44-025 6
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 MG.L. c;111 § 150A.
Address of Work: c)/6/ Xo eti
The_debris will be transported by: VT - el
The debris will be received at: Vg
Signature of Permit Applicant -
I ,
`Date T/e?
Building Permit Number:
•
1•
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
°ea01s .
•
— r t_ 600 Washington Street
Boston,MA 02111
�s+•'ter . www.mass.gov/dia
-Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): /1/1....:::-i�lM d4-A)S -1,) 0 Shit ll CT-/d
Address: 7 7 Rya_ % 1-c:Yi,
City/State/Zip: / 1 k,-7 Kt/ .M Phone.#: Sr6 / O c?-�
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4.. 0 I am a general contractor and I
6. New construction
,employees(full and/or part-time).* have hired the sub-contractors
2 0,I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These subcontractors have 8. Ej Demolition
working for me in any capacity. einployees and have workers 9 Building addition
[No workers'comp.insurance comp.insurance.t
required:] 5. El We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their ii.❑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' 13.0 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.
tContractors 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 th pains and penalties of perjuty that the information provided above is true and correct
Signature: � Date: 7/ `?r _
Phone#: 6 .—/09 3
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#:
11t uposttt - J
ri NEWMAN'S CONSTRUCTION
697 Bridge Rd.
Northampton, MA 01060 11 1 8
413-586-1093
PROPOSAL SUBMITTED TO PHONE DATE
STREET t, Joa e E
( t
SQ U!" f:
rn
CITY.ST TE and Z P CODE JOB LOCATION s
O� ��'KCe v '"I GtC; G 7 .r'�
ARCHITECT DATE OF PLANS . f JO ,..^NE=',
We hereby submit specifications and estimates for:
7'42,' 1-X•S Tr A,..7......., Z 1�rr vi-70,,r2- //�� l/
r_.c�c�r _�� GCt�jLf�„S_ �'�_ C;_b ,S< _`1..�
1 .
_5 d/� L t„rit-i X� 7�I L r 6 y? _ �4 Li— . R.'f 5 _._21 01 `�
r-- l
.S f4(/ - _ / Lj.�-,/ pc 212.vz% fK –1 T 44 t2 5 6y
iecizi3 C7N J/�,£{'L 27,„,,,,,
.5/62 'u,7 s. i _ 4/?G')). .i_ Cli, ' i,7. _ 5_ ondfi-c/7/11-1 0,7
79
7 7;13. .....7,// 4.--Lc.)".4-1,'.1 4.)ii--7 ..5 7-1.A‘p / 4a.,9z_t_ A-2.5 h,)4 s. _7/25- ,i ,..-.A 0
,,,,,/e7/ ,iL u:tir r ti L' .5p/(2 52.4.//,7 f)', g/?`, . ..•
.� ..5/e/,/ L3,- /2 . ,2c L r It ii5A,,,/ _ 44S- t/ o, _t e /120 f ./ 2 ze -( f /
. O og o
//
/ / o//i,,c :1 .._/f 7-- ..2id , -5 / e F 9 °L/2"e
r_
r`AG! Af. O _..D th/t?.5 12Cl144 L_4 C,'✓LI
_ /4 c21 ,.2 i_/Lr %Yz LJcJALPZ../ -4-T.-_ 7 6(2_ _s,?Q) _.A 2/1-:2. el,-i4in.. y_..sJ� ra f J� .
'fie Propose hereby to furnish terial and and labor—complete in cordance with above specifications, for the sum of:
T/ ,5 v1 / G ., I'5 7fIGr^ P. 1 C)1-)et 41 v `tt'� 1'' 11� �/ �",' dollars(S /L7 v5C).UC ).
Payment to be ma as follows: /
U
All material is guaranteed to be as specified. All work to be completed in a workmanlike
Authorized . r
manner according to standard practices.Any alteration or deviation from above specifications
Signature .
involving extra costs will be executed only upon written orders,and will become an extra g -
charge over and above the estimate. All agreements contingent upon strikes, accidents
or delays beyond our control.Owner to carry fire,tornado and other necessary insurance. Note:This prop, ay be `
\Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not ac. . d within C7 days.
Z> <
• Acceptance of Proposal —The above prices,specifications
and conditions are satisfactory and are hereby accepted. You are authorized Signatur /, ,_
to do the work as specified. Payment will be made as outlined above. / /
Date of Acceptance: Signature
ISECT!ON 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: [1 , Not Applicable ❑
Name of License Holder: e7y I?li5 id ) jf.J 1/V! (� o , Lj q 6
/ License Number I ) 1 5
LI Address / U Expiration ate
r `j�6 -)G 9 3
Signs Telephone
100
9.Registered Home Improvement Contractor:; , Not Applicable ❑
( y ado �
Company Name 6.) 1,75_jj / Registration Number AlCI Address Expiratidn Date ti
a VL ` 0 - P cx • Telephone A — (Or/
I — "lt 4.7kt jy,).e."A./
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 1083.5.1.
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
I I
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ ! Addition ❑ Replacement Windows Alteration(s) n Roofing
Or Doors El
Accessory Bldg. ❑ Demolition n New Signs [IM] Decks [0 Siding[CI] Other[CI]
Brief Description of Proposed i-lam5) ( f �� i i 5 ` S
Work: srrz`� y�LCSt + ( [ all Inv t V)� Y` 7\ t
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
V> y(J
C � �(,,J v'V) � �i %tom"Zrvt �}V�'S U' �� c%. Ac , as Owner/Authorized
Agent hereb7declare 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 Narre
Signature pawner/Agent D- e
y
I^ i
Section 4. ZONING I 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
Rear _. __ _ ___ _.
Building Height
Bldg. Square Footage - I --
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces — ___
Fill:
(volume&Location) __.
A. Has a Sp cial Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:...
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
m
IF YES: enter Book Page µ~m and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 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 0 NO 0
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,a cavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES,then a Northampton Storm Water Management-Permit from the DPW is required.
0 J
r------RECEIVED`' Department use only
��VE® City of Northampton .of Permit:.
Building Department Curb Cut/Driveway Permit
AUG 19 2013 212 Main Street Sewer/Septic Availability `
Room 100 Water/WellAvailability
DEPI:OFEUILDNGINSPECTIOn� Northampton, MA 01060 Two Sets of Structural Plans
NORTHAMPTON,MAO1o60�hon 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
5 (1 C)1-- 9 c-,--,, l 5Q tO Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT I
2.1 Owner of Record:
...)---e3 y C"z 1)v 1 U oicl ,,,...,(3 lkl c)
Name(Print) /
Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Printy Current Mailing Address:
/ <76 _)0 q"3
Signatur Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS 1 I D j 4 <� "�
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 1P5-- (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 C
6. Total=(1 +2+3+4+5) , Check Number 77g'21 36
This Section For Official Use.Only
Date
Building Permit Number:
Issued:
Signature:
Building;Commissioner/Inspector.ot buildings
Date
50 OLD WILSON RD BP-2014-0193
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:44-025 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-2014-0193
Project# JS-2014-000327
Est. Cost: $10450.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: CYRUS NEWMAN 064690
Lot Size(sq.ft.): 24001.56 Owner: AUGUST JOYCE L EXECUTOR
Zoning: Applicant: CYRUS NEWMAN
AT: 50 OLD WILSON RD
Applicant Address: Phone: Insurance:
697 Bridge Road (413) 586-1093 Workers Compensation
NORTHAMPTONMA01060 ISSUED ON:8/19/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE 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 8/19/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner