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12C-119 (2) 1 4S�pT O O Gll a 6 �assAChnsrtfs m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFMAVIT (licensedpermittee) with a principal place of business/residence at: y , i/U�S�� �/�i ,,/t-�G�Z�f� %rj�iZ'�Z >�� (phone#} �f=7SZZ (str=U6ty/s' tP;dp5 do hereby certify, under the pains and penalties of perjury, that: 0 I am an employer providing the following worker's compensation coverage for my employees working on this job: (insurance Company) (Policy Number) (Expiration Date) ( ) I am a sole proprietor, general contractor or homeowner(circle one) and have hired the contractors listed below who Have the following worker's compensation policies:. (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/policy Number) (Expiration Date) (attach addidoml shod if necessary to inchude information pertaining to all coatractors) O I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:please be aware that while homeowners who employ persona to do inamtmaner;coastr=00 or rspairwodc on a dwdling of not more than throe units is which the homeowner resides or on the gtnunds appurtenard thando an not generally 000sidered to be employers undo the worker's cemp=eim Act(GL152,ss 1(5)),application by a home ow=for a license or permit may-idea-the legal ctatua of an employer underthe Worker's Compoasation Ad I underst=d that a copy of this sratemew may be forwarded to the DepartmwQ of Indus iial Anadeats'o1noe of tasuranca for the coverage verification and that failure to secure coverage under section 25A of MOIL 152 can lead to the imposition of m=ail penalties cowisting of a$ne of up to 51,500.00 andlor of up to one yrar and civil penalties in the form of a stop Work order aid a fine of 5104.00 a day against tae. Signed ' day of J r' (fj n. 2��'3 For dqmtm=W use aaly i Pt rmit Number Lot# ipab=of Li ermiitte SECTION 8-CONSTRUCTION SERVICES .1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:- Nelson Shif f 1 et•t _ 060300 Valley Home Improvement, Inc. License Number 340 Riverside Drive, Nort•hamp n. MA of 060 9/22/1.' Address Expiration Date 584-7522 Signature e A , Telephone m . :9.Ristereci Home,'Improvement Contractor . ., Not Applicable ❑ Valley Home IMprpyement, Tnr 105543 Company Name Registration Number 340 Riverside Drive 7/17/1 Address Expiration Date Northampton, MA 01060 Telephone 584-7522 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....... Z No...... ❑ 1 . dome wxW Egcmp'ud The current exemption for"homeoNvners"was extended to include Owner-occupied Dweilines of one(1) or bvo(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 ands or farm structures.person who constructs more than one home in a two-vear 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 fu0i OF PPOPOSED WORK(chc-tk l!Li'n:prlg!-hIC,-) N(,w HouLe Addition 01 Re:0acement Windows ¢ Attetation(,,) C;, Roofing 0 0�bows Accessory 8!d6. :2 1 Dem-llitic-, 71 New Sirs Decks T Siding Otl D, YIL�l 11 Nn plar�s !ittzvhod RON S�lo t Ga. If New house and or addition to existing housing. complete-the following: (J-,& C11 nullcin 0--c- arlllv Two:7--mly Otnv r- 1�, 1�nl�fa a garage artacheu? j S;Quara lluola& ("I new 1-on'strocti;Dn f. "Acti-,oz!OF htalllng�l Nksmb-! of each E Fr;r-r7_v 10cn,;ervaticn Clomp.lar-ze. M scheck Energy C.;m,;Aiznca form atached? or cc:^COfucticrl mthin 10D lj. ,)fv,-e,V4,,n0s? Yes No. Is construction %mzhir.. 100 yr. 1=3plaul YErs Dt pp h ofbwjernent or cellar flaor !)elovi mished grad* k. ."dill buzidin,,P cortform to ttie Buildinp and 2onine naplatlen.0 -Yes- 140 I. Septic Tank Cc Sewer Privete welff __ City%vater$vppy SECTION 7a -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner ci tr,,e subject peoperty m a�:t o my bv!zlf, IFI e0l to aulhsvlze,G by tots Sig ma"ire of 0q.,ler . .Ii�9�nn� �1±i �l��f:t'�',,�_. Val' a �QID�71r1 lift.-� i5 u:�.°t�er'lr�tlt'�nrrT.i✓rt fxb�nt �,I(l tmt! arld �scuuratc, lolle Cl Illy herety dcctmc turnc its ttrid- irffomnut�url un t1w fort, k.rc-odet-go End belic-f, ,fir ned .::-,Cv th-- pilvris ord Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF 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 Orkin #of Parking S aces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW _ YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Deeds to be obtained Obtained Date Issued: 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_ No IF YES, describe size, type and location: grit r TIt1J, L7f Njartiplujiturn w ' �� ;• �'tttssttrf)uselts �, r._ DEPARTMENT OF BUILDING INSPECTIONS `tt � 212 Main SI,r•eeL Municipal Building Northampton, MA 01060 U Si ASBRULO OCK BUILDING PERMIT FEES Phone: (413)587-1240 BUILDING COMMISSIONER Effective July 21,2008 Fax: (413)587-1272 DEMOLITION $ 20.00 ACCESSORY STRUCTURE $ 35.00 PRINCIPAL BUILDING—Residential $200.00 PRINCIPAL BUILDING-Commercial *NEW CONSTRUCTION $ .50 per square foot for 1''floor .30 2nd floor .20 " 'A floors,attic,basement,garage STRUCTURAL ALTERATIONS IN ALL USE GROUPS $6.00 per thousand dollars of estimated cost or fraction thereof, with a minimum fee of$55.00 $25.00 WOODBURNING STOVE *NEW ACCESSORY STRUCTURES one hundred twenty(120)square feet and over $ .20 per square foot with o minimum fee of$25.00 *NEW ACCESSORY STRUCTURES under one hundred twenty(120)square feet $25.00 per inspection *SWIMMING POOLS $30.00 for above ground $60.00 for in-ground *SIGNS&AWNINGS $30.00 *DECKS $50.00 REPLACEMENT WINDOWS $35.00 SIDING&ROOFING Residential $35.00 per structure Commercial $55.00 min.per structure OR$6/K of estimated cost TENTS $25.00 *ZONING REQUEST FORMS $15.00 (includes home occupation registration) REISSUE OF LOST PERMIT $25.00 CERTIFICATE OF ANNUAL INSP. $100.00 (minimum) Temporary Certificate of Occupancy $25.00 PERMITS REQUIRING ONLY 1(1)INSPECTION WILL BE A MINIMUM OF$25.00;ALL OTHERS WILL HAVE A$50.00 MINIMUM. PERMIT FEES SHALL BE PAID TO THE ORDER OF THE City of Northampton AND SUBMITTED,WITH THE COMPLETED PERMIT APPLICATION,TO THE OFFICE OF THE BUILDING INSPECTOR. WORK STARTED WITHOUT PERMIT IS SUBJECT TO DOUBLE NORMAL FEE. !! NO CASH -CHECKS OR MONEY ORDERS ONLY !! *Filing deadline is 12:00 pm(noon)on Wednesday. Department use only City of Northampton Status of Permit: !u L JAN J 614 Building Department CurbCut/Dnveway,Permit 112 Main Street Sewer/Septic Availability t - - -'° ROOm 100 WaterNVell Availability " Electric 77-7 7, r c c h spections o,oso ampton, MA 01060 Two Sets"`of Structural Plaris phone 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 This section to be completed by office 1.1 Property Address: �l L is\ Dk". Map Lot Unit `-+p M,!� o j 6�- Zone Overlay District I't Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: _ 1�Q i oo -Rob nson R(r iR I'c k Dr, old rer� MA-6 i©c�"a- Name(P" ) Current M� ailing Addre s:, Teleph ne ignat ire if 2.2 Authorized Agent: ti i-san 30 l?lv de Dr More>�cP; - Name(Print) Current Mailing Address: d)tXo q/3- 5-3Lf- '7S-a�L Signature Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Buildin g � a (a)Building Permit Fee (� . ov 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) (>0 Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-0823 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE (413) 584-7522 PROPERTY LOCATION 96 RICK DR MAP 12C PARCEL 119 001 ZONE RI(100)/URA(100)/WSP(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ST-1—a5 Fee Paid T_ypeof Construction: INSTALL ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 060300 3 sets of Plans/Plot Plan THE FOL 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 e uuo Delay Signature of uilding 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. 96 RICK DR BP-2014-0823 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 12C- 119 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-2014-0823 Project# JS-2014-001411 Est. Cost: $2000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 060300 Lot Size(sq. ft.): 10846.44 Owner: ROBINSON ROBERT C&MARY LOU ROBINSON Zoning: RI(100)1URA(loo)/WSP(10o)/ Applicant: VALLEY HOME IMPROVEMENT INC AT. 96 RICK DR Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.112412014 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION 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 1/24/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Louis Hasbrouck—Building Commissioner