11C-071 (3) The corng1011Wealth of Massachusetts
Board of 13ti'Mrig Regulations and Siandards FOR
Massachusetts State Building Code, 790 CMft MUNiC[rt1JfAt,l"TY
1 � C
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
----------
This Section For Official Use Only-_ -------_-__--
Building Permit Number: Date Applied:— _
Building Official(Print Name) Signahure Date
SECTION 1:SITE,INFOIZN1A` fON ,
1,1 Property Address: 1.2 Assessors Map&Parclel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Cnforrnation: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G_L c.40,¢54) 1.7 Flood Zone Information: 1.$Sewage Disposal System:
Public 0 Private❑ Zone: — Outside Flood Zone? Municipal❑ On site disposal system 11
Check ifyes❑
SECTION 2. PROPERTX ONVNERSIT1Pt
--
.2.1 Owners of Record:
Name(Print) ----- -- --- City,State,ZIP --_'
No.and Street Telephone Email Address
rz =
SECTION 3 DESCRIPTION.OF PROPOSED WORK (check all that.appIy) £=i
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Atteration(s) ❑ Addition ❑
-- - -- -- ---
Demolition ❑ Accessory Bldg ❑ Number of Units Other ❑ Specify:-
-- -------------
Brief Description of Proposed
SECTION 4: ESMIATED CONSTRUCTION COSTS
EsJed - �
Item Official US ..A
(Lab
1.Building $ uilding Periait Fee:$ _ <Irid cafe fiow'fee is deie'dmmed;
fc tyiro'wm Application Fee <2.Electrical $ otal Project Cost(Item 6)x multiplier x
3.Plumbing ther Fees: $4.Mechanical (HVAC)5.Mechanical (Fire Su ression) l All Fees:$
-.L
Check No. Cheek Amount': ..=ti=y_ Cash`Amounf
6.Total Project Cost: $ — a _t: :.. ,:__--
❑Paid in Full El Outstanding Balance Due:
SE:CCTON5: CONS't'ItI1C'I'TONSE.:IZVICIIS
5.l Canstructinn 5npervisor T.iccnsc(CST,) � ���
l` e -or - � �. License Number tixpiralioo Datc
Name of CSL E(older
List CSL"I"ypc(sec bclorv)
No.and Street Type Description
U Unrestricted(Iluiidings up to 35,000 cu.R)
---- —
_ R Restricted I&2 FamilyDwellirg
Cityfl'own,Slate,ZI(' — --- - - -- -_ -
_M_ Mason_r� --
RC RoofinLCovedri&
- - - - WS 4Vindotiv and Sidin
- - -
t` SF Solid Fucl Burning Appliances
2-- sulation
Telephone EtE addre U Demolittnn
5.2 Re istered ITome Tmprovemeut Contractor(MC)
A -- -- -- - __ [((C Rcgislration Number Vxpiration Date,
IIIC Comp ame or II1C Registrant ame
o>-1 Cum-\
No.and Street I;maiE�address ---
T AL-Y eX1LC �Q_ oLo(Ve7. -
City/Town,State,ZIP Telephone
SECTION 6 WORKERS'COlYIPE1VrSTIONI�ISURAIriC `rLFIEIDAVIT 25C(6))
_ LL
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..........Ell- No...........❑
&1 7a#OW1vER TI ORIZATIO irTO E C014fPLETED
_�r� v_. _6WNER AGENT�OR CQhITRAGTOR A$PIIE 'OR BIIILDIlt'C PEFtMIT
I,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.
Print Owner's Name(Electronic Signature) Date
7 SE Tl<OI`116 O NERi OR" IIORIZED AGIJIY I'_DEGLL4R.AT10N
By entering fny name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this pticatio is true and accurate to the best of my knowledge and understanding.
Print Own s r Authorized a is Name(Electronic Signature) Date
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(1ffQ Program),will not have access to the arbitration
program or guaranty fund under AG.L,c. 142A.Other important information on the IIIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eoy/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch)
Gross Iiving area(sq.fL) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type ofheating system Number of decks/porches
Type ofcooling system Enclosed -
3. "Total Project Square Footage"maybe substituted for"Total Project Cost'
The Commonwealth of Massachusetts
Depaannaerat of In dm,tr'ial Acc Mon ts
Office of 1nvesfigaa.tDns
r 600 Washington Street
Boston,MA 02111
-}= www.mass.gov/d'ia
Workers' Compensation Insurance Affidavit: BuDdeirs/Contractors/Eiectricianns/Piannmbers
Applicant Information Please Print LeLiblv
Name(Business/Organization/Individual): A1F11/ i
Address:
City/State/Zip: N%Llrl�✓��?,f/�y�,jai G�i 0 C� Phone#: 2,0"
Are you an employer?Check the appropriate boa: Type of project(required):
1. X I am a employer with 15 4. ❑ I am a general contractor and I
6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp.insurance comp.insurance.$
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑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
employees. [No workers' 13 Other 0-6U10-410n
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating 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 isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site
information. _
Insurance Company Name:
Policy#or Self-ins.Lic. Expiration Date: .G- /'/,-
Job Site Address: City/State/Zip: Let�t5. MA-O(t)53
Attach a copy of the workers' compensation policy desiara iflou gage(showing the poncy number and exp irraden 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 c ins and eraaides d n/e ry th the information provided a^b-o�ve is tie aaad correct
I'�'?� /,, ;f.�—��f l
Signature: . � ��i1 / Date:
Phone#• 4/Y
Official use only. Do not write in this area,to be completed by city or town official
City or Town: IPermit/lLiceuse ri
Issuing Authority(circle one):
1.Board of Health ?.Buiidflnng Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector �
6.Other
Contact Person: Phone r:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su`aervisor: _1 Not Applicable ❑
Name of License Holder: ��°`� 1 s N���C't e)(o o co
�1Q�1P� C�(T�c �L �OJ2 M G r1-� �YZL License Number
P.o _ coc�loa-1 1 Loref1Q- \-�a Oro bZ 9122- 114
Address
Expiration Date
X113-5S4-i s,zz.
Signatu Telephone
9_Re istered Home Improvement Contractor: Not Applicable ❑
a Inc_ 10 ss(t3
Compann y a Registration Number
';F\crencf- VACk- O\0k2 -1 )
Address Expiration Date
Telephone«-Cgli D 2.2.
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....... X 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 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[p] Other[ , VTO
Brief Descri do of Propose YtSi�(Gde a 1"' Lt% l�, ("d I V t SC' b."nq 'fit ci, f-e-fxt 4-
Work:s .l 11f (t 1C'} ct l� /AI ei�r 'L�f'1 ' :1 '
Alteration of existing bedroom Yes No Adding new bedroom Yes N
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.if New house and or addition to existing housing, comulete 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
as Owner of the subject
property
hereby authorize�,J e%on SW,4�et k � ��(tn Pt"OJ�(y1ey�•4 �'Yc 1 L
to act on my behalf,in all matters relative to work autho ' ed by this building PI? mit a pli ation.
See 04f-i r t rx,,.1+ _ ��m -730 >�
Signature of Owner Date
y0&f2:� j!vt> x -a(Ac- as Owner/Authorized
Agent hereby declare that the statements an nformation on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
�Ne150n
Print Name
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 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
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Rndin ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the tegtstry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , 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 Q NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradin exc ation, 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.
Department use only
G�ity rthampton Status of Permit:
BUildin 1 epartment Curb Cut/Driveway Permit
AUG _ 1 2014 212-1 in Street Sewer/Septic Availability
00 100 Water/Well Availability
Electric, Plurnhmg& -as
n, MA 01060 Two Sets of Structural Plans
N�r;lpFttrte.4�1' - 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
f 7jC)re'ry�' = Map Lot Unit
Leeds .&4"9 01053 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Printp Curren Mailing Address:
ki Se A1,0- Vi�'R1 tt rn Telephone
Signature
2.2 Authorized Agent:
' aOA� xnt �m�ro.>enncc�-� �r� P.o.6c t�o�oa� c�re+rtcc �-t� ok o(,2
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 0, Qty (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=0 +2+3+4+5) . 00 Check Number _ 3
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Comm issionedlnspector of Buildings Date
File#BP-2015-0143
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 110 FLORENCE ST
MAP 11 C PARCEL 071 001 ZONE URA(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: INSTALL ATTIC INSULATION,REPAIR FRONT DOOR
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOR ATION PRESENTED:
pproved 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
Dem 'f Delay
Si a uild n Of icial 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.
110 FLORENCE ST BP-2015-0143
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: I IC-071 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-2015-0143
Project# JS-2015-000252
Est. Cost: $3000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 20516.76 Owner: NELSON KAREN
Zoning: URA(100)// Applicant: VALLEY HOME IMPROVEMENT INC
AT. 110 FLORENCE ST
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.81412 014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION, REPAIR FRONT
DOOR
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 8/4/2014 0:00:00 $55.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner