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31A-091 j _� City of Northampton y ,d 1,` Massachusetts * ,- s � DEPARTMENT OF BUILDING INSPECTIONS y. � n Municipal * 212 Mai Street • Mun Building -'4:P. r ar Northarpton, A 01060 t b�V k?� M A ....--- e— ( „, , . _) D ' 7 rN Property Address: i ' ._.-- Contractor 4 Ski �- � ,_ .,(. ,� Name: f� ,� Address: t ) '.A:k 1,,/e'' `` 1 J City, State: r J/ ' �_.6 f-z I") l .' l J l l / 6 '? L 2 1 . Phone: �/ D /v'- J --- , j L I Property Name: Owner l (I /44/7/ 1 Address: 3 ) fAor j"311 j / I City, State: AZ2) , , t 1�,r; ��'^ /- Yi I, J 7 �. �,' -/i `/ (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_�h a copy of this affidavit. i ■ J Contractor sign u_ ( f Date / 0 ) j / The Commonwealth of Massachusetts PfitltFotm_ Department of Industrial Accidents Y1 Office of Investigations #= 1 Congress Street, Suite 100 == � Boston, MA 02114 -2017 '' s* www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): ( S ) ( • - i "✓ L' Address: PO /�—. co/ r f City /State /Zip: Phone #: 41-3 J ��� 7 Are yo n employer? Che Ic the appropriate box: Type of project (required): 1. 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 capacity. employees and have workers' g any P t) 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. ❑ 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 re - insurance required.] t c. 152, § 1(4), and we have no ❑ p ,,. employees. [No workers' 13 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. ' / 1 l,Lz Insurance Company Name: Policy # or Self -ins. Lic. #: t'x C / - 3 ) '"J'�� 7 c v / 1 Expiration Date: OS /3 Job Site Address:3 5 14"Ic►rl co-d4 A O� 0 6 6 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 certi - the pa' : d penalties o periury that the information provided above is true and correct. Signatur-. _ ., 44 Datel - Phone #: / y/3 - V7 Vg 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 Su ry r: & rJ k )11 Not Applicabe ❑ Lf731/ / l /�/`► License Num r !/ 6 60/c. 1 - f � c off, ,'» 0/0a) j 3 Address Expiration Date /� I 1 L ` �I - /a S/ 'gnat Telephone 9. Regis #ered Home Improvement Contractor / L --LC Not Applicable ❑ /6 ci 7 Com an Nam Registration Number 6 q 0_16 Address � /t /'� V ) Da d ` .Y°17-5° Expiration Date ` � / / c- / 1 L e. ini L Telephone`s /5 SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers Compensation Insurance affidavit ust be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildin permit. Signed Affidavit Attached Yes No ❑ 1: - 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 Ls � al Zoning L nd tate of Massachusetts General Laws Annotated. Homeowner Si nature . ' / / �', a " �/ " 10lL.� 1 g I i SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House [] Addition ❑ Replacement Windows Alteration(s) n Roofing I I Or Doors 0 ' Accessory Bldg. El Demolition I:=1 New Signs [D] D c s [❑ Siding [D] Other Brief Work Description of Proposs )v . I (4 ` j 4 ` `AR (a Pi k+r S Alteration of existing bedroom Yes 17 No Adding new bedroom Yes ✓ No / Attached Narrative Renovating unfinished basement Yes ✓ No Plans Attached Roll - Sheet 6a. if' Near house amt or addition to existing housing, complete the followfna a. Use of building : One Family I 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, i /NA 1A , as Owner of the subject property hereby authorize # ort/AL to act on my behalf, all matters relative to work auth rized by this building permit application. X ) 7 1/J Pli -'-' ,-, ---- C. -) Signature of Owner Date I, r l^ k /Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best f my kn ge and belief. Signed under t arcs and penalties of perj ry. j , .... irt-i116 / Print Na m , J 5gfii ( 4 Signatu f 0 gen V 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 ver been issued for /on the site? NO 0 DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Regi ry of Deeds? NO 0 DON'T KNOW YES 0 IF YES: enter Book ! Page a d /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date sued: 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, ex ation, 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. •1■0 001°." 4."1",;75-711 otw, 1l Eg illrrn-A. t ( . 1 SO 413E0 144r—nj - • rafigriFainia., t Department use only City of Northampton Status of Permit: SEP 1 0 2012 Building Department Curb Cut/Driveway Permit, 212 Main Street Sewer/Septic Availability, II IIIROF111U11.01r10iNaPE0TIONS Room 100 Water/Weli Availabil4 ,,, jrIttillitaLiliftotos) Northampton, MA 01060 ... . Two Sets of Structural Plans phone 413 Fax 413 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION I This section to be completed by office 1.1 Property Address: ,-- . / f'- V-eri\- -) - Map Lot Unit ..../...." t) Zone Overlay District I( (//V: ,.. i ::) i i i , ,,,,) , ',1.- 1 1., , ' I Elm St District CB District SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 7 'N' ; : Name ( rin Curpent Maili410 , 0 kt,4.(4'7 /174L-L—r- /kit) i Telephone Signature 4 / .. * .5 )(;:i-:- ___v' 2.2 Authorized Agent: ,- - 1 -- 5L 7 C1 ,...j't L-)': 1 "e v 11 ,, Pi -- i /,)- 1 ,- d i i„..., , ,...,, - / - (,.. o n ‘.. /-:(-,--, ,4„ , , li ..------, Narn,,efrnt) ,. . Current Mailing Address: 1 MIE!Tr Telephone SECTION 3- ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 4. rik (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) , ,g--a--- Check Number A ' ir F. 3 S This Section For Official Use Only Date ' r t? Building Permit Number: Issued: -. Signature: Building Commissioner/Inspector of Buildings Date Illomminomininummoim., CM-,(-- " K i J 0� t, u e� File # BP- 2013 -0272 ? A ��dkv l tissi RAN ' For-r4 APPLICANT /CONTACT PERSON JEFFREY BRADSHAW ADDRESS/PHONE P 0 BOX 1276 CHICOPEE (413) 427 -5481 C f + F `� p �, ) Lo-t PROPERTY LOCATION 35 VERNON ST MAP 31A PARCEL 091 001 ZONE URB(100)/WP(14)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT �� Fee Paid / 6� < Building Permit Filled out Fee Paid /v 9g �. Typeof Construction: INSULATE WALLS at t" Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 094734 3 sets of Plans / Plot Plan THE FO OWING 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 am. G ,9/1z Si 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. 35 VERNON ST BP- 2013 -0272 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A - 091 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit # BP- 2013 -0272 Project # JS- 2013- 000439 Est. Cost: $1622.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JEFFREY BRADSHAW 094734 Lot Size(sq. ft.): 4761 1.08 Owner: HOLLANDER PAUL & MINA M HARRIS Zoning: URB(100)/WP(14)/ Applicant: JEFFREY BRADSHAW AT: 35 VERNON ST Applicant Address: Phone: Insurance: P O BOX 1276 (413) 427 -5481 WC CHICOPEEMA01201 ISSUED ON:9/19/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: INSULATE WALLS 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 9/19/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner