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24A-185 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 outthe, workers'co nn cation affidavit c e y checkingtlie s - eynur yn 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 returned 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 of 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.obtainin 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 tnjve usa call_ = -- The ifepait nut's address, telephone and fax number. The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street . )3oston, MA 02111 Tel. # 617 -727 -4900 ext 406 or 1 -877 MASSAFE Fax # 617 -727 -7749 Revised 11 -22 -06 r www.mass.govldia The Commonwealth of Massachusetts ;IT . _ Department of Industrial Accidents = Office of Investigations ="4 1.t* 600 Washington Street � Boston, MA 02111 ,;. www.mass.gov /dia - Workers ' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Let( Please Print Legibly Name ( Business /Organization/Individual): � I U \ -..e) h , Address: `5` ✓k- Bey, s I City /State /Zip: 1 (c c. t ei Phone. #: v� -5i - 7 Are you an employer? Check the appropriate box: Type of project (required): 1. II] I am a employer with 4.. 0 I am a general contractor and I have hired the sub- contractors employees (full and/or part- time). * o. ❑New construction 2 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have. no employees These sub - contractors have g, 0 Demolition working forme in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ 9. 0 Buiirlingddition re aired 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3. 0 q ] officers have exercised their I am a homeowner doing all work „ 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption 'per MGL 12.111 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. lithe sub - contractors have employees, they must provide their workers' comp. policy number. Iam 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 Investieations of the DIA for insurance coverage verification I do hereby certify under the pains and penalties of perjury that the information provided. above Ls_ -_ 15 � (� /ril Signature: A ate: (( _ Phone #: 5 7 5_90.1 Official use only Do not write in this area, to be completed by city or town official f City or Tu wu: r ermit/i.icen # ___ 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 : k„ v 1 it 0 7 License Number Address Expiration D to L(( Ski - 9∎ 11 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ c . ?L. i,, ,;a, ,; �� � t CO 6 7 3 Company Name Registration Number 1/t-^ec . 5 . it 7/%o Address Expiration Date Telephone Y S `j 1 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 2E9 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 -vear 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 buildine 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, von 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 !Q Or Doors O Accessory Bldg. El Demolition ❑ New Signs [0] Decks [p Siding [0] Other [0] Brief Description of Proposscc Work: r ., p .- .i ✓ c, .z. 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 K I, L_-/ SC G J • pa /ertrZ°0 , as Owner of the subject property (� , hereby authorize C ° �tl f 1--c&v to act on my behalf, in all matters relative to w authorized by this building permit application. Signature of Owner Date „r1.1., + ci , 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 penal ies of perjury. Print Name 1 VG/4; 7 Signature of Owne Agents'" Date Frontage Setbacks Ergn 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 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 ® DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES © NO t IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® 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 C NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit m_ Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans a � J phone 413-87-1240 Fax 413- 587 -1272 Plot/Site Plans • ; S 1 Other Specify `APPLICA'PION IA£ONSTRUCT, 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 Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: C LILTa , pal G5 3? C VS 2 Name (Print) Cu t i ali g r / / J/ �vn r�7 dd h 7.717 /7 2 X '-'/7 � f e7 J 2/ Z Telephone Signature Q (PO 207 - 2_ L,G 2.2 Authorized Anent: C ` �\ � , t ∎\ - t C 51 Mo. , • Ste', Name (Print) Current Mailing Address: $� ' 4 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building — 14° °° (9° (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 v,c #36 This Section For Official Use Only P(/ Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date • 5444 BP- 2010 -0531 GIS #: COMMONWEALTH OF MASSACHUSETTS 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 -0531 Project # JS- 2010- 000745 Est. Cost: $7000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: C PHILIP ANDRIKIDIS 071107 Lot Size(sq. ft.): 5009.40 Owner: PALERMO LISA J Zoning: URB(100)/ Applicant: C PHILIP ANDRIKIDIS AT: 55 JACKSON ST Applicant Address: Phone: Insurance: 52 MAIN ST (413) 585 -9171 FLORENCEMAO1062 ISSUED ON:11/13/2009 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 11/13/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo AGAR[! DATE (A NIDfNNYYY) CERTIFICATE OF LIABILITY INSURANCE J 11119,2010 PRODUCER Reim 413 - 8634373 Fax 4134634658 TINS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION A.H. RIST INSURANCE AGENCY, INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 159 AVENUE A HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. BOX 391 ALTER THE COVERAGE AFFORDED BY IltiOUCIES BELOW. TURNERS FALLS MA 01376 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: NAUTILUS INSURANCE COMPANY IDEAL HOME IMPROVEMENT, INC. INSURER 13 PILGRIM INS. COMPANY 142 BOYLE ROAD INSURER C: TECHNOLOGY INSURANCE COMPANY GILL MA 01354 INSURER D INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE itistmerie NAMED ABOVE FOR THE POUCY 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 INSURA E AFFORDS) BY THE POIICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE UNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CANS. EtSdt,„Re POUCY EFFECTIVE POUCY EXPIRATION LTR IVJSRC TYPE OF INSURANCE POUCY NUMBER POUCY ANAVOINTYI CATE Q ANTOrn1 LIMITS GENERAL L MBRrTY GL 20109221 11119110 11/19/11 EACH OCCUIINENCE $ 1,000,000 X COMMERCIAL GENERAL uaea m s N $ 100,000 1 CLAMS MADE fl OCCUR MIED. EXP (Any one pennon) S 5,000 A PERSONAL & ADV INJURY S 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE UNIT PEtt PRODUCTS - COMP/OP AGG S 2,000,000 — 1 POLICY Flom- n LOC S AUTOMOBILE UAftY PGC10009703302 11/17/10 11/17/11 COININNED " AN AUTO ) INGLE Li INrT 5 1,000,000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ B X HIRED AUTOS BODILY INJURY X NON -OWNED AUTOS (Per ) X MASS. POUCY FORM! PR - s GARAGE UABI JTY AUTO ONLY - EAACCIDENT _ S _ R ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG S EXCESS I UMBRELLA LIABIUIY EACH OCCURRENCE 3 OCCUR EJ CLAMS MADE AGGREGATE S S DEDUCTIBLE S - RETENTION S WORIERRS COMPENSATION AND WC1136680 11/18/10 11118111 X ( I 1 I ortim EMPLOYERS' LIABILftY Y / N EL EACH ACCIDENT S 500,000 C OFF CE EXCLUDED? © E.L. DISEASE -EA EMPLOYEE S 500,000 Wand/dory iMN If yes, demobs wger EL DISEASE LIMIT S 500,000 SPECIAL PROVE balm OTHER DESCRIPTION OF OPERATIONS /LOCAT1ONS/VEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS Classification: Insulation CERTIFICATE HOLDER CANCELLATION IDEAL HOME IMPROVEMENT, INC. SHOULD ANY OF THE ABOVE DEAD POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS 142 BOYLE ROAD WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO GILL MA 01354 DD SO SHALL SSE NO OBUGATIDN OR L ABIITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES. AU HOWED REPRESENTATNE Attention: raC .JRU WNCz ACORD 25 (2009/01) Certificate 8 23873 ®1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registemd marks of ACORD - " • 'V '-' ' - - gge ‘ 4 „, , # A . if 1 A 4 i 4 - - 1 Board o t m • mg , P..egu I a ns an. tans ars s One Ashburton.flat;e , Room 1301 , r-z-----g.— i . _ . - , ..:._-- Boston. MasschasetIs 02108 . . . - Home Improverrief 1;,._, - - . --..!.. _.....,. . . . ... , Registration'. 1413402" • Type: * Private Corpciration - Expiration: 4/22/2011 Tr# 281491 _ — . . IDEAL HOME IMPROVEMENT INC: ,*- JAMES ELLIS ..._ 142 BOYLE RD • . GILL, MA 01354 . , •_____ ______ _ _ ____ , • ,.. • , s -- . ' Update Address and return card. Mark reason for c!ranL - - ri Address. 0 Renewal 0 Employment f: Ust 0- DPS-P <.'1 -CA1-080S-D8SUFORYDA1 08212006 * •-- , ... ,.., . , . . . • . - • • , . . *-. V .,,-- NhissitehttNett■ - Department of Public `safeh Board of Buill iinv. Reimiati(ms and stanttarCis License: CS 91207 . T JAMES P ELLIS 142 BOYLE RD GILL MA 01354 — _......y.. A111 1101.111114 .: Expration: 10/16/2312 t iiimiii.siiinci- :, 322____ romit_ Property Address: Ja ckMYL h c e._ N ame: for (VIAL— /' 6 N.L I N f ov e N Name: +�"(1 Address: 14 City, State: CI J (1 4 01 Phone: 4-K ° R.3 07 Property Owner kJ S ¥ajermc) Name: Address: 65 -Jack SSn City, State: rP. vl P e.. 04— 01010 1, JO rune E I I S (contractor) attest and affirm that the building I intend to insulate does not have any open air (knob and tube) wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit. Contra • ' "gnature C V Date If)c� 1I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations r.:; ',., -= , 600 Washington Street r - � Boston, MA 02111 f sw # www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Mat. / /4 - 014-e / t f '2 0 V '-', h Address: 14 ) yJ (_ eol City /State /Zip: 1 j i 19 D 13 S4 Phone #: 4- 113— 8 i)3-- 2/ c 1 Are an employer? Check tl} appropriate box: Type of project (required): 1. I am a employer with 'r] 4. [ ] I am a general contractor and I 6. ❑ New construction employees (full and/or part- time).* have hired the sub - contractors listed on the attached sheet. 7. 0 Remodeling 2. ❑ I am a sole proprietor or partner- ship and have no employees These sub - contractors have 8. El Demolition for me in any capacity. employees and have workers' working Y P tY• 9. 0 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 R of its ' insurance required.] t c. 152, §1(4), and we have no 0 j � " /I employees. [No workers' 13. Other / n S ik/GC., D�'U 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. 1 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: LeC h nO 4 /ji rail—1 —e----all pa-f — Policy # or Self -ins. Lic. #: W C / /,3 (4, tel. 0 Expiration Date: i i 1i 8 I / J Job Site Address: 35 JO C kS() City /State/Zip: — 4i 0 (r1 e 0106 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 certi , under the pains and penalties of perjury that the information provided , i ove is true and correct. / Si a ature: �!_ 'i i 0 Date: I / 0 / Phone #: /3 ° 2 /ci 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 #: . SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Sup rvisoorr: , Not Applicable ❑ a Name of License Holder : r n e c Q/o w r7 License Number 1 LDk & 1)Ci. 6,I/ M4 01 Address J Expiration Date '413 ( Si Lure Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ &L UjAL__ 1 M rizoVe ite ay I i-/-6 zfo.:), Com an Name Registration Number „ , // r 4� 0)34- 1-t- ,9 / Ad s Expiratio Date Telephone T& - j 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 build permit. Signed Affidavit Attached Yes Q 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 o o family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who construe a than one home in a . . s • is s all not be considered a homeowner. Such "homeowner" shall submit to the Building : •.1 e . orm acceptable to the Building Official, that he /she shall be responsible for all such work performed and • - e buil ill • ' • rmit. As acting Construction Supervisor yo . esence on the job site wi : - required from time to time, during and upon completion of the work for which • • permit is issued. Also be advised that with re ence to Chapter 152 (Workers' Compensation) an hapter 153 (Liability of Employers to Employees for injurie •t resulting in Death) of the Massachusetts General Laws • stated, you may be liable for person(s) you hire to perfo r• ork for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the .te Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General La Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Oth r [ Brief DescrJotimolf Pr. • . e Work: / C ko > , G tO 3 ac k t'19 , n Knet ;a91 • l03 s ' k'iv (Wail 4 0o r k' i Alteration of existing bedroom Yes �No Adding new bedroom Yes �--No 4 r Attached Narrative Renovating unfinished basement Yes i No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete the foliowinq: 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 a (lf rM , as Owner of the subject property hereby authorize '�.J a/'ne 5 F'i/1 S to act on my behalf, in all matters relative to work authorized by this building permit application. �..✓ - ' B IZ ` - ice 6mC 117/11 Signature of Owner Date , 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 t e pains and penalties of perjury. a YW F7i t S Print Name i d ( 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 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 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DONT KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW ;�9� YES O 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 O NO ✓' IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® 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 (3 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 t 1 Room 100 Water/Well Availability orthampton, MA 01060 Two Sets of Structural Plans ph one 413- 587 -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 _..t S jacks-AA Vr Map Lot Unit Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 1`1 S oL. Pale Vr 10 ,Vune. prope r�y Name (Print) Current Mailing Address: l J K67- f:- -- > Telephone i 7 - eci Signature 2.2 Authorized Agent: .Icy r>72 S 'il/ /Lf & y 1L 6i ii i'/4 Ol'35Y Name (Print) Current Mailing Address: i f 13 - X 6 3 -202 2 S' ure Telephone 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) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection _ 6. Total = (1 + 2 + 3 + 4 + 5) ( ri 1 X Check Number / L5 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2011 -0628 APPLICANT /CONTACT PERSON IDEAL HOME IMPROVEMENT INC ADDRESS/PHONE 142 BOYLE RD GILL (413) 863 -2128 PROPERTY LOCATION 55 JACKSON ST MAP 24A PARCEL 185 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid ,( Typeof Construction: INSTALL ATTIC INSULATION r_ New Construction N e& I/14, a tY J 51 C2 e- e ry c \ ,::,eJ I Non Structural interior renovations Addition to Existing d a.-e rekeeL Accessory Structure / , f j Building Plans Included: / f 1 a er55e' i SCI'' b e p._ bitoc,1/4J Owner/ Statement or License 091207 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN ATION 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 II -- . litio . 1 :y :>,,,,„---, � � . ..f# I - l 2-- 1l Sig 7 of Building • icial 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. �= s q, BP- 2011 -0628 GIS #: COMMONWEALTH OF MASSACHUSETTS 485 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 -0628 Project # JS- 2011- 001013 Est. Cost: $1712.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: IDEAL HOME IMPROVEMENT INC 091207 Lot Size(sq. ft.): 5009.40 Owner: PALERMO LISA J Zoning: URB(100)/ Applicant: IDEAL HOME IMPROVEMENT INC AT: 55 JACKSON ST Applicant Address: Phone: Insurance: 142 BOYLE RD (413) 863 -2128 G I LLMA01354 ISSUED ON:1/13/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATIONKNEEWALL MUST BE ENCLOSED OR DENSE PACK,ATTIC AIRSEALED BEFORE BLOW 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 1/13/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner