two of the policy applies to work in each state as indk:ated above. The
Limits of LiabBity under Part Two are:
Bodily Injury by Accident Badly injury by Disease Bodily Injury by Disease
(each accident) (policy limit) (each employee)
$ A90 iV $ 5&34eX $ AV/Lee
X-I286 0407 MA -1-
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : k j 0 S a Jo 1 38Y
License Number
1a af pti 6c1 r v � 11,'01 .� m n cya% / a / ao'a
Address Expiration Date
- V � -� y 3 — a/6 -/S/7
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Peg Se. flee., j ,, Say ce f / W9' 7
Company Name Registration Number
Srr«fi w t I w,.,,,, j bCiLl A'kS•r C/ d f / S /o)C/%
Address Expiration Date
Telephone 03 - ? /!J - 6y26
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 f,$ 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
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SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House n Addition ❑ Replacement Windows Alteration(s) ( I Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding [0] Other [0]
Brief Description of Proposed
Work: 5"]'r +'e WWI KC,, - Rc c X ay 5 t
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 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 , P a t ; T < . 4 G , }, s as Owner of the subject
property
hereby authorize 'T 0 • ( G
to act • - • -halt, in all matters relative to work authorized by this building permi applicaf n.
k x in
� (O
Signatu ' -r , Date
T21 0, Pe4 , 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.
Toclik 0 Pe4'S
Print Name
Via„( .ID YA2/ /ow
Signature of Owner /Agent Date
l
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 tilled 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 t DONT KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW Q YES Q
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO g DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained ,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 Q 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 Q NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
. Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
Aril 2 2n10 Room 100 Water/Well Availability
'Northampton; MA 01060 Two Sets of Structural Plans
phone 413 Fax 413 - 587 - 1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: j This section to be completed by office
i M.1Y..t'1 St 4 Map Lot Unit
T L ( [ e rr, s r Zone Overlay District
0
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Ps I-' `Gib %k r) H ?nKk c e�c rnv:s r cio&A
Nam- • 14..A.a. Cu rrent Mailing Addr
► yf ho - :S86 -0 7e,
Telephone
Signat w e -
2.2Aut dA•ent:
20 0. e_ i c pc rea- W I I : 4intsiv..f 5 n't4.1 l
Name (Print) Current Mailing Address: GtiG 6
D ____Ir,e----`-- -- Y/3 - a1'e.i - 176
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building W ( * 00 (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 /ag7 tr57 y
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
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147 HINCKLEY ST BP-2010-0937
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D - 151 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 -0937
Project # JS- 2010- 001395
Est. Cost: $4000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TODD D PEASE 101384
Lot Size(sq. ft.): 18513.00 Owner: DAVIS DEBRA L & PATRICIA CANDEE GIBBS
Zoning: URB(100) Appiicant: TODD D PEASE
AT: 147 HINCKLEY ST
Applicant Address: Phone: Insurance:
1200 CAPE ST (413) 210 -1476
WILLIAMSBURGMA01096 ISSUED ON :4/27/2010 0 :00 :00
TO PERFORM THE FOLLOWING WORK :STRIP & SHINGLE GARAGE 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: OK 512.40 1,0 (S
NUi at PS NOT d N)
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
O "S ,y�,,,, k
Certificate of Occupancy ( Signature: m44
FeeType: Date aid: Amount:
Building 4/27/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo