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31A-115 W 5 Iv' 6e)S-11)1 >10 I 60/V r 41/4 111101%/._/ Ifiev — INNS 38 VERNON ST BP -2010 -0395 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A - 115 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 -0395 Project # JS- 2010 - 000530 Est. Cost: $100000.00 • Fee: $600.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BARRY R COHEN 005639 Lot Size(sct. ft.): 10628.64 Owner: WEIS RICHARD & KELLY COFFEY Zoning: URB(100)/ Applicant: BARRY R COHEN AT: 38 VERNON ST Applicant Address: Phone: Insurance: 40 O'DONNELL DRIVE (413) 303 -9092 0 FLORENCEMA01062 -3525 ISSUED ON:11/9/2009 0:00:00 TO PERFORM THE FOLLOWING WORK: CONVERT 2 FAMILY TO SINGLE FAMILY POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: iS,rvice: Meter: Footings: Rough:" V hough: 401 ,�1 House # Foundation: (o>J gel Driveway Final: P• ' �'� Final: J Final: 7 r s t ' 3 r/0 Rough Frame: ( ? C. RP j'"\ 11/Z3/o Gas: Fire Department Fireplace /Chimney: tl Rough: Oil: Insulation: Q 1 Final: -3 ''p/4' Smoke: Final: OK ' oz- col C i z Lau, l s THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATN OF ANY OF ITS RULES AND REGULATIONS. Certificate of Y — Occupancy Signature: p FeeType: Date Paid: Amount: Building 11/9/2009 0:00:00 $600.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo The Commonwealth of Massachusetts 4 Department of Industrial Accidents Pt - 1 t Office of Investigations „ _ • i7 600 Washington Street e. "m. Boston, MA 02111 `+ www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information y, Please Print Legibly Name ( Business /Organization/Individual): M ) V, C I) eirty) Address: CIf (?tkrbier f QC). City /State /Zip: L� 1 f �J^. Ol3jj Phone #: 5 � " S 9 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub contractors 6. ❑ New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' insurance.$ 9. ❑ Building addition comp. [No workers' comp. insurance required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ 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 13.❑ Other employees. [No workers' 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 r , d penalties e, perjury that the information provided above is true and correct. e Si. nature: '-- - — '�� � Date: S . / Phone #: I f6'.59 a - 9 4 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 Supervisor: Not Applicable ❑ Name of License Holder : CS C25 filry-i F ryyjn4 License Number Address Expiration Date I 5 ' P49-5 t ] (e--' OC P Ci- ZOl Signature / elephone 9. Registered Home lm vement Co tractor: Not Applicable ❑ . -� I Z 1 5 5 SY Com nv Name / Registration Number nfrj /:71/ erh rcad C- V6 /zv 1 Z Address /� / Expiration Date ./ f fiNeee25/ r �-) -r ' , Z t T J5 8 elephone —928€ 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 ❑ ii. - Home Owner Exempt 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) t l Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [lam] Decks [(] Siding [O] Other [t]] Brief Description of Proposed Work: ftF - /I,v -Two rt.e /JAY./ "Lrrittbv 6 ir/4.0" c.f &. 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 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 !c_D � N AA-0 W 0 5 , as 421, - uthorized Agent h by 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. ru CKAM La S Print Name 5 /i`7 /i0 Signattife 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: 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 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO QD DON'T 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 NO (-z 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. Departmenypse only., City of Northampton Status of Per ,1it Building Department Cu utt rove y Pefittrt I U1 212 Main Street Sewenl$eptto tlabfl R ��{ 1 ' , Room 100 W ,;Northampton, MA 01060 Twe;Sets of St t aural Puns . phone 413-587 -1240 Fax 413 - 587 -1272 PioftSite Plans OtherSpecify ' 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 N.l ,n/ j1 fL i Map Lot Unit Zone Overlay District Elm St. District CB District 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Kg ( CoffE (cf -z0 i,✓k J �- Name (Print) Current Mailing Address: qt 3 _' 8 8 Telephone Signature 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building Z'S© (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) 1 '2150 Check Number /f _. This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date BP- 2010 -1015 GIS #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: 00 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -1015 Project # JS- 2010- 001496 Est. Cost: $2150.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 10628.64 Owner: COFFEY KELLY & RICHARD WEIS Zoning: URB(100)/ Applicant: COFFEY KELLY & RICHARD WEIS AT: 40 VERNON ST Applicant Address: Phone: Insurance: 40 VERNON ST (413) 588 -1652 0 NORTHAMPTONMA01060 ISSUED ON:5/17/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:REROOF 2 SECTIONS 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 5/17/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo Sep 21 09 01:52p Robert Fortier 4078941440 OW 411 LLIC1.;.] J.J• L..) ',1“0,,,,,,u.a. _ JD . 7 _ _ ....01, Rae ' . . 1 . • • . ' . . . , . . HOME OWNER EXEMPTION ACKNOWLEDGEMENT - • . . • • . The State of Massachusetts allows the homeowner the right under 108.3.4 to i act ar his/her construction supervisor. Tie state defines - Ham eow ' ern as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one r twofamibl . dwelling, attached or detached structures accessory to such use an or farm structures. A • person who constructs more than one home in •two period .-, ll not be considered a home owner." . . , i for* Ci..4tON.i .* P ., : • ' 9W .0 -#0.P. u . s - e the.bonteiiiiiiitexeroption;.to act as their oiyiiumtilisti ioilil;eliwiii fiat by„dping soyou become responsible for compliance with spate 1i codes and .icegiiionitiuiresiliet the :build'. , • .,. : ...ent be called to inspef:t Workatvarious stages, which include fountlitianifoqtinffs . . or .backfith sonotube holes (before pearl. a roughlbuiitlinilisPeeilon (befo work is . conee:iled)...insidotion linspeittion lif re4iireell' and tnal build', e inspection. The building department requires these;inSpeati Ons 'ocealed, failure to . sceual: ltese.in t.:..., :. i '.c ' ; .2,.... ult.' , failure t , ob - ..a . • Cs . uhtillheiftrk can beiliWitied; . ' 1 . " • " . • • . • . Ittliebotneacvnerhireslother -trades to .p work .(eleCtfiaal, 411 .. i ingLit.,gas).:the. home.cwnet will be responsible to make sure that the trades hired $ cure their proper permit issued,and_tbat they get their required inspections: Failure of the individual trades to securethe permits a .d inspections as - . requind can DELAY the project until such time as the proper pe .. Is and inspections are made . . . - ' • • . -' . , • . .. .. • '. - - - - */ iti t ,..,..,, . p , 4 .„ ,..4 1, e,.. 2. _. . . _ . . .. . erstand the above. Yr elitiii . --. • ; . 7fAetirsOurgre - . • .--,.- ': - • • • .... • I will !:a11 to schedule all required building inspections necessary to the building permit igtidd .. ",..•r• •....“..4.: : ., • • '. ' . . .o..........*••-■-.......■..1.■••••■•••••••■........ ......... ... . ' . . Addr(Ot s of work -...■ - locaticn . • — ....- - - : id . , . .40 i 41.,,t • Ag • / - • I . - • ..- . . . „ . „. — . ... ... . ,.- .. . ... .. . - " . • — . 0 dil. la 4 - AA I . 0 (X; - . ... ...___ • • . , • • /6 s . . Sep 21 09 01:52p Robert Fortier 4 0 7 8 9 4 1 4 4 0 P - s 89/ 21 / 20139 i3:3 . 413ttib (1101 UULILIIN rpivc. uweo . . .. . . . • • . ' . .,C: ■ The Comm.. nwealth ofiVassachusetts ' • _. . ' 7_..-.-.—.._. , • Departme . ofIndustrial 40cidents • . 0 , e of Investigations . . . . • • 600 Washington Street • " 1' T....A1, .13 tort, MA 02111 . . . . . . vvIdia • .. . -..„,....... , .. , .mass.gov/dia : , . .. 'to . • • ."..: -Workers' Compensation insurance -' it dark: Builaers/Contraciors/Eleetricians/Plumbers • •:::: . Applicant .(o.formation • .. Please Print Le6blv • : .•fi ,. . • - • Name Ottsin'esi/Org*ationandivIdnal): ' . - . . - • '. :::.','..: ' • A.dc1=5:____ ' c256 1 • - h ' ,. 1 . _ • 0 - 0 f 4‘ o'c 3971'6. • ... ... • . . cit • phone.#: LICL - E 9 ii-P' . . . . Are you an ea the appropriateloa: . , • . 'TYPe of piviect frequired):. 1/ 1. 0 I ana a ea:plajten *lib: . 4, 0 I a general corctractor aini. r 6. .0 New cotiscivition . ceaplOycc:: (fall and/or part-e) have bired•the rig■-coatractors i 2.0 I am a iOln pi-aprietor'or.ziattaer- ' . .... ■-.! pil flie sheet: 7- 0 PAlF" • 14.*P'll'av•Fi..*q7'.!c33Ts. • m14 Aavm 8. 0 DeinalMon - . ' - - ' Tiorkim ik_zaeica a= cailac vk itz. . ....... .... .- et:0 :=3iiidevEcdrVaNie irktes' '• ' - • • •• • •• ,• • • - ' • - • ..• --- • --9,-.441341.14*-a . . . - . • 5. 0, We. • a.c ,..,,. . .'9EL ai'd its 10.0Electnical maim or adations • • recluilcr-.1 -- - ' 3.Z 4-tun-a-hettleowrient-deing-ell-week---r--Qt ' . or adatioos , . . . • mysel lacn L tl■') i62')v cOmp. • , right . `f 7 Per 14101, . . . 2.D.Roof tepairs inswaiice :tdquir" all , • . .. . ,c: , il(4),_andiv4 hav6 • . , e 2 • • • eirpt•x -.:..- [No weckers' • . /AD °lei' . ' ... . - - • . ... . . - • • . • .• . • , ' • ' . :. '' • . ' . .. • crcimP- iPsataziie 'Any applicant-that ti7 gt rei41*44n oat die ,,ctio. idaw.... ,.. gm! Cron pbt4 ininpatiegt. ' ' . ' : 1 ' Horocowizecilwboqxtinittiaiie 2154:Whvgaarinkittiiiild'aing al: - .nidAticixiliri awsida*Tioinctsinuai a new saThinvit diCasingsunts: ' tgairnacans OW clodt.gbil box . mast inaand sin idiStiond Awe till74a : tbe nazni of the vnbmansficzciar lad s ' ,. *Wier or not-shosavittitles law '. • .. • anspli,res. 1{ tha iai):1isairaital itiiii.insileielict mitiseprovilit .--- • Tfo*Cie comap,poriCirstutpbcr. I - • • . . '. • - .. '. . ' • 1 me ex employer thegisPiovisting workers.' . compezteatia inswance for pzy ereployees: Below is eke policy au! jobwile _IT_____Igtio2_!- ,...,.....1.:._ 1...._...-.... ......_:: : ,.....,.... ...._ . • t • :•-•-•-•••:. ••?•‘,-- - - • - -, - •• - • .' :. • ' • ' • ' • . ' Iiisniance Couv azy Name: . : • ' • : • • , . . . . . . , .. . ... .., .. . • , - - . . Policy 4 ne,Solf-ini. Lie: #: ' • • . . • - . ..1q:itintion Dai: ' .. Job Site Address:- • ' . • • • • • • •• '' . • :. City/Stile :' ". - - , . • ' • . • ... • Attach a •copyr of be Trtirkeie''epriiiipistigon•pOliCy-d; - ' :on patelsh arizig the policy iininbeinl:41xpis:a.#6' n tla FailizreJO seeiCe.'cOoir.44* lICA--` -:' k5..,..m.i*...t.cief.frii..Aci4,_'6.6i213 a . fine Up to $1 an.cl/or - dvii pen kit the farth, of* STOP W ORD*2.. 44 a f ' ' Of up to $250.00 a diy•agaiiilt,t*Wiolaterl.-Ale advitoel"11* • cy cafe:its slannaleat fciisynided.,:iiv tiln-CtlEce'of . . . „_T=At____2f_tu:icnis. fia: DIA: • • ".:•• • - CO -,Lcie L .. . - di . 7 ifilii 4:14;iiiiiiibi)iii iiiiiiia 4 ,-,itia0 ".'--- '';:-V4i .- L . ' .. . ' ' ''. • . , .. ... . .. ..... . . . ... . • . ■ • • , ,•.... , ... ... ■. •■ . • , .• .. • • . . ... .... . .• . . . . . . . • . . • _ i ate:. .■ ., - /At,- , - . ..I . -.,_--_. ''' . - - :' •- - .. • ..--... ' ' • -.-.• . 1 . • ' . • • . ' I .. . . . . _ ... . _ . ..... - . . .. .. USe zij 0;til5a - , : n . 1;;711111if,tg, -- - tibe comp .ed tor.city or rma ' ' .. . . . - ' • • • • . - . ' . lItiiy, zr . . _ Town; ..... • • . . . • . . _ .. '.....: • • L Pinititicirse 0 '. . • , - . . ' . . . Issuing Authority (circle one): . . . • 71,--Board of14a.t:k 2... Stnikli 3.: CItyll'owzrelerk- . ti..-Etectriegl ....,:••• ‘ 0 5..linzajn.g,,Ingector.,_ _ • i. cither • ' k ' . . . • • ' • Contact Person: . • Phone #: • . . • . ' • . . . . . • * 4 . , . Sep 21 09 01:51p Robert Fortier 4078941440 p. G J LTJTJ-1 J• LOVA. • ••., • • SECTION a - CONtliTRtfM1Qhf ..1•CgS 11.1 Licensed Coast ruction superyorN Not Applicable 0 Slame of ticeue Hokin ; • License Number Address Expiration Pate • Signature Telephone • • , , , , Not Appliceble 0 Cam ra_Dr Name Registration Number / Address \ Expiration Dale • - . • Te aphoon • - • • „ . Workers Comports-all 3n InsufanCe . affidavit must be completed old subrnitted with this application. Fattu\toprovide this affidavit will result in the denial ofthe isrluance of the building permit. Signed Affidavit Atinehed Yes 0 No...... • • - - ..--,..-The.etur.c:Lcacmptipnlor..1MIXIMOVES." walalMiltdioinolac °weer-occupied Agoellities of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provichld that the owner acts . as sanely isar—CIKR7X0. §tottlt F.xlidon Section 193.3.54. pefinictOrt of filkiineoWrier: Person (a) who own a Pakeel cifland ou'which'helabe esides or inberals.to reside, orr,vobich there . • is;'orisivndedlo iineyr twolamilir:dweiling,•attache&ordctachad ossory• such-uscandiar-forre — • • • structure. . .. ki)ersisn wale erniSiticiiets Val" oallifod•shall iiiot be voilaIdeked.'s isernmowner. • .S6Ciithceili.OT*21:4..w:00v)sitC1.34Cg.C.),ffic a1 on a pinsitecuptable to the Building 0 fheial.-that harsh e shall be resoonsjoie... I ok erio 6 I a iUdin • . e t-• since On the job eit6Will be renuired from imc to time, during and upon completion of the wait for which this permit is issued Also be abised that with ref:rano.To piapter151 (Weekors' 'Compensation) and.Charer 153- (Liability of Emplorrs to Etoploy.eli; for mjurte not'resylting-ktteAh) pf the MasiachtFetts General Law Annotated, vbn may ba liable for person(s) • • • ' • • •• • • " - • " The Undertigned "homeowner" aastan .,,.mr-ttotnp hence with "hi State sigicung Cede; city of " " • " . . . , • • 1 . c • c C;• < • w< '0 Ibl: P.: • lb bi • • eki011:204.461k1:601;k10:: 1=7: 7. 1;4:meow:ler Signature.. it • , - -•• . . • • • , • • — • • z476, Sep 21 09 01:51p Robert Fortier 4078941440 p.4 o7/ 4. LOOT I.J. LJ .4,1..1.-100 1 CH .7 VV1.T711Y:J . ,.- v.a. vv SECTIONS- DE;,.iCRIFTION•OF PROPOSED WORK (the ell apo1IC thlel . .New Noose Q Addition [l Re . iaacement Windows Albaration (s) [] Roofing 0 ' Or ► - ors it - ' Accessory Bldg ❑ Demolition - ❑ N Signs (©] Decks [© Siding (J Other (C$ Brief Description ❑f Proposed {� Work r i ,.,, e , / i►,« - a...•. . • 1[ k S Alteration of oat ng bedroom 'Yes )C ' No Adding new bedroom .. Yes X No Attached Narratjvtt .R= novating unfinished basement es )C • No Plans Attached Rolf - Sheet • a. Use of building : 0 = amity Two Family Other , b. Number of roams in each • ay unit umber of Bathrooms -,.._ • c. is there a garage attached? d. Protioied S,3 :lore footage of new col+" . • - bit D40err91one • e. Number of s4 :•ries7 _ _ _ _ f. Method of h._iiting? -- - - _ Fireplaces or Woodstoves Number of each g. Energy Consi: rvatlon Compliance. Masscheck Energy Cornptianoe form attached? h. Type of consliuction , i. Is cOnatnaction within 100 ft. of wetlands? Yes No, is «.• structien within CO yr. floodplain Yes No j. Depth of bacernent or cellar floor below finished grade . k. Will building conform to the Building and Zoning regulati• s7 Yes Nc . i_ S _ ; pity Sewer Private -l1 f ity'watef Supply *.! VNllilt RO ACgNjl , 6 t`d - - --or— r . s4, i &. 4_ - •-e..,-• . • ' • 1. _,miiimminni- ` • , as Owner of the subject property authorize . w • hereby autho • to act on my behia in el matters relative to work authorized y this building' application. . Signature of Otvits _ _ _ i7lte 1, _ . ..:as Owner / gent hereby deuliare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge tt iz+itef: .. . . . • Signed under the pains and Penalties of perjury. I,Ildr� - . coC41 4/1-' . Pent Name /w : ' - • ature pi nerAgaant _ _ �te . X. Sep 21 09 01:50p Robert Fortier 4078941440 P • 3 09/21/2009 1:3:23 .413586 filtll. CaUtakal.Ne t"'HUt VG/ [JO . ' . . ' . • Section 4. ZONING All Infortna tfon MUSt Be Dieted, Permit Can Be Denied Due t. Inc amp,.. Infomietion .., .. Existing Proposed R !uirod by Zoning . .. . • N. Thi• column no be filled in by _. N . Bid -*.g Department I _ Lot Sizs m III , IL — i 1 — From . -, 1 .\ 11 i.- 1 _1 • Setback! Lktit. =•\., 1 ] r--1 . , . Side L:= R.: L:1 IR11 --.. Building ileigbr - 177 \ = . 1 j Bldg. Senare Footage r I 1 1% I \\i I i i .1 °Ike Siiaii Footage j % \ eLocritta calm bit% & paved I, 1 1 j 1 i r" • :". - - .....--- 1 - -- # of Parldttz Spaces 1" I 1 _.........• _ !..,_ i 1 1, 4,, _ . _ Fill: 1 i volume a ticatiun) f I t ill t .4 A. Has a Sp • errnit/Varlance/Finding erer been issued for/on the sit;? . . NC) 0 DONT KNOW 0 YES 0 . W YES„ date issued:' . . W YES; Was the permit recor. -. at the Reg'stry of Deeds? • IF YE3: enter Book Page '" -- -- - •-• ' .. - . I and/or Document #1 1 . ; B. Does the site contain a brook, body of wate i • wetlands? NO 0 DONT KNOW C.) YES 0 IF YES, has a permit been or need to•be•obtai - • from the Conservation Commission? • Ne?tis to be - 0 : tiiiiineci Ili , Date Issued: [—:—.—... --1 .—_—____J C. Do ai signs exist on the pnaperty? YES 0 ? ' 4 O 0 i I • _ ,___,.. IF YES,' tiese'rfbe•si2e; type and 1r/cat 11 ion: , 4 • ...____ ... . .. .. . .... .. D. ..Ara...there any.woposetr changes to or.:eridibo.tis of interocg v tbe ? YES 0 NO . ..... .. . IF YEi, describe size, type and location: I - t . . . ., _. .. E._ .W4l.the.00Nsttuttiotiadkay-disturb4oleatiag;:gratlip or In over.1 a. - or is it part ofa common.pIan - that will disturb Over f OErti? YES 0 . M P 0 1 . ........ .. .. . • -:-- " IF ''f'-'• t P-NarglemPito StPril Water-Management Prearit frinet-tere:OPW.la_requa*j_... .. ._ 1 . . . . . Sep 21 09 01:50p Robert Fortier 4078941440 p.2 U! 411 4QCJ 1J. GJ `•i..1dov r 6K./1 V1J,1 1arl., I ntiar_ cra vv • S x City of Northampto 1 �< , ` ,., , Building Departme �_�i _ = a • 212 Main Street ;z��.: . ,: - n -- • Room 100 , Y ...;,_11.,....:. a Northampton, MA 01 F • 0 � phone 413 -587 -1240 Fax 41 887 -1272 ' F _: APPLICATION TO CONSTRUCT, ALTER, REPAf - RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING • `•' it1 ce /1.1 Pr :.* - _ Tius sedioa to. be Comp' } 4v O r •. 1 .• „]„ � 0 . Q 1 °6 'sit° . • . ' ..''. D veit a yZa f t d "- ' i y9ii MMte - •• Ca •Oi v t . „ . •.Uangin_ •• P.F#,I E'F1'*.ililtiEt EEh 3F i`' ! . • ..IA 4 �: 2 .1 • tiwifir of Rriiiniii: _ . -•.•�+, n ,,.�.. __ Nam p�� .. i 4 t.t1] g9_14.... ('.. 9rrr • Name (Print) i k T i 3i.`tp'° e o ..' Current Mailing Address ""'tJ ''J gh �� :5?... e- Telephone 7 Sign 're _ • 2.2 Auth6rtzed ant ^ C ' • Current Mailing Address: l (*id.— .... • • Signature • Telephone S _ .. ..�i 0 :0 li f� , 1 �Y�4�Z: .. . _. -. Item V •+ Estimated Cost (Dollars) to be Y = ' " ~ : — i' t3te U9e completed by permit applicant r.:',.•;... ',. -.... . 1. BuTding a; _ � d j /��!� , pL� i d; ri: - 2, Electrical " sq`,i,ta;7aic9t� • • 'tr am+: ' . 3.. Plumbing .. - --- iiifiirWi l6tt kg, • MM ; S A. 4. Mechanical (}-P, AC) • . ' • 5. Fir - Protection - = :. •:` - - � - .. 5. Tail =.(1 t , 3 +4 +5) - d l 40J• °° . , T N � b1r :.. - . - - - :S_ -.r.: _.,: ::... -n,. ti5. ,t:w :":7,-.:. , t .T. t a' �:T� "4' er } J: •.'. -: _. •..... — �' 4 .. "'a .. .. . v. . .,.b1:1' L1 ti � ssveflC . • • - ` r.. __ -... t'6r3e g Teb b riir''kliat ariDrt iinalligs - w -.: .. ._ . - - - dote'• • • • .-- ' • • I I/6: ■ .Ja.n, fi s1 6.1A . • pCk r,3 „14 ,5-4-6 . File # BP- 2010 -0310 APPLICANT /CONTACT PERSON FORTIER JANYCE & PHYLLIS MISCH ADDRESS /PHONE 2506 DELLWOOD DR ORLANDO (407) 894 -1440 Q PROPERTY LOCATION 38 -40 VERNON ST MAP 31A PARCEL 115 001 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 JJ ,��,// Fee Paid /L `�` Typeof Construction: REMOVE LATHE & PLASTER 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 F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 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 Demolition Delay i _......gailliel _mai—it 4 " 2.2..- 2.496; 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. BP- 2010 -0310 GIS #: COMMONWEALTH OF MASSACHUSETTS .; iB1ock: 31A - 115 - 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 -0310 Project # JS- 2010- 000412 Est. Cost: $1000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 10628.64 Owner: FORTIER JANYCE & PHYLLIS MISCH Zoning: URB(100)/ Applicant: FORTIER JANYCE & PHYLLIS MISCH AT: 38 -40 VERNON ST Applicant Address: Phone: Insurance: 2506 DELLWOOD DR (407) 894 -1440 O ORLANDOFL32806 ISSUED ON:9/23/2009 0:00:00 TO PERFORM THE FOLLOWING WORK: REMOVE LATHE & PLASTER 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 9/23/2009 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo v , 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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation 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 obtaining 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 to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE Revised 4 -24 -07 Fax # 617 -727 -7749 www.mass.gov /dia The Commonwealth of Massachusetts Department of Industrial Accidents 41 --1; � � Office of Investigations '141 600 Washington Street Boston, MA 02111 '1_ ` www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): 7?/OvL 4,C. y /L Co/i." - -tti/ Address: -° ef) inj,.,,ci t2 - D,,e. City /State /Zip: f2 o,z e-,oc T ol662 -7 s`ZSPhone #: 5 -505' 2 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and 1 employees (full and/or part- time).* have hired the sub - contractors 6. 11] 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 capacity. employees and have workers' g any P tY 9. ❑ Building addition [No workers' comp. insurance comp. insurance.* required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] 1. 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: -/ -� Date: 1 ?At /2 o a y Phone #: ¢/f —?s7 7 6 5 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 Supervisor: Not Applicable ❑ Name of License Holder : %3,4 Ye. /j GO/t( s License Number ¢° C 4- lac / %co,cLswc 6 /662- - ?SZ Zoa // 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 ,1- 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 r SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) .® Roofing l i Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding [O] Other [o] Brief Description of Proposed Work: `,, Z�� p ,, l2 � �N auv ® ,NS (iV /Z��� � (((���j , !�«- -- 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 • ENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT a I, t r ► � r h / S , as Owner of the subject prope y I V � hereby authorize to act on be I, in all ma ters f ive to work authorized by this building permit application. ../e / / -' Signature of Own " ( 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 Department Lot Size N/A Frontage /(:)/4 Setbacks Front Side L: L: R: Rear Building Height /f Bldg. Square Footage )//A Open Space Footage (Lot area minus bldg & paved fr/4 parking) �Q # of Parking Spaces //✓ Fill: (volume & Location) /U/ A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0- DONT KNOW Q 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 EI DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 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 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. Department use only City of Northampton Status of Permit: , Building Department Curb Cut/Driveway Permit 1 . 212 Main Street Sewer /Septic Availability 6A Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 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 r _ ¢e v •e mow f Map Lot Unit No QTNra 4fa .J n, ra o/ oc, o Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: l'(CHAco te2.Ly coT /SC y 78 -1-0 M .✓Taw a/s(a Name (Pr t Current Mailing Address: f ' — L f1? o ✓- 4, ?- 6fftj Telephone ea ure 2.2 Autho ' ed Agent: ' Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building S7 2 j (a) Building Permit Fee /' 2. Electrical (b) Estimated Total Cost of l 0 ° Construction from (6) 3. Plumbing Building Permit Fee S od 4. Mechanical (HVAC) 5. Fire Protection / 9 S -4) 494 6. Total = (1 + 2 + 3 + 4 + 5) o 0 Check Number 30■ This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2010 -0395 APPLICANT /CONTACT PERSON BARRY R COHEN ADDRESS /PHONE 40 O'DONNELL DRIVE FLORENCE (413) 303 -9092 Q PROPERTY LOCATION 38 VERNON ST MAP 31A PARCEL 115 001 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 al r J Typeof Construction: CONVERT 2 FAMILY TO SINGLE FAMILY New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 005639 3 sets of Plans / Plot Plan /// fr (A 1 / 1114/1 ° T HE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INATION PRESENTED: A pproved 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 .„,„... , ... / Ad' Signature of Building Of 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.