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25C-021 (3) �Y- r City of Northampton y aryv; c,\S S1 � y Massachusetts �w�' "- `��G. t Q4- ., d t Y DEPARTMENT OF BUILDING INSPECTIONS 1. yv° 212 Main Street • Municipal Building vds C`D \N.,'y Northampton, MA 01060 SNW 3''D‘^ Property Address: q Nor-1k Contractor ` Name: ain-?S D i 1 S 1 . iik4 efeo lfr iwt J Address: P4,91 f lk cL . City, State: G i 1 01 &L- -\f Phone: T 3- g(v 3 - ale) d Property Owner Name: K akc,ik A-c__ Gt CC Address: I q i- No r City, State: NO r`dCfAirApqM 1 c I, kW S Di , 3 (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 with a copy of this affidavit. tractor si ng ature 7___ eix... Date riIt 5 (i3 \ The Commonwealth of Massachusetts Department of Industrial Accidents l� Office of I fv'estigations � :ler 600 Washington Street V_ gi Boston,MA 02111 6�. Tlifill-i.nitiss.gov/dia Workers' Compensation Insurance Affidavit: B€ ilders!Contractors/Electricians/PIumbers Apnlicallt Information Please Print Leaibiv Name rganization/lndividual): /f j ¢e G(£._ LL, 1 -1 ti r 0 tI e t1tLG`i J /1\ C • (Busine..s.O� /�� • J Address_ !1 Eta\lie_ 1-2c4_ - �J l C /State"Zip: �J i1/4-11-1-- 01 '`1- Phone}#: 4-i r- L' '3- ,4142 A:-e you an employer?Check the appropriate box: j ; i Type of project(required): 1 1.1:0 I am a employer Rath fl 4. Q I am a general contractor and I 1 employees(full and/or part-time).* have hired the sub-contractors j 6. r New construction 2.; I I am a sole pt oprietor or partner- listed on the attache sheet. El j I. Remodeling 1 ship and have no employees These sub-contracto s have f g_ 0 Demolition i working for me in any capacity. employees and have workers' j y comp.insurance.} p. ❑Building addition 1 {[ o workers' comp.insurance p 5. r; it a are a co oration and its 10.( 1 Electrical repairs or additions { required.] s— Tp 1 3.1 1 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. o workers'comp. - right of exemption per AML _ p c. 1�2 1t" and whave no 12.p prof repairs , j insurance required.]t ,g • )_ —✓ 13. employees.[No Ivor ens' E Other 1 n i Gt a h 6-Y L comp.insurance regiired.] j j 'Any apes .t that chxls box ill must also liii out the section below showing their worker's'compensation policy information. 'Hcmcot hers who submit this affidavit indicating they are doing all wore_and then hire outside contractors must submit a new affidavit indicating such. =Contractor that check this box must attached an additional sheet showing the name of the sub-contactors and state whether or not those entities have employes. If the sub-contractors have employees,they must provide their workers'comp.policy number. airs an employer that is providing workers'compensation insurance for my employees. Below is the policy and job size info Ti. ) Insurance Company Name: 1.'(C 6 a,Z 16_, /11 S-GLt tl is, ( G y),Api/,'./R,G t 1_, policy#or Self-ins. tic.=: iry C - U 0 :00 Li-4 LW 1,-)6 Expiration Date: ( I 1 i l a2' I 7 lob Site Address: 1 qii ✓ 1 OiKi'L \cf. C't/StatelZip: ✓ L'rOan► �IM t m4-- 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 NIT,c. 152 can lead to the imposition of criminal penalties of a fine up to 5 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine o 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. 1 do he - E. , lb,under the pains and penalties ofperjuly that the infoimation provided above is true and correct Signature: '�- G��-- 1`� 1�S Date:�i( �( _ Phone=_ '' 1 - gc,-,3 - ,QIdis - 1 Official use only. Do not write in this area,to be completed by city or town officiaL 1 l; `t • f I City or Town: ?ermii'Li =nse T I; issuing Authority(circle one): I i' 1 1.Board of Health 2.Building Department 3.City/Town Clerk 41 Electrical Inspector 5.Plumbing Inspector 1 I 6. Other t i it 1 f[ 11 Contact Person: Phone#: ; l SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable Name of License Holder: e,JU rnS fi I ' N q I �1 License Number !,+). yk ec4 • 61 11 m4-- o ► 3.cN obko Address Expiration Date Cei � I 2Z -ELK ature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ 0 rte_ M ere 0v`e N i 1 4(4, 4O Company Name Registration Number lid, e yIc &c_. . JJ..f 5 Address ) Expiration Date lD ( 0) 3 Telephone"1/3 — 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 121 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:Perso• (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 .• ily dwelling,attached or de . . • • ctures accessory to such use and/or farm structures.A person who constructs mo han one holm• ' two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building it i ,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed and: e .•ding permit. As acting Construction Supervisor your p sence on the jo: .'te will be required from time to time,during and upon completion of the work for which this •- 't is issued. Also be advised that with referenc- • Chapter 152(Workers'Compe •.tion) and Chapter 153 (Liability of Employers to Employees for injuries not resu 'ng in Death)of the Massachusetts Gene .1 Laws Annotated,you may be liable for person(s) you hire to perform work for 'ou under this permit. The undersigned"homeo er"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 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 0 DONT KNOW YES 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 Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0) YES 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 0 NO t> IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © 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 ® NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors E Accessory Bldg. ❑ Demolition El New Signs [D] Decks [EJ Siding[0] Other[I /113 Wan i->- Brief Description ot Proposed Work: /Jo - Ce rise ()etc Lea, cas k Cp tc I 1 i 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, ka re n 6 Par e_ ,as Owner of the subject property I hereby authorize KY)? S E I ` t S to act on my behal ,in all matters relative to work authorized by this building permit application. lC J c11,IA-- -_,A.,-. -` ► Signature of Owner Date I, la ITV-S CI 1 1 S ,as Owner/Authorized Agent hereby declare that the tatements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and enalties of perjury. 'Jodi -' 1 Print Name ature of Owner/Agent Date __�_ Department use only t j City of Northampton Status of Permit: 13uil ing Department Curb Cut/Driveway Permit 2 2 Main Street Sewer/Septic Availability i________ JUL U 2013 Room 100 Water/Well Availability N rth mpton, MA 01060 Two Sets of Structural Plans DEPT OF BUILDI Ip jig( _58 -1240 Fax 413-587-1272 Plot/Site Plans NORTHAMP7�j�.j}Q��A�b90�p 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 f q`f n IQ r, 1 A. Map Lot Unit / V '1'! Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 1, d,r-C ' 6-(ACC J&ie as prype ir'(y Name( nnt)) Current Mailing Address: )(\ n J'47 66)0C—R------- Telephone Signature /41 3 G t 7 — p oo 2.2 Authorized Agent: s er1 , s iLiON &. k eck. 6, 111 1,'j4- 'm3 Name(Print) Current Mailing Address: --- .. c{I. & L 3 ,,,2) Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building ,2�j0 ,`?i -- (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) 01-0 4`"f - Check Number .2//..:l 3 This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-0104 APPLICANT/CONTACT PERSON IDEAL HOME IMPROVEMENT INC ADDRESS/PHONE 142 BOYLE RD GILL (413)863-2128 PROPERTY LOCATION 194 NORTH ST MAP 25C PARCEL 021 001 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 dig �s Fee Paid Typeof Construction: INSULATE WALLS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 091207 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ION PRESENTED: 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 � 7- 3/-/3 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. 194 NORTH ST BP-2014-0104 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C-021 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-2014-0104 Project# JS-2014-000201 Est.Cost: $2044.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: IDEAL HOME IMPROVEMENT INC 091207 Lot Size(sq.ft.): 6229.08 Owner: DEPACE KAREN Zoning:URB(100)/ Applicant: IDEAL HOME IMPROVEMENT INC AT: 194 NORTH ST Applicant Address: Phone: Insurance: 142 BOYLE RD (413) 863-2128 Liability GILLMA01354 ISSUED ON:8/1/2013 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 8/1/2013 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner