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30B-107 Lip/noa'SSLiiI AVAA'1 6tLL-LZL-L 19#x-ed LO-VZ-P PasEnaU E3VSS` JN-LL8-I -10 90#,;xa 006t-LZL-L 19# Ia l I I IZ0 vw `uolsog jog-,qS uojfuTgseA'�009 SUORRAusaAug JO aaUJO sluopaoaV felgsnpul jo I.uougieda(I mosup-ess-eW jo ifootAuouiumo a%L :Taqumu xej pue auogdola;`ssa.ipps s juam4.tuda(l otU -Ileo a sn ant2 o;amtsogjou op aseajd `suor}sanb fie aneq noA plttorls puE uor}E uad000 moh ioI aouenpe ut rroA 3ittetP o;o3UI pinon%suot}e�.1sanul jo z3gjo OVT ;tnu PTA std a;ajdutoo o;paitrei3aa yplq,si uosiad pies(•o}a saneai umq o}.;!wmd so asuaoll gop a•a•t) amluan letaratuuroo so ssaunsnq fus a}poTelai;ou}Iuuad so astuaarl a'unnE4qo sr uazt}uo so iounmo amoq a arat�y� lead tloea}no pall.j aq}snw;uneptgje mou V -sasuaorl m s;tuuad am4}loI alq uo sr}uepr}pe pilun a}eq;jooid su aus9gdde atp ol papinoid aq nuut umo}io 4o atl}Xq paslmua io Pads XIlEtotgo uaaq SEq IMP II.nePDJE aql jo Adoo y so f}to) w soot;eaoi tje„a;tom pinogs}tteatlddu aup.<�a1PPFT a;rS qol„sapun pue(�es�au�tj uor;ecwojut ktlod ;uarmo&f;tatpuf;rnEPzgJe ouo}twgns dluo paau°.read uantg Niue to suolmild&osuaotl/Itw3ad aldt3lreut xfwgns;snot;etj; ;ueozldde ue`uor;Tppe ug saqurrtu aouasala t e se pasn aq iltn�gotgm iagwnu as¢aorl/irmsad aq;ut II3 of arcs aq aseald ;ueotldde atg Sur pngaj noh;ou;um o}seq suot}ESt}sanurlJo aor�ip aq;;uana acj;to}no jl3 0;reap roI}tnu pt�E atl;jo mo-4oq aq;;e aoeds u poptnoid serl;uau lmdaLl o LL ljgt2al pa;uud pue a}ajdwoo sr;tneptRu arp;erl;airs aq asuald slopujo uyo i,J0 4!j -autj oTupdoidde atp uo 3aqu nu asmag aou=sat jlas ra:l#.aa;sa pinogs satueduroa pamsurt Jiag -mojaq paysil aagwnu aup;e;uaut}.tedaQ ati'}Ilea aseald`f�atiod uot�usuadutoo csmyom a utz;go of pannbai am noX jl io eel zip Sutpw&j suoipsonb Aue anuq noA pinogS •s;uapgoov ILLvsnpul o;raam;tedaa otp;ou`pa;sanbaa gutaq st astraatl so}ttusad atl;toy uot;eotIdde atp;uq}umo;so f ca aq;o;paum}ai aq pjnogs;fneptje zq,L •jjaep!Mu aqp a;sp pus iu&s o}anus aq osff •aZuwA(a*mumsut jo uot}ewzguoo aoj s;uoppov jw4snpul jo;uau wdaG aip o;paultugns aq,(u:tu;tnePUP std}Eq}pasrnpe ag 1st tlod E`saaRold= anuq swop<I'I I io oqq uo jj -aauemsut uo4esmdcuoo�s WoAi Luuo of palmmloi jou are`slaL4md,ro siagwam oig ueq;iaq}o s=Aoldwo ou rpm(d'I'3}sdtgs—,zupud f4ijjgei'I palm—Ito(D-I T satuet3mo AlTltget�pa;turtrl "o -our jo(s)a}eorgtuao=IR tgtm 2uoju(s)aaqumu ouotld pue(sa)ssaippe`(s)a=u(s).ropP-,4uoo-qns_flddns`kaessaoau ji`pue uoz;en;ts mo�i o,X;dde}eu};soxoq oq gt pp;;go Xq`AlapIdwoo}tnepgu uot}usuadwoo�=Njom aip Ino IIg amid s}tae-q d+dy «f�}uotprte Dut;ouoo atlx(;pa;uasatd uaaq aneq aa;dega snll jo!4uauta amba r aouemsuf atj;t{;tm aouEtIdmoo jo oouaptna ojge}d=:)u jPtm tu on1 ailgnd�o_aauEtodtad atp taJ}oEZiuoo AU-0 o}ut 3a;ua IIEZ;s suotstnrpgns lEO.4god s;t jo Auu tou q;leannuouuwo9 oxg aaggoa ,sa;e;s(L jSZ§ `ZS I sa;dego'jDjq`XjjeuowppV «paataritaa�a�eaaeoa aatae tnsut aq#q; a3uut1dtttoao aauaptna aige}dame paanlwasl;on sEtl ogaa;ntidde Xua aoJ q;ieaatuomruoa aq;ut s2mpltnq pu4moa o;io ssau"q a a}eaado o;}tuuad so asaaaq a jo Izrmaua.1 ao aauenssz aq;pio$tpi;�Begs fsua�e�tgsaaari Iesoi ao a;qs�an3„;Etp sa}e;s axle(9)�SZ§`ZSI as}detlo`IJI/ii «saAoldtata ue eq o1 paumop aq jtaur,4ojd=gonslo asamaq;ou llegs o;aaatp;ueua}mdde Ruipltnq zo sPtmot�atT#uo to asnotl gutilamp dons uo 3fiom.rruda3 so uor -gsaoo`aouemluisuu op o}mosiad sAoidwa oqm latpoue jo asnoq gufllamp aul;3o;uednaoo arl;ac`trtaaaq;saptsaa oqh:pue s}uaur�rude aarg;treu{;aaout;ou$tr�netl asnatl�utllan�p t;�o aaun�a aRI.ranamoH -szoAojd=2ujAojd=`G}t}ua Ill iatgo ro uotn osse`dttlstatzmd`lenpaArPuf tre�o aa}stu;ao aae aoaa aq}ao`.m Aoldwa paseaaap udo sant}emasoAaa jEBaj mp$uuprgoia pue`astad mTm lmpf a ur paWao Btgo$aio3 atqj o aaout ao OA14 but= ro`fit}era ludal iat{}o ao not;saodroa`uoj}ufaosse`drgstau;aed`jenprnrput ue,,se paugap sf jafvpdaard ttV ,,-ua};urn ao 1wo'pi.ldurt ao ssaidxa `aafq jo;os4uoo flue 3apun raq}oue,jo aara3as aq;ut uos3ad�Saana•••„se pougap st aad©ldw ue`a;n}e;s sgg o;;ttettsatr�j -=Soldwa acaIP aoJ uog2staadaroa�saa3iion aptnozd o}saaAojdura Ijs sa-�nbat ZSl sa;dzgs snsEI fpj2uao s asntjoESSe SUOWTIJ49ul PUB UO9vul-l%7 ul The Commonwealth oflMlassachusetts Department of IndiistridAccidents Office of Investigations 600 Washington Street kvi Boston,AM 02111 www.massgovfdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibiv Name(Business/Organim ionllndividual): q 4 J Cam.f�� ►^ Address: /i;► IF Y1-7 r V1 City/State/Zip: ,O go�1hg e,n a• d d y3 Phone#: ;1 !3-5"� #r/C)t - Are you an employer?Cheek 4e appropriate box. Type of project(re(yired): 1.0 I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).' have hired the sub-contractors 6 E]New construction 2.Q I am a sole proprietor or partner- listed on the attached sheet 7. [►Remodeling ship and have no employees These sub-contractors have g. Q Demolition working or me in an capacity- employees and have workers' g y� �'- 9. F1 Building addition [No workers'comp.insurance comp.insurances Y required.] 5. [] We are a corporation and its 10_[3 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their i 1. Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12 Roof repairs insurance required.]t c. 152,§1(4),and we have no 13 Q � employees.[lo workers' comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f 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.Lie.#: 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 pen es of perjury that the information provided above is true and correct Si ature: d� Date: 44 ®ZO/ Phone#:41-3 Official use 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 0 Name of License Holder: 2�2 A h R CG —0 // 071 // License Number NiG,AKbTo /77.1 • 0/0 13 4 -��,► /lo Address Expiration Date M.e�,/-�J,0', Signat re Telephone 9. Registered Home Improvement Contractor:� 4 Not Applicable ❑ _MgrR C/� 1.,/"A, i/o(� n r f-r�Le *l f/i V. /.2 78'3 7 Company Name Registration Number Address Expiration Date Telephone /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....... 2r-' 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 ❑ Accessory Bldg. E!f Demolition ❑ New Signs [p] Decks [0 Siding [[3] Other[dJ Brief Description of Proposed �r {mpeir y Avelwoe J%L�" an ApN9 rih Work: Gr1w de O nAMR�,�. 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, S q nl,A c C d ny as Owner of the subject property hereby authorize A' PA( to act on my behalf, in all matters relative to work authorized by this building permit application. 7//y Signature of Owner Date A r t as Owner/Authorized Agent here 6y 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.. ( /04 U rk Print Name h �• / Signature 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 filled in by Building Department Lot Size Frontage L o� Setbacks Front 3 0' Side L: It R: 10 L: R: Rear 6' Building Height a Y Bldg. Square Footage A6loX1P-- % Open Space Footage % (Lot area minus bldg&paved -kin #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO ® DON T KNOW V YES IF YES, date issued: IF YES: Was the permit recorded at the Regi try 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? Needs to be obtained O 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: E. Will the construction activity disturb(clearing, grading, exqpvation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES o NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability ` � + Room 100 WaterMell Availability dons orthampton, MA 01060 Two Sets of Structural Plans E�ectr,c.F`." 3-587-1240 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 G gr .977 Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Jyc► (0,11 Name(Print) Current Mailing Address: L/17 Telephone Signature 2.2 Authorized Agent: 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 q �— (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) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-1023 APPLICANT/CONTACT PERSON MARK CLARK ADDRESS/PHONE 16 FOMER RD SOUTHAMPTON (413)552-8632 PROPERTY LOCATION 68 MILTON ST MAP 30B PARCEL 107 001 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 Fee Paid 16971 A0­0�,J Typeof Construction: REPAIR FRONT PORCH(SILL 7 2 X 4'S, STRIP&SHINGLE GARAGE ROOF New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 096071 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Demolition Delay 4 Si ature of Buil ng 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. 68 MILTON ST BP-2014-1023 GIs#: COMMONWEALTH OF MASSACHUSETTS MU:Block: 30B- 107 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2014-1023 Project# JS-2014-001773 Est.Cost: $3900.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MARK CLARK 096071 Lot Size(sq. ft.): 9713.88 Owner: CONSTANTINE SANDRA Zoning.URB(100) Applicant: MARK CLARK AT. 68 MILTON ST Applicant Address: Phone: Insurance: 16 FOMER RD (413) 552-8632 SOUTHAMPTONMA01073 ISSUED ON:41812014 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPAIR FRONT PORCH (SILL & 2 X 4'S, STRIP & SHINGLE GARAGE 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 4/8/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner