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ITED STATES
P TALSERVICE® USTOMER'-S RECEIPT
'ABR Use Only.
BA. OF IS RECEIPT Pay to
FOR I ORT, CLAIM '111' O/V M Ow d f /I1 KEEP THIS lion No:
IN ON Address A RECEIPT FOR
NOT YOUR RECORDS c Date:
NEGOTIABLE H •E
Serial Number lril Year Month,Day Post Office bn Date:
21258820282 Amount Clerk
2013-11-19 414350 1254.00 0005
1. NAME OF APPLICANT: Jay Watson
(MUST BE EITHERAN INDIVIDUAL,CORPORATION,LLC,LLP,TRUST,OR OTHER LEGAL ENTITY)
2. NUMBER OF EMPLOYEES:
3. APPLICANT TYPE: X INDIVIDUAL _CORPORATION PARTNERSHIP _TRUST
(CHECK ONE--MUST BE SAME LEGAL ENTITY AS THE ENTITY IDENTIF1ED IN#1)
4. SOCIAL SECURITY#: 107 64 2373 FEDERAL TAX ID#: n/a
5. APPLICANT PHONE#:413 522 7769 APPLICANT EMAIL ADDRESS: bickford67 @hotmai1.com
6. MAILING ADDRESS: 50 Maplewood drive Amherst Mass 01002
STREET CITY STATE ZIP
7. PERMANENT ADDRESS: same
STREET CITY STATE ZIP
PLEASE NOTE THAT A P.O.BOX IS NOT ACCEPTABLE FOR PERMANENT ADDRESS. YOU MUST LIST A STREET ADDRESS.
8. IF TILE APPPLICANT IS A CORPORATION OR A PARTNERSHIP,PLEASE PROVIDE THE NAME,ADDRESS,SOCIAL
SECURITY#AND'1T1'LE OF THE INDIVIDUAL WHO WILL BE RESPONSIBLE FOR THE CORPORATION'S 1.11E
TRUST'S OR THE PARTNERSHIP'S WORK(Please review the Instructions before answering this question):
LAST FIRST SOCIAL SECURITY# TITLE
9. IF APPLICANT IS DOING BUSINESS UNDER A D/B/A,PLEASE STATE THAT DB/A,AND ATTACH A COPY OF THE
FICTICIOUS NAME CERTIFICATE FILED WITH CITY OR TOWN CLERK
DBA NAME. I use my name (jay Watson), not filed
10. (a)DOES'1'HE APPLICANT OR RESPONSIBLE INDIVIDUAL HOLD ANY O'1.111R CONSTRUCTION-RELATED STATE,
CITY OR TOWN LICENSES OR REGISTRATIONS? X YES No
(b)IF YES,PLEASE FILL IN INFORMATION BELOW.ATTACH ADDITIONAL SHEETS IF NECESSARY.
LICENSE TYPE ISSUED BY LICENSE/REG.# EXP.DATE LICENSEE NAME
Construction Super Mass cs-079105 10/09/2014 Jay b Watson
The Commonwealth of Massachusetts
EL,.....,—. , Department of Industrial Accidents
Office of Investigations
=' `_ r, 1 Congress Street, Suite 100
_°it..:, Boston,MA 02114-2017
t www.nuzss.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): 3 AN S , W F4'TS J ti
Address: S 0 M.9tP4 a woot' Dt ••
City/State/Zip: .nn 4 e.t b r d ► b p t Phone#: y (3 S 2 2 " 1- 6
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
employees (full and/or part-time).* have hired the sub contractors 6. 0 New construction
2. I am a sole proprietor or partner-
11!1 listed on the attached sheet. 7. []Remodeling
ship and have no employees These sub contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers'
g y p y 9. Building addition
[No workers' comp.insurance comp. insurance.:
required.] 5. 0 We are a corporation and its 10. 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 Roof repairs
insurance required.] t c. 152,§1(4),and we have no
employees. [No workers' 13.0 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.
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: 3 a.,,r„7 Date: Nov. /�C t 2. 0 i 3
Phone#: 4.1� (3 5 Z. +Z, ` - 6 ck,
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: J h►Y 6. W s A-rs. ,- C,- G.$ 'a Q 1 'I 10 5
U V 0.2. License Number
Sv MAPh•0. woo 0e . AAuk%C..ej }" )0f aI 14'
Address c ' J` Expiration Dat
/4mt4acs3 /MA-53 0(00 2
Signature Telephone
1 .. L( (3 5' 2 2 -i
9: estfstllttteti%ion*l tii€olielnreltf O+ssthr2 tti#; Not Applicable ❑
SAY wlArrs0 - 15 S e1► 4
Company Name Registration Number
1,,,,km 6s ... t:•dwS T to L. ri J-. ( l2.4 I':.o ix
Address .7"7` i Expiration Date
SO 1•1014‘.4-140009 Ott. Yrti >WCA-. '1(3 2 S Z
Telephone —{
I
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(8))
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 buil ing permit.
Signed Affidavit Attached Yes No ❑
11. I ome;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 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,Stat' ■. s•cal • ,t La an State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing 0
Or Doors El
Accessory Bldg. ❑ Demolition El New Signs [D3 Decks [C] Siding[L]] Other[CI}
Brief Description of Proposed . � �
Work: AA.111r;An WotxK soVC' to S ; Oz b 6-Air"JJi
Alteration of existing bedroom Yes 'i. No Adding new bedroom Yes /' No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Sheet
6a..If New hogs*and or addition to existing housing.tomoletelhe following: A a i\ 4;o.,.. 1-o
a. Use of building : One Family Two Family Other (rA CArG 6..
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached? 1
d. Proposed Square footage of new construction. 3 0 0 Dimensions '2.. LI # 1 2
e. Number of stories? t
f. Method of heating? /%F t! 4"4 6A-r Fireplaces or Woodstoves o Number of each U
g. Energy Conservation Compliance. Al(3 Masscheck Energy Compliance form attached? A) V
h. Type of construction W OW) 'F 4114,AA%A
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 Li Y II
k. Will building conform to the Building and Zoning regulations? ‘17 Yes No.
I. Septic Tank 1A City Sewer N./4' Private well 14'44 City water Supply 14*
SECTION Ta-OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, -----1-- / Nt
1, �� e �� ,as Owner of the subject
it property
1
hereby authorize �-4 OI L../ 1,14 5 ON—N
to act o alf, in II masers tive to work authorized by this building permit plication.
t
/r'!9/ .
Sig Owner (' Date
I, J A/ w PC=6J"' ,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.
a A►Y w Arts 4
Print Name •
�),- i✓• wOV • I$ l Lui 's
Signature of Owner/Aged Date
C:
/A Pr1r=��-1 pb3S yam'`! cr
Section 4. ZONING AU 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 Z,.p Not N trr
Setbacks Front
APP
Side L: R: L:: R: rJ N
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking S aces
Fill
(volume&Location)
A. Has a S cial Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued::
IF YES: Was a permit recorded at the Registry of Deeds?
NO DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES 0
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 (
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,exc vation,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.
D scent i 04;
City of Northampton of P
Building Department Cu-� eay
;t am:
`1` "f 212 Main Street Se r{ gpt�c �v a �r ,
t� 1 9 23\ Room 100 �p is
s s 4 f s f S
�� �� )Jo ampton, MA 01060 t`wo ' � f�,,� , ., s
l�„�__r;�--p-1161.18-741-112t- :7-1240 Fax 413-587-1272 P t
Electric. . n _ o 1, U1 J � �
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
I
1.1 Property Address: This section to be completed by office
60 Ai ix $ r.
Map ` Lot Unit
sof /Vb12-rMAM VI-Dti
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
JOHn., F lete`f 6o AvorLZrt sT. ,vorto
Name(Print) Current Mailing Address:
4413 3z(,) 12. 6e
,/ Telephone
2.2 Authorized Aaent: t O o Z
JAY W, T () ,-' 50 rnAac-r i1NJO1, prz. A/ti,Ii+.2sr
Name(Print) Current Mailing Address:
ci k/\./ciu, 4t3 5 Z ”Z - 3- b `k
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 0 J v (a)Building Permit Fee
2.2. Electrical (b)Estimated Total Cost of
2-1 U Ci v Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection 0 451 l y
6. Total=(1 +2+3+4+5) Z 2., O(2 u Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2014-0634
APPLICANT/CONTACT PERSON JAY WATSON
ADDRESS/PHONE 50 MAPLEWOOD DR AMHERST (413)522-7769 O
PROPERTY LOCATION 60 NORTH ST
MAP 24D PARCEL 088 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building 4547, 16
Building Permit Filled out #70 (�
Fee Paid
Typeof Construction: CONSTRUCT 3 SEASON WORKSHOP APPROX 12 X 24 TO GARAGE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 079105
3 sets of Plans/Plot Plan
THE F LOWING 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
D-a.•lit Delay
A p
/ , /.�i
Trir-417 B ilding 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.
60 NORTH ST BP-2014-0634
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24D-088 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ADDITION BUILDING PERMIT
Permit# BP-2014-0634
Project# JS-2014-000970
Est,Cost: $22000.00
Fee:$57.60 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JAY WATSON_ 079105
Lot Size(sq.ft.): 8886.24 Owner: FREY JOHN D&JENNIFER K DIERINGER
Zoning:URC(100)/ Applicant: JAY WATSON
AT: 60 NORTH ST
Applicant Address: Phone: Insurance:
50 MAPLEWOOD DR (413) 522-7769 ().
AM H E RSTMA01002 ISSUED ON:11/21/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 3 SEASON WORKSHOP APPROX
12 X 24 TO GARAGE
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 11/21/2013 0:00:00 $57.60
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner