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w" 6: DEPARTMENT OF BUILDING INSPECTIONS = t
°_
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION NtSURANCE AFFIDAVIT
y LS 0 A.r ._a / // _ v,//7--(... 5 Ato /IL L, ,�7� /:z.aGf , 7 /r2_S,'7 i, 1r�'°1 L
(licenseelpermittee)
with a principal place of business/residence at:
•
3 -fv /0//f e$ 1 2, 1 ), -zVZ /0, `1 nri AV (phone #) `38 - 7 ZZ
(str sttatehip) 61/64 C%
do hereby certify, under the pains and penalties of perjury, that:
Q) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
%SZ /_.r_`ss' ..��1_5 (fa GO G F6 O' 55 / 27/7 %2
(Insurance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company /Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional shed if necessary to include information pertaining to all coo radors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself
NOTE: please be aware that WE I: h=a orra VAIG erisp1oy persons to do te an , construction or repair work on a dwelling of
not more than three units in which the homeowner a esi s or on fk gs v'ards ,- ¢ re • e.a aft not g ail y i &r:d rc. t;
employers under the worke s oatpnta ation Act (GL152,sa 1(5)), application by a homeowner for a lid or permit may evidence the
legal status of an employer under the Worker's Compensation Act.
I cuadersfand that a coFy of this statement may f arded to the la.pern000t of Industrial Accidents' otiir. ea of Insurance for the
coverage verification and that failure to secure coverage under se ..ion. 25A of MUL 152 can lead to the imposition of criminal penalties
consisting of afire' of up to 51,500.00 and/or imprisonment of up to or : year and civil penalties in the form of a Stop Work Order and a
fine of 5100.00 a day agairzst me.
Signed this ? day of 0e- /2 : r 12 gr ° ' /� 6, For dal use only
f%' / 14 ;� '` ''� e f �' .e° Permit Number Lot #
c: „a..- .-, '_f t F'A!
�• �� �:wee.rermiifee
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
- / Not Applicable ❑
Name of License Holder : /v hLS ,57777" / 0 3
r L2- / c w/ £ j fi / • License Number
5 v 7(:/ �'S / rL /G/ j /G'C!`/7/7 %7,. Z7V- ; /✓I/ 6/v6.7 � 21/ T
Address Expiration Date
7
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
j / , 1 z — ' 7 7 4 , - 0 / / / . Z % , 2E ,/‘>
Company Name Registration Number
1c/f / l 1)/�tG/� 7/j:77 �
Address Expiration Da
k' f /7.7f- M/7°1(" °76 (, Telephone 571-
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 ig 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 Euii'ding 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 Wipdows Alteration(s) Roofing n
Or Doors L�
Accessory Bldg. ❑ Demolition El New Signs [D] Decks [El Siding [0] Other ED]
wor no� rqp� s f d Lott v f�✓ ' 7 !A"' / -54 /( t3 to tt A J S 4/..�
Alteration of existing bedroom Yes 'V No Adding new bedroom Yes it•
Attached Narrative Renovating unfinished basement Yes A/ 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? // / 17
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Oh 4 t/v 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
I, �.G/ Z4 77/ Z /L -L , as Owner of the subject
property
hereby authorize /VGG:SQ /v -5/f/ L £ 4 ! /ft" 1 f_ /i l /�'/2Z /PLf j/ . / /L C
to act on my behalf, in all matters relative to work authorized this building permit application.
I
Signature of Owner Date
I, //e4. -- S 7 .- (7 //r7 — / J7 T ', LE / /72, 17/ / 27 1 144 s 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' ent 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 33
Side L: R: � L:
Rear
( 3 ow
Building Height �(�
Bldg. Square Footage C % {
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Sp ial Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO a DONT KNOW 0 YES O
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO (V DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained 0 , 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 O 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 I}-
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
-.
,. ----
?i,J;;;■.1 - .
__. . .
Department use only
•
• ity et Notthe trip ton ttatut at iltriTitt:
uric g Department Curb CutiOnveivey Fruit ._ ,. ______ . . . ___.
• 80 00 04 • ' • ' 12 Main &milt • BeAreriBebtlo Avtilability _._ • .
ROOM 100
Northampton, MA 01060 Tveb Sett ot Strticturill Rent
phone 413-587-1240 rex 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAiR, RENOVATE OR DEMOLION A ONE O TWO FAMILY DWELLING
SECTION i - SITE INFORMATION
- is sottish to bo somp.skati by office
tiallaSatilif:
ii 2 /9 77/ ?)E.i5cS. Z__ Map .. .. _ _ Lot _ __ _ unit
q2 "4 /if 6.5 fr- 3
tone •_ . Ovetisy District ___ _ _ .
ft / I , W 1 /7. 741 ti n t ' / Z.V1, _ .:
Si District DS District .
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZEO AGENT
Xi OvinathtitesuNi:
2 4../912,/ ;e?."i:)Zi-Z- .., .3s C Klifot•__ etl
Natne Petit) Current Mailing kitireSs:
6
h( e' teltphont OZ-L3ie
Sigsiatu t ___ __ 7 "
uagtagot 4-22-_ 5 / / /16X
//IOW i ri-77 , ,/2x , / -/ - ) / C 4; ._
Name (Print) Giutent Mailing Addiete:
Signatute ._ . _ _. ____ Telephone _
. item tstirnated Cost (Dollars) to be Orticiat Use Only
completed by permit applicant . . . _ _ _ _
1. &Wing 35 (a) Building Periiiit r se
a 6 J .
2. 1ectriteit (b) Estimated Totsi Cost of
,5 a .C_Ottnictiori ttotti_f_6,)_ _
. ._ _
3. Plumbing __ .
@Witting Pont Fes
/4 Q 0 a •
e
4. Mechanical (14VAG)
5. Fire Protection
Total . 7---0_+2 4 + 4 + 5) - - te / c7 - 16_ --- . tis& -- .-
__ - - 2//7 • 6. O r 7_,._ ere
._.... _ _ _ _._
._
This Sottish Fbt Offisisi tits Ohl _
--- - ------ - -- ---
Date
Building PeriTht Number: Ittued-
_____ . _ _ . . . ______
Signature: __ . . _ ___ _ _. . _ _-__
Building commissioner/Inspector of Buildings Date 1
File # BP- 2011 -0741
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 Box 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 242 PROSPECT ST
MAP 24D PARCEL 226 001 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 c2 1 /7 3z) c
Typeof Construction: REMODEL BATH & KITCHEN & INSTALL NEW WINDOWS �;
C..
New Construction 1V 1 `i p f- � �'
Non Structural interior renovations
Addition to Existing (�
Accessory Structure
Building Plans Included:
Owner/ Statement or License 060300
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN/ OpiferrioN 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
Demolition Delay
-- ; 2 3 7/
nature of : uildin. 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.
242 PROSPECT ST BP-2011-0741
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D - 226 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2011 -0741
Project # JS- 2011- 001232
Est. Cost: $50000.00
Fee: $300.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 5706.36 Owner: SKOWRON JEFFREY J & SUSAN E MAYHEW
Zoning: URB(l00)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 242 PROSPECT ST
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584 -7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:3/24/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL BATH & KITCHEN & INSTALL NEW
WINDOWS - ENERGY STAR WINDOWS
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 3/24/2011 0:00:00 $300.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner