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24A-171 (2) The Commonwealth of Massachusetts . . Department of Industrial Accidents '° Office of Investigations l alliP 4) , - t NT= i 600 Washington Street Boston, MA 02111 , www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): (- Ivy) Welly, Address: 20 dalaov) 51- -. z ' Fkorr City /State /Zip: L 4-tv- 1' YID 0Itf 1c(c Phone #: 1/13 6 676 v7 /yq Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ 1 am a employer with 4. ❑ I am a general contractor and 1 employees (full and /or part- time).* have hired the sub - contractors 6. ❑New construction 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 working for me in any capacity. employees and have workers' comp. insurance.$ 9. n Building addition [No workers' comp. insurance p. required.] 5. n 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' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: _ City /State /Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 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 perjury that the information provided above is true and correct. Signature: ° t Oi i , i ‘ 5-' Date. �`� / / �A♦ Phone #: - j 12 - J i`' qi =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 #: ■M■11 ..M.11■■ ■■•■•■•••■••■■••■■••■■■■•■.-..- . . .,. 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I, ) f 11 ; \ , ) t . 1 ) ; 1 I (to ------ ' 6 4 ] /IT I") k) Au __afl 9j__ 1764 1'5 0111 lotvid .(,) i Yet I V ck 1e.,0 ,.., , J .,/ v e e p , 1 ,_, , V., r't z Q u 6C >k ) Nt. r t-J'1 h - 0 )-10' -4, 17— — - 4 I = r ..: ',,, i , c n A r - 7 c , ) "1)r , 7 i , -) i j • c I_ ........ _ 1 1 , 1 I 7 ' : I I 4 4 / I I 4 ` • 1 I , 4 i 1 I II 1 I ' I I I 4 , 1 4 I . 1 I 1 i 1 ' 1 4 I I ' , I ' I ; CI ti , 1 1 , ' 1 1 i 1 i , 1 , i .. 1 , . . ! t . 1 1 , I . 1 , 1 i ; $ ...,., ,.., . ...., I ' ...,., . . ... , . _ . ...._ _....... „ ....,. .„ , .... _ _ „..... : . . ' •:ik‘ '' '4 4 "e , ' 4 . c i Y.) \ 1. -` ) ! ) i _ r - - r - i 1 - -t. -- 1 . - ' - e . I i 1( t .., i , ,--; , , ,... / \ I ,t ‘44.4.4 I ,04, ...:3, ,k C1 j -- ii ti 1 ,... . ,. I I- SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 9. Registered Home improvement Contractor. 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 ❑ * Home Chimer : 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 (check all applicable) New House E Addition EJ Replacement Windows Alteration(s) © Roofing 0 Or Doors WI Accessory Bldg. ® Demolition ® New Signs [0] Decks [p Siding [0] Other [D] Brief Desc iption of Propose _ Work: Re..�� ti 16 AAP.v, t b6 •■ • gtww.tt. bcrl karl it t.3 a < Alteration of existing bedroom Yes )& No Adding new bedroom Yes ,- No Attached Narrative Renovating unfinished basement Yes Y No Plans Attached Roll - Sheet $a. if New house and: addition to existing housing. Complete the following: a. Use of bu ,.ng : One Family Two Family Other • b. Number of rooms -ach family unit: Number of Bathrooms C. Is there a garage attached? d. Proposed Square footage of new cons • ion. Dimensio : e. Number of stories? f. Method of heating? ire• -ces or Woodstoves Number of each g. Energy Conservation Compliance. Mass - k Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlan. . Yes No. Is construction within • 00 yr. floodplain Yes No j. Depth of basement or cellar flo• •elow finished grade k. Will building conform to t • 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, , 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 I, , 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. Print Name Signature of Owner /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 pepartment Lot Size Frontage Setbacks Front Side L. R:. L: R: 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 YES 0 IF YES, date issued: 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 (93 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 i NO O 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 (3 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. ' I 4 f . I I , 1" Departtnent use only ,to (0* City of Northampton Status ft wit". - building Department Curb Permit _ -....' 212 Main Street Sev rt�tdt lak�� � � ° : Y Room 100 Vuaterlvtd Availability e ° Northampton, MA 01060 Two S t ZCt raf ns °,`.,° phone 413- 587 -1240 Fax 413- 587 -1272 Piot(Site Plats Other Spefy APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING S ECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office 20 JO..C.'-t,D n 'Jrrc -elf Map Lot Unit ;1 f1Ooy Zone Overlay District / NoiiMalp rVlft ota(oo EIrrt St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: .-r be\ t ,cv -4u ) Name (Print) Current Mailing Address: 413 c ai Telephone Signature 2.2 Authorized Anent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use' Oniy completed by permit applicant 1. Building (n 0o 0 0o (a) Building Permit Fee 2. Electrical G d of �� p 1 000. pO Construction from (6) 3. Plumbing �, o c Building (b} Estimate Permit Total Fee Cost 2 000, 1 4. Mechanical (HVAC) 5. Fire Protection �ry �i I, O O 0, so 6. Total = (1 + 2 + 3 + 4 + 5) 411, •pe. ° Check Number 01 ) (0' 1'3 00 'aill° ' This Section For Official Use Only Budding Permit Num ber: Date Issued: Signature: Building Commissioner /inspector of Buildings Date File # BP- 2011 -0962 ¶ APPLICANT /CONTACT PERSON MARTYN TIMOTHY 0 & JANET FLO 0 (L. e LA R ADDRESS/PHONE 20 JACKSON ST NORTHAMPTON (413) 586 -2144 Q Fo f. 51 14.,0 co PROPERTY LOCATION 20 JACKSON ST 1 E 1 E c r O ,S MAP 24A PARCEL 171 001 ZONE URA(100)/ f THIS SECTION FOR OFFICIAL USE ONLY: �',ra (,. C.-. b 6 - ) / 2 M I N I PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT (t4 Fee Paid Building Permit Filled out 0A lJ �j s Fee Paid Tvpeof Construction: REMODEL KITCHEN, BATH & REMOVE LOAD BEARING KITCH WALL 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 INFQRMATION PRESENTED: 'L, 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 S' 7 (A 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. 20 JACKSON ST e BP-2011-0962 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24A - 171 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: WIRING FOR RENOVATION BUILDING PERMIT Permit # BP-2011-0962 Project # JS- 2011- 001551 Est. Cost: $18000.00 Fee: $108.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 6882.48 Owner: MARTYN TIMOTHY 0 & JANET Zoning: URA(100)/ Applicant: MARTYN TIMOTHY 0 & JANET AT: 20 JACKSON ST Applicant Address: Phone: Insurance: 20 JACKSON ST (413) 586 -2144 () NORTHAMPTONMA01060 ISSUED ON :5/27/2011 0 :00 :00 TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN, BATH & REMOVE LOAD BEARING KITCH WALL 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 $108.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner Ntassachusetts - Department or Public Safeis Board of Building Regulations and Standards is di Construction Supervisor License License: CS 102263 Restricted to: 00 L CARL HUME 119 NECK RD LANCASTER, MA 01523 o�,.�G. -- -- Expiration: 1/13/2013 t'unnui.siuncr Tr#: 102263 / - �. Board Tiiii t .gan aft t it f fr HOME IMPROVEMENT COMTRACTOR •\1 r = -41 1 Registry J in: 123204 -= Expi 1/2/2011 Tr# ' 282271 1 Tyke: Individual • a CARL}IME_, r • CARL ROME 119 NECK RD. .�. :; LANCASTER, MA 01523' e. Administrator i RightFax C1-1 . - 3/15/2010 9:31:49 AM PAGE 2/002 Fax Server ACORD. CERTIFICTE OF INSUR DATE (MM\DD\YY) 03 -15 -10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE G B NICKERSON INS AGCY HQLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR MILL BROOK II ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 321 BOSTON POST RD STE 4 -C . COMPANIES AFFORDING COVERAGE SUDBURY, MA 01776 COMPANY 264DT A TRAVELERS DIRECT ASSIGNMENT INSURED COMPANY •B HUME MARL DBA PEAK ROOFING CO. COMPANY 119 NECK ROAD C LANCASTER, MA 01523 COMPANY D • 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, NOTWITHSTANDING 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 :Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LINTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO'. POLICY EFF POLICY EXP LTR , • TYPE OF INSURANCE POLICY NUMBER DATE (MM\DD\YY) DATE (MMU)D\YY) LIMITS' GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY PRODUCTS - COMP /OP AGO. $ CLAIMS MADE OCCUR. PERSONAL && ADV. INJURY $ OWNER'S && CONTRACTOR'S PROT. EACH OCCURRENCE $ FIRE DAMAGE (Any one fire) $ MED. EXPENSE (Any one person) $ AUTOMOBILE-LIABIUTY • • ANY AUTO COMBINED SINGLE LIMIT ALL OWNED AUTOS BODILY INJURY (Per Person) $ SCHEDULE AUTOS BODILY INJURY (Per Accident) $ HIRED AUTOS PROPERTY DAMAGE $ NON -OWNED AUTOS GARAGE LIABILITY ANY AUTOS AUTO ONLY - EA ACCIDENT $ OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGREGATE $ EXCESS LIABILITY UMBRELLA FORM EACH OCCURRENCE OTHER THAN UMBRELLA FORM AGGREGATE $ WORKER'S COMPENSATION AND A EMPOLYER'S LIABILITY UB- 9665L154 -09 09 -17 -09 09 -17 -10 STATUTORY LIMITS X THE PROPRIETOR/ EACH ACCIDENT $ 100,000 PARTNERS/EXECUTIVE INCL DISEASE - POLICY LIMIT $ 500,000 OFFICERS ARE: X EXCL DISEASE - EACH EMPLOYEE $ 100,000 OTHER JlEscRIPTION .QEIIP_ERATIONStLOCAT1QNSLVEH1SSL E$LRFSTRICTIQNS /SPECIALJTEM$ THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE INSUREED'S MA WORKERS COMPENSATION POLICY AND ITS LIMITED OTHER STATES ENDORSEMENT AUTHORIZES THE PAYMENT OF BENEFITS FOR CLAIMS MADE BY THE INSURED'S MA EMPLOYEES IN STATES OTHER THAN MA. NO AUTHORIZATION 1S GIVEN TO PAY CLAIMS FOR BENEFITS IN STATES OTHER THAN MA IF THE INSURED HIRES, OR HAS HIRED EMPLOYEES OUTSIDE OF MA. THIS POLICY DOES NOT PROVIDE COVERAGE FOR ANY STATE OTHER THAN MA. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION ROOFING PRODUCTS INTERNATIONAL INC. DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE ATTN: RON LAFOND • SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY. ITS AGENTS 57460 DEWITT STREET OR REPRESENTATIVES. 'ELKHART, IN 46517 AUTHORIZED REPRESENTATIVE ACORD 25 -5 (3/93) Charles J Clark G. B. Nickerson Insurance Agency 321 Boston Post Road, Suite 4C 11111 Sudbury, MA 01776 Phone (978) 443 -3332 Fax (978) 443 -7527 Email GNickerson @verizon.net SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : 6 ,4- l A ° t ei . '3 License Number III U C � J� 0t t v� Q_cx kt� f .�% � ` 6 v 5 � >- d 1 Address Expirat n to Signature 1 Telephone t (r____1 Ci 7 - &Cock ? 7 9. Registered Home Improvement Contractor: Not Applicable ❑ t,,2 3 t Com an Name Registration Number , CC4, 14. C0 c,tiY`� I (74-- r,? l Address c� s Expira n Date /it k; ac(-(__ Qe �'u ' � Telephone 1 7L-- mac' " �_2: ,2 — 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 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 (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [p Siding [0] Other [O] Brief Description-of Propose} [� Work: �1tt -t") 'f')(k51i sGtC c( -'A (ZOLCQ t oC Alteration of existing bedroom Yes k No Adding new bedroom Yes x 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, I i;4 A / 0 , as Owner of the subject property hereby authorize -TO k c, to act on m behalf, in all matters relative to w rk authorized by this building •-rmit application. Si.i of Owner Date a,vkv. 1 - ce C t"._ , as Owner /Authorized Agent hereby declare that the state a d information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and p- alties of perjury. Print Name ra ( ' ,�/ Signature of twner /Ag Tate ___ 0 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 e YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 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 SD DON'T KNOW 0 YES O 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 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 4) 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 iQ� `212 Main Street Sewer /Septic Availability \1 \ \,\, 2.. a Room 100 Water /Well Availability ; ,North mpton, MA 01060 Two Sets of Structural Plans phone,4a - 3- 87 - 1240 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: This section to be completed by office 2° �� J a p,,- -� ,t/� Map Lot Unit k".\*.n �1�cm ' Av1im da c(cc; Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ` t C Tm I' \0.r vi S C•r eS(.Ey‘'- \ov'� NCkw,- O IOCIO Name (Print) / Cu lent ailin Address: (qt3) f,? 1 yLI Telephone ._ Signature 2.2 Authorized Agent: 3 ' (4 Name 'ri my Current Mailing Address: Signatur Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building L 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) Check Number This Section For Official Use Only Building Permit Number: I s ssuu ed: Signature: Building Commissioner /Inspector of Buildings Date d TA SON ST £ . BP- 2010 -1203 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24A - 171 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 -1203 Project # JS- 2010- 001737 Est. Cost: $10000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PEAK ROOFING CO 102263 Lot Size(sq. ft.): 6882.48 Owner: MARTYN TIMOTHY 0 & JANET Zoning: URA(100)/ Applicant: PEAK ROOFING CO AT: 20 JACKSON ST Applicant Address: Phone: Insurance: 119 NOOK RD (978) 660 - 8872 WC LancasterMA01523 ISSUED ON:6/28/2010 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 6/28/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo