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29-408 (2) cY►� y 36i. c1( fu S r�cf 55 t ,bodcCi hocL 1 01(3,(\ t o _ / ooj t ci, -Posh o 6 i•u s s� ' f �4 tc -t f e s k t• l Sn Skt � 3 v ty, j�Fcif S ilodsc e ‘rt Soy4 (i4 11. Alyr 611 SO I ( N, V/ .j1-114 I\.,0v , v v v 'j ru5S 't e/ft e)-)k Ac... 1 I avek-:-MQ / , 2,j_j, ci ') ?)10,1‹. corfe,,,J2,0 .6b %ft) ho d< P �w '� roe 5 o :� . /air ‘ ' t gps / 1t ^-( h1 N .w 3U " 4i 0u-f. T-ros 5 ' c) -1-te. 1 j 4) 1 ( o -3 0 I' /Pro �II � roo� \ � oua- h-04` eAd. 1 f f oc,1L 1 o _ v y0_0. prtc;r, --fr epS-t 712i e pre' (JJ )N. /to & S Ley G. 1L - v+ r 0)(\5 9 t,tr Ig9' il,z) . 0 ill 74 qg3 rccq- q/ 7 CITY OF NORTHAMPTON , Construction Debris Affidavit In accordance with the provisions of MG.L. c. 40 § 54, all debris resulting from any work covered by a Building Permit shall be disposed of in a properly licensed disposal facility, as defined by M.G.L. c. 111 § 150A. Address of Work: , J t9t, Al1 // 4,,,P The debris will be transported by: 9'"c//34.,,—/ 5 (2,At The debris will be received at: Vc //t ,, , Signature of earl' Applicant a....i _4j, Date ( / n / I_ Building Permit Number: • i. The Commonwealth of Massachusetts Department of Industrial Accidents —W Office of Investigations r j 600 Washington Street ok ':1. ,,, Boston,MA 02111 m e ' www.mass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers Applicant Information Please Print Legibly Name(Business/Organization/IndividuaI): Address: City/State/Zip: Phone.#: Are you an employer?Check the appropriate box: Type of project(required): /i 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 subcontractors have g. ❑Demolition ° working for me in any capacity. employees and have workers' g Y P tS' 9. ❑Building addition o workers' comp.insurance comp.insurance. required.] 5. 0 We are a corporation and its MD 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.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required.] ' *My 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). t M 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 cert.,i u thr p ns e Ides of perjury that the information provided above is true and correct. Signature: I� _/( Date: (� ;)-t) 13 Phone#: Y/. S_ ! - Li1 g Official use only. Do not write in this area, to be completed by city or town official , • , t f M ' M • t ♦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 F Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor. Not Applicable Name of License Holder: License Number Address Expiration Date Signature Telephone 9. R-..,..•- r- . a• u a 1 • IL_, .• u_r_a: Not Applicable d4 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 ❑ 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 twn 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. (9 Homeowner Signature /4,Ct .1{,,eQt_ SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Ad Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs ED) Decks [p Siding[DI Other(C31 Brief De ption of Propospcl /' f Work: to y1/Lo f a `t✓ `I .e V t 6.4.Q �t�c r I(Lc CM f().o r 6 An v - cI G�cQ /o\-' 0 tre4 Ae-n11 Alteration of existing bedroom 1' Yes ° \ No Adding new bedroo Yes X No O1 3O/ 6-4 ; T C Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Be. 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 I, l , /- OAis ,as Owner/Authorized Agent hereby declare that the statem and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed u der the pains and penalties of perjury. �ri1 -t T --t, mss . P int Name all ---/ ;� 6 , 6 7 O/ Sign u • of Owner/Agen 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 DONT KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 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 DONT KNOW © YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO ED IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO , l IF YES, describe size, type and location: E. Wit 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 O NO /dip IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only RECEIVED y of Northampton Status of Permit B Iding Department Curb Cut/Driveway Permit '12 Main Street Sewer/Septic Availability 7 2013 Room 100 Water/Well Availability ort ampton, MA 01060 Two Sets of Structural Plans DEPT.OFBUILDIN a' I"r -5 :7-1240 Fax 413-587-1272 Plot/Site Plans NORTHAMPTON,MA 01060 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 g3 leej2 Map _ Lot Unit J/\--(f /1') o i o 1- Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Ow per of Record: lbr Ecnr,L7noct s-t, a5g_ 7--/In 40s Name(Pn t) CurrerttiM ing Aoe n �- e� pI// � r Telephone X&re 2.2 Authorized •ent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only pompleted by permit applicant 1. Building R 0 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) �s 5. Fire Protection 917 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Numb- Date - , /�-f Issued: / — Signature al iG�l / ��� 0/3 Building Commissioner/Inspector of Buildings Date 89 SANDY HILL RD BP-2013-1172 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29-408 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-2013-1172 Project# JS-2013-001931 Est. Cost: $3500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 17206.20 Owner: ST ONGE ALBERT J Zoning: Applicant: ST ONGE ALBERT J AT: 89 SANDY HILL RD Applicant Address: Phone: Insurance: 89 SANDY HILL RD (413) 584-4198 () FLORENCEMA01062 ISSUED ON:6/7/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF &ADD 12" OVERHANG 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 6/7/2013 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner