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RECEN RECEIVED SEP (3 7 2fir.
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SEP 1 2012
CITY OF 'NORTHAMPTON •
„ .
bEpt OF BUILDING INSPECTIONS
MA Construction Debris Affidavit •
In accordance with the provisions of MG.L. c. 40 § 54, all debris resulting from any work
covereckby a-Building Permit shalt be disposed of in a.properly licensed disposal facility,
as daned by M.G.L. c..111 § 150A.
Address of Work: 50 - Center St. ( Bldg.) '86 Masonic St.
wilt be transported by: Dump truck- or dumpster Co.
the will be received at: Waste -1 Ma.ssachusetts, Inc. in
Wilbraham, MA
Signature of Permit Appr
tare 9 2012
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Building Permit Number:
D.P. Carney Construction, Inc.
34 Horseshoe Circle
Ware, MA 01082
413-967-7124
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c^ "t,, The Commonwealth ofNlassachusetts
,
I ,__:
I)epartntei t of Industrial tion Accidents
t I �' Offtce of Investigas
rc )
�' ' 600 Washington Street
W
Boston, MA 02111
_ -=� www.ntass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( rtnsinessi Or, /tndividttal): D.P. Carney Construction, Inc.
Address: 34 Horseshoe Circle
City /State /tip: Ware, MA 01082 Phone #: 413- 967 -7124
Are you an employer? Check the appropriate box: Type of project (required):
1.IX I an a employer with ID 4. n 1 am a general contractor and 1 6. I I New construction
employees ( full and /or part- time).* have hired the sub - contractors
2. ] I urn a sole proprietor or partner- on the attached sheet. + 7. n Remodeling
_
ship and have no employees These sub - contractors have S. n Demolition
working, for me in any capacity. workers' comp. insurance. 9. n Building addition
1No workers' comp. insurance 5. 1 1 We are a corporation and its
_ required. officers have exercised their 10.1 1 Electrical repairs or additions
3. U 1 ani a homeowner doing, all or right of exemption per MGL. 11.n Plumbin repairs or additions
myself. I No workers' comp. c. 152, §1(4), and we have no 12.['Roof repairs
insurance required.' t employees. [No workers'
comp. insurance required.] 13.1_1 Other --- _.__ - --
.An} applicant that checks ho.x H 1 must also rill out the section below showing their workers' compensation policy intbrmaiiou.
I lontcowners wbo submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
{'o that check this bo.v must attached an additional sheet showing the name of the sub - contractors and their workers' comp. policy information.
1 am an employer that is providing workers' compensation insurance for my employees. Below is the police' and job site
i►rfnrn
Insurance Company Name: Chartis Company
Policy II or Sell -ins. I,ic. is WC009930624 Expiration Date: 11/15/2012
Corner Bldg. 50 -52 Center St.
Job Site Address: - - _86 Masonic St. City /State /Zip: Northampton, MA 01060
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 MGI. c. 152 can lead to the imposition of criminal penalties of a
line up to $1,50(1.00 and /or one -year imprisonment, as welt 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 oldie DI A for insurance coverage verification.
I do hereby certify ' ► u nder the pains and penalties of perjury that the information provided above is true and correct. ,30 5 mature: ' _ Date: Qc-__AD._
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t
Phone II: LV _ 9( r?`- -J -7 lc
Of iciul use only. Do not write in this area, to he 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: Daniel P. Carney 99798
License Number
34 Horseshoe Circle Ware, MA 01082 8/19/2013
Add Expiration Date
e a t ..o 413- 543 -3150
ignature =J� Telephone
n Not A licable ❑
9�; 1? datsten�d��Hortiilrriprd�rernettf� �• :c #+brL�2�. �•` ��, �.
D.P. Carney Construction, Inc. 121178
Company Name Registration Number
34 Horseshoe Circle 4/12/2014
Address Expiration Date
Ware, MA 01082 Tele 967 -71`24
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.. 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 f3c No ❑
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 - ocal Zoning L. and State of Mas . - ∎ s General Laws Annotated.
Homeowner Signature k : '� �� ��
ice ..,.►1
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SECTION 5- DESCRIPTION OF PROPOSED WORK (check ail applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing D.
Or Doors 0
Accessory Bldg. ❑ Demolition El New Signs [0] Decks [p Siding [0] Other [0]
Brief Description of Proposed (� _ri / �• , n Q d
Work: r t : , �R/YU I t C_
Alteration of existing bedroom Yes ,( No Adding new bedroom Yes J'C No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa fN -, .o iWal c a cl ao o e i ti q hoes neaini lefith olio t76:
a. Use of building : One Family Two Family Other A
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 la OWNER AUTHORIZATION - TO BE COMPLETED WHEN ,
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
P. Duke Corliss, Esq. ,asOwnerofthesubject
property
hereby authorize D.P. Carney Construction, Inc.
t on m eh in al afters relative to • horized by this building permit application.
Q , ii August 30, 2012
Signature of Owner Date
I D.P. Carney Construction, Inc. , 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.
Daniel rney
Prin
i , , 610 August 30, 2012
t Date
Sign • ure of �„ � - � gent
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 I a I I
Frontage 1 4 1 i '
Setbacks Front I t I xN
Side L: ` R:! L: R:L_.
Ti Rear ,
Building Height i I = 3
Bldg. Square Footage i I % I" ff g
b
Open Space Footage
(Lot area minus bldg & paved i ? w i 1 .,-
parking)
# of Parking Spaces
Fi11: i II 11 s
(volume & Location) £ :+ !I
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW • YES 0
IF YES: enter Book 1 1 Pagel I and /or Document # .
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: I
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO Q
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.
dt L
BE s City of Northampton : , ° ¢ �
Building Department ,
\----__ 6 212 Main Street �
12 Room 100
prthampton, MA 01060 s s �� �� w "
; �∎ ., 0`, SPEC ION
pEFT. OF BU.. a ^ ' '
NoRn +MF ,��, MA 3-587-1240 Fax 413- 587 -127 °� -,
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
50 -52 Center Street (Corner Bldg.) Map _.`Lot Unit
86 Masonic Street
Northampton, MA 01060 Zone Overlay District
Etrn St District CB District I
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Corliss Ruggiero, LLC 50 Center Street Northampton, MA
- Name ( "nt) .,■ Current Mailing Address: 01060
413 -58 -2289
� � " Telephone .
Sienature allr
2.2 Authorized Agent:
D.P. Carney Construction, Inc. 34 Horseshoe Circle, Ware. MA 01082
Name (Print) Current Mailing Address:
0._ 413 - 967 -7124 CA—..---"--'----- Si natu Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
`
1. Building -Re, $22 , 796.00 (a) Building Permit Fee
2. Electrical ` � ,r (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 22 796.00 Check Number jp ✓ 3
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0246 m(OS rvw
C
APPLICANT /CONTACT PERSON D P CARNEY INC o ktm ti J
ADDRESS/PHONE 34 HORSE SHOE CIRCLE WARE (413) 4803 ^)6Pjs€
PROPERTY LOCATION 50 CENTER ST ! (s 1 ' i l (122 , (SS �e 0 a. S
MAP 31B PARCEL 281 001 ZONE CB(100)/ 41. i I��6 l
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
B uildin Permit Filled out /36, 9g
Fee Paid
Typeof Construction:_REPLACE FLAT & SHINGLED ROOF
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 99798
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFf�RM 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
/4"--49 Yd —
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.
50 CENTER ST BP-2013-0246
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B - 281 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2013 -0246
Project # JS- 2013- 000408
Est. Cost: $22796.00
Fee: $136.78 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: _ D P CARNEY INC 99798
Lot Size(sq. ft.): 12196.80 Owner: CORLISS RUGGIERO LLC
Zoning: CB(100)/ Applicant: D P CARNEY INC
AT: 50 CENTER ST
Applicant Address: Phone: Insurance:
34 HORSE SHOE CIRCLE (413) 543 -4803 WC
WAREMA01082 ISSUED ON:9/11/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE FLAT & SHINGLED 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 9/11/2012 0:00:00 $136.78
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner