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31A-201 ie'naissance Builders P.O.Box 272,Turners Falls,MA 01376 (413)863-8316,Fax(413)863-9712 www.renbuild.net To: Louis Hasbrouck Building Commissioner City of Northampton I, Gerome Miklau, certify that I am the Owner of the property located at 40 Washington Ave.. I hereby authorize Stephen Greenwald of Renaissance Builders, 390 Main Road, Gill, MA 01376 to submit a building permit application on my behalf for replacing 11 windows. I agree to conform to all applicable laws of the town and state, and I believe the work proposed to be in compliance with all zoning regulations and the Massachusetts State Building Code 780CMR. Signature of Owner: atlt�.�4L Printed Name: Gerome Miklau Date: 5/23/2014 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 a condition of the building permit all debris resulting from the construction 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 15OA. Address of the work: Yo 6)6757k�/U* S J The debris will be transported by: I VyCICZA A The debris will be received by: Building permit number: Name of Permit Applicant 57L�--P`f'eew X23 I Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name: Renaissance Builders,Inc. Address: 390 Main Road (PO Box 272) City/State/Zip: Gill, MA 01376 Phone#: 413 863 8316 Are you an employer?Check the appropriate box: Type of construction 1. K I am an employer with_l5_ 4. ❑I am a general contractor and I Please Check One employees(full and/or part time).* have hired the sub-contractors ❑ 6.New construction 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 me in any capacity. employees and have workers' ❑ 9.Building addition [No workers' comp. insurance comp. insurance. # ❑ 10.Electrical repairs or required]. 5. ❑We are a corporation and its additions 3. ❑I am a homeowner doing all work officers have exercised their ❑ 11.Plumbing repairs or myself[No workers' comp. right of exemption per M.G.L. additions insurance required]t c. 152, § 1(4),and we have no ❑ 12.Roof repairs employees. [No workers' ❑ Other Wi4_djX6JY� comp. insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contactors that check this box must attach 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. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 0 d w 7 r- / 'A�Ebt..l-&-e Policy#or Self-ins. Lic. gq 7 39Ll - 0/ ^ Q / Expiration Date: Job Site Address: yd �eJQSGI l vtR 1� 57. City/State/Zip: IUOV/4a_Kkje�riv, 01 d 60 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 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 $250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverag verification. -- -------------------------------- I do herby cert . and pe s o perjury that formation provided above is true and correct. Signature: Date: S�2 3 / Print Name: 5 TTEP H-e Al RC'E N w P�'L t> Phone #: y/3 66 3 , 9-",314p 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): ].Board of Heath 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: License Number 3q 0 �A ,u o 1 7 -5 Address Expiration Date Signature Telephone 9. 0 Re tered Home m r ve' en Contractor: Not Applicable 'P.y�cussGtNt Ge $Ui lo'�-mss /� Company Name Registration Number L/ Address A. Expiration Date Telephone L/13 '�1�3 '8'3/ 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....... No...... 1 - dame OWri+e r kx MIDH©n 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 Wpi dows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[0] Other[0] Brief Des ipti of Proposed Work: o fr�P_ - 6)1 kk G�I CXUY�g��s Alteration of existing bedroom Yes_X1 No Adding new bedroom Yes "ANo Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa. If New house and or addition to existing hour r a. comple#e'the following: AA 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. imensions 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 w ands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cel r 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 &ftO�J I-)IATI /V ac, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, 21E&� if_:� , as Owner/Authorized Aunt 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. S7 7/ 1 Print Nam Signature of er/Agent Date Section 4. ZONING Al Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning ./' his column to be filled in by Nilding Department Lot Size t z go Frontage _ Setbacks Front Side L: . . R: L:+ R: Rear l Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location)_. A Hasa Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW YES 0 IF YES, date issued:: TT IF YES` Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW YES Q IF YES enter Book Page; and/or Document # B. Does the site contain a brook, body of water or wetlands? NO 9 DONT KNOW Q YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Date Issued: ' C. Do any signs exist on the property? YES Q NO IF YIES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 IF YE,$ describe size, type and location: _. E. Will the construction activity disturb(clearing, grading a avation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. 1� 1 V{I h is &G as Ins ectlan Ity of Northampton f FI i 1 �� r,.k� wh ililll„hlt'^^ling Okla �,1a'I� ti�lr7i�III Ilia y a N y E 7f 4I Electric Plumbing 01060 ildin Department rjorthampton,MA _ g p x 91 �" "4 FII IIIItl X�� r� r s 11�11�17 iyi i"Iii I II,I VI h4lyll, 212 Main Street '4i la V V Ixp�l q q IX°Ili s V 61 ull lu Vlh III f 8 Room 100 Northampton, MA 01060 ry„wa Illq lap„3 t l°Nh"'I Yllk�l"l„'�''{I15 p hone 413-587-1240 Fax 413-587-1272 �h�gn�� �°I„ ��I�,� I dq, I��'ll�"wl�,lu�lll„�11��Illlwllllh�ll`Il�il�1� VI I �d �r+Vl�ilEl�d Ilmf hIhM Y a fir, I Iii s 411 rZyl I Y TI+ Ix 1 h,"r Ike I�rtl I Ih 4� £c 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 , . /Q �QC✓ /1�J' f/V\ �/� �e Map Lot Unit N Ov Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Aaent: /J &9k5E)J t! )M-'L. P, p, 0. BOX 27 Z XUYMe.5 f a�G�s 013 Name(Print) Current Mailing Address: -L/3 - fi&3 - &3l Co Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building G 7 3'1 (a)Building Permit Fee 2. Electrical O (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) '7 Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 40 WASHINGTON AVE BP-2014-1254 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 3 1 A-201 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:window replaced BUILDING PERMIT Permit# BP-2014-1254 Project# JS-2014-002109 Est.Cost: $8739.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RENAISSANCE BUILDERS 013302 Lot Size(sq. ft.): 11238.48 Owner: MIKLAU GEROME Zoning:URB(100)/ Applicant: RENAISSANCE BUILDERS AT. 40 WASHINGTON AVE Applicant Address: Phone: Insurance: P O Box 272 (413) 863-8316 Workers Compensation TURNERS FALLSMA01376 ISSUED ON:512712014 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL 11 REPLACEMENT WINDOWS 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 Sisnature: FeeType• Date Paid: Amount: Building 5/27/2014 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner