30B-052 T'ke ConYmorewearM of Manarckmdts
DgwlnwW of1ndresWdAcdfdm&
Of=of Investoadow
600 Wasluh"n S&eet
Res tan,MA 02111
WWW.Marss gate Aa
Workers'Compensation Insurance Affulavfit:Bu&lersf Contraetom/EIectricians&lumbers
Applicant U onmatian Please Not Le�tbly
Name( }: J rNa-JT S:�t.x4;t4
Address:.„(00l44or4�rtX�t
CitylStateJZip: Phone#: - 4
Are you an emplayer4 Che a the appropriate box: Type of project(required):
.�0 4. I am a general c�tractor and I
1 employees(full andior p .' have hired the sub-=42ctoax 6 New construction
2.Q I am a sole proprietor or partner- listed on the attached suet. 7• ❑Remodeling
ship and bave no employees "ilese
haver 8. ❑Demolitio
[Nor}cmos omoa py msttcaa►ce � have wo�t9cecs 9 ❑
dition
required.] officers S. Q We are a corporation and its 10.Q Electricat repairs or additions
3.[{ I homeowner doing all work officers have exercised therr 1 LQ Plumbing repairs or arsons
workers' rio of ex onr pct MGL
i yselnce o�►�l t comp c.152,§1(41 and we have no 12.Q Roof repairs
employees.[No workers' 1311 Other
insurance regtired.]
•Aoy appiieaat that ChWU boot#1 amt dso sit oat tbo secdw blow sbowia dWk=dCre oompioo patiq kformarioa
Homeowoas who srabmit ttB4 at8dtrit they anti daq$ail wort Bad thou hse oastsida medractr:rs arose aa6aeit anew at3iidavit indicating such.
�Ceostrauoas tba chair t6isbeac aaastita�tached an addaiaunai daowhtgdat naaaa attbe ssdrooat>spa and staao wBetha a not these eno sies!lave
employees If tha have eaployroes,ffieY mmt provide tt+eir workus'eoavp.pohq munbcr.
I ante an awptayer h prarlbg roamers°c»vgwudd at haswnwefor my a sm show is(kepoll+aad job ske
infornasrHanr
lnstmoc compsay Name• _11+- co- k'i4:cx^ci_L r+,c .c2 '� (�-y. •L'�
Policy#or Self-ins.Lie # � . '3 tit t Expiration Dabs: w r G
J Site Address: l93 i 5, i)G. eky�swcaip: ��r�
Attach a copy of the workers'co mptasatiott policy declarat=page(showing the policy number and exptmtdan date).
fail to serum coverage as required under Section 25A of MGL c.152 can iesd to the imposition of criminal penalties of a
fine up to Su,500.00 anchor on"eaor 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 69 a cagy of this statement may be forwarded to the Office of
investigations of the DIA for fimm ace coverage verificatim
I dry bvetX11-1 der t&tpstras a!araCpeaaalhlas of pwfiu'chart th iarfonnaitiox pr rwidad £s bate corer
Si - I
Phone#
offx l Ilse a* Do rat wrttt in arts,to be caarteled by city or form 0fiWat
City or Town; Per mittLicenst#
Issuing Authority(circle one):
L Board of Hearth 2.Bubdieg Department 3.City/Town CEsrk 4.Electrical Inspector S.Plumbing Inspector
b.Other
Contact Person: Phone M
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: S- .n•�e t` '` 1 -� 0q3
License Number
-ate a�, fie E� ��1aq Sf 3:
Address i Expiration Date
SignaturEK Telephone
9. Registered Home Improve ment Contractor: Not Applicable ❑
� ib10�
Company Name Registration N mber
1 �l f � ��I�fAI`� N (3 0 0 S'a E c � u
Address L Expiration to
m o W VIC(&Y4 ?t N:fzl 5OLho,r5.(-CMTelephone ���-3O�-`i LD
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 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other[
Brief Depeription of Proposed
Work:.��;
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes V"I No
Attached Narrative Renovating unfinished basement Yes ✓" No
Plans Attached Roll -Sheet
6a. If New house and or addition lo existing housing, complete the following:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: '-7 Number of Bathrooms �
c. Is there a garage attached?
d. Proposed Square footage of new construction. n\,(L Dimensions
e. Number of stories?
f. Method of heating? ( 1C&S art-) 6C Xj`�L Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. iii Masscheck Energy Compliance form attached?
h. Type of construction 191-1
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
h.
hereby authorize - c
to act on my behalf, in all matters elative to Wolk au honzed by this building permit application.
� , i i;t l i
Signature of ner Date
1
I,�I ,(A P� ;-e .� � �-�� �`i: '!s - �T1.tLii. �,��tc �'t<c�, •, as Owner/Authorized
Agent hereby declai tha the stake�ts 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 Name
,O'er !liw� I- 3.1
Signature of Owner/Agent 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 tilled 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 Sp tat Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:,
IF YES: Was t permit recorded at the Registry of Deeds?
NO DONT KNOW 0 YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO G DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 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 C) NO (1�,
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 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:`
2Y� Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
r
pwR�no•S'h�,060 l
Northampton, Two 01060 Water/Well
Setseof Structural Availability
Plans
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
1.1 Property Address: This section to be completed by office
O S RlvG1._S t k Q(_'/�/ Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
C k- Z3R� s��QE 0c.
Name(Print) Current Mailing Address:
LA 13�-58
G Telephone
Signature i
2.2 Authorized Agent:
VlG
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building r�o0 (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) 1 Check Number A L12/11/1 It 1 W675-
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Comm issionerllnspector of Buildings Date
File#BP-2014-0851
APPLICANT/CONTACT PERSON VICTORY ENERGY SOLUTIONS LLC
ADDRESS/PHONE 1 HARTFORD SQ SUITE 206 NEW BRITAIN (877)206-4483
PROPERTY LOCATION 183 RIVERSIDE DR
MAP 30B PARCEL 052 001 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 3 17-1
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 93101
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO>MATION 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
Demo it
elay
Si e of Building fficial 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.
183 RIVERSIDE DR BP-2014-0851
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30B-052 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categorv: INSULATION BUILDING PERMIT
Permit# BP-2014-0851
Project# JS-2014-001483
Est.Cost: $1500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VICTORY ENERGY SOLUTIONS LLC 93101
Lot Size(sq. ft.): 15246.00 Owner: HUNKINS ALAIN&MARY L CLARK
Zoning: URB(100)/ Applicant: VICTORY ENERGY SOLUTIONS LLC
AT. 183 RIVERSIDE DR
Applicant Address: Phone: Insurance:
1 HARTFORD SQ SUITE 206 (877) 206-4483 WC
NEW BRITAINCT06052 ISSUED ON:21412014 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 2/4/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner