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31A-143 City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit in accordance of the provisions of MGL c 40, S54, i acknowledge that as condition of the building n.Ar►rit ail debris rR?ct�ltinry fro� the Lnrls±r!�ctinn activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: L_ S 67 i �e Aueb) is vviti J ti C-3Sp-.4 i L cu by. The debris will be received by: Buildina permit number: Name of Permit Applicant �/IC r -f-CV)A Gate Signature of Permit Applicant The Commonwealth of1''✓Massachusetts _ Department of Industrial Accidents Office of Investigations 1 Congress,street,.quite 100 (�X Boston, M-4 02114-2017 www.mass govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLft 14i mar i' �L�i i teSw«rb 12T. GLLt ti iz.":.�c I31�. I[�[L! S -�it huuress. Po City/State/Zip: QZI Phone#: ��-© O (O Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* nave hired the sub-contractors El New Aonstruc�on 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition working for rte in any capar-4y, employees and have workers' [No workers' comp. insurance comp.insurance. # ❑fsuiiding addition :equircd.', We are a corporation and its 10.❑Fiectrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 1 L❑Plumbing repairs or additions myself. [No workers' comp. right of c xc riiption per MGL 12❑Roof repairs insurance required.] t c. 152, §1(4),and we have no '" u employees. [No workers' L. Other 9 3 � 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 ne^v affiidmrit ndiea+mg such +Contractors 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 andjob site information. Insttrarce Company Name- Policy#0-Self 1nS. L ie.:ft' Xpiration Date. Soli Site Address: %ityiStateiGip: 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'we11 as civil penalties yn he form of a STOP'7tORK 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 verificatioii. I do ere., ce€ti •rit er the pains and penalties afpci ury that.lie h formation provided above L r::e and acv:r e4a Si .'..iU.rc: Drat e: v hau" Ir►f*cval use on!y. Do not x f?t4 e�*!:is area,to be Cois ple-ted by Cj' r.'}.' toJ'71 G�iCItI� I try or i own: rernuvLiceuse 0 1 Issuing Authority(circle one): � 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector . 6. Other I� Contact Person: Phone#: i� i SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ o� n Name of License Holder: i I! NUM z aw Address ExpiratioK Date i Signature Telephone 9.Registered Horne Improvement Coq_V3S#or. Not Applicable ❑ Company Name J Registration7 Number { Addres �/f,� Expir on �- � �"C �j( C Telephone I 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....... i No...... ❑ 11. - Home Owner Exemption The curierit exeitiption rut nurneuwneis 11 was extended to include Owurr-occupied Dwellings of utie(t) or two(2)familiez, and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CVMR 780, Sixih Edition Section W8.33.1. 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 an or iaiiii 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 ameptable to tide BuAding Gf it:ial,tka hhe;she shall lie responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the jolt site will be iegL ircd fiviii unte to tit-tie,duffing and upon completion of the work for which this permit is issued. Also be advised that with reference to C$apier l52 tiv orkers' Cotnpeiisatiofi) ai d Chapter 1333(Lid aiiii;y of 1!!TV)ycrS tU 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 i awe afxd SLac of Gelierdl Laws Atuiviat:"'. Homeowner Signature SECTION 6-DESCRIPTION OF PROP06-F-0 WORK icheck all applicabiei I New House F-1 Addition F-1 Replacement Windows Alteration(s) r__J Roofing ❑ or Doors 0- Accessory Bldg. ❑ Demolition 12:1 New Signs (01 Decks Siding(01 Other[CM Brief, Description Work: Ve" Ic L V Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement —Yes Y No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing,comofete the following'. Twalr'aimlly 011-faF b. Number of moms 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 constructior% Type i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. flondpipin—yes Nn_.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 1, LvL�{ as Owner of the subject property hereby authorize Z2- : cr _Z0 I L4 10 ztrffy behalf,ir.all matters relative to CVK authullL 'by 111iyupiiding permit appficaii6 Signature o O er Date Tg 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 III Signed_ _ un" r the pains and penalties of periury. Print Name �YA_ � A C) Signature of Owner/Agent ' Date I i !Sec"on- 4, ZONING AR tnforma",on l test Re Ccxnp#ete!. P-rAmt f7ar,Re Opni-d 0 k-To lnc Bete frtfnmr mativn Existing Proposed Required by Zoning this wiutun to be Ifiled in by Building Department Lot Size 1p� Frontage __,_..---------- Setbacks Fronts Side L: T' R: & r L: R: Rear L f s fi Building Height titD Ch,w6 0L Bldg.Square Footage !/ (� % �—pcn Space Footage — - f----ot area minus bldg&paved arkin ) #of Parking Spaces L 7J- Fill: qq� b (j`hq/1/GL� I tN•alL;aL ai.LVL-iiliilj 1 i 1 1 A. Has a Special Per mitl,Iat iancei Inding ever been issued for lion the sits`'? NO Q DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT'KNOW YES IF YES: enter Book Page and/or Document B. Does the site contain a brook, body of water or wetlands? NO W DONT KNOW � YES W YES, has a permit beer,of need to be obtained from the Conservation Needs to be obtained Obtained . Date Issued- C. Do any signs exist on the property? YES {� NO i 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,ex nation,or filling)over 7 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. D4-*c-a i*nt use only City of Northampton Status of Permit D �� Lc rp M E nn Building department Curb Cut dvewayPermit 212 Main Street Sewer/Septic tic Availabili P tY E MAY 16 2014 Room 100 WaterNVell Avallability 6 v u �iampton, A 01060 �TWO Sets a Siucural plans^"^fie 4,14'3-587-1240 Fax 413-587-1272 Plot/Site Plans Electric Plume !n GaE inspections ons Other Specify APPLICATION T O CONS,RUC T,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING I SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be compieted by office 3 Map Lot 01 Zone Overlay District Elm St.Di4tr4vt CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: f L L/o, j _T,�c + rvIGw &Ph/- i�1 i:urrerrt iutad9� pss:{� Signature i 2.2 Authorized-Aae 1h000jPC h- po Name(P' } Current Mailing Address: o/o Co Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be official Use Only � mm completed by ermit applicant 1. Building lb(.i (0 Jf/5 (a)Building Permit Fee 2. Electrical 0 !✓ __._._,......__�_ __ G.61 (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 Data Permit Number: vIssued: Signature: Building Commissionerflnspector of Buildings� Date File#BP-2014-1208 APPLICANT/CONTACT PERSON THEODORE M TIRK JR ADDRESS/PHONE P O BOX 36 ASHFIELD (413)625-0106 PROPERTY LOCATION 34 FORBES AVE MAP 3 I PARCEL 143 001 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 Typeof Construction: REMOVE INTERIOR FINISHES INSULATION&EXTERIOR SIDING New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 050212 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFqRMATION 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 Signature of Building 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. 34 FORBES AVE BP-2014-1208 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A- 143 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-2014-1208 Project# JS-2014-002043 Est. Cost: $15000.00 Fee: $90.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THEODORE M TIRK JR 050212 Lot Size(sq. ft.): 6708.24 Owner: TIRK LUCY&DAVID ERICKSON Zoning: URB(100)/ Applicant: THEODORE M TIRK JR AT. 34 FORBES AVE Applicant Address: Phone: Insurance: P O BOX 36 (413) 625-0106 ASHFIELDMA01330 ISSUED ON.512012014 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMOVE INTERIOR FINISHES, INSULATION & EXTERIOR SIDING 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 5/20/2014 0:00:00 $90.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner