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32A-233 (4) __ . N .max w.. � s .......... 'unit W d J st'6 r .d I R „ Vv i kFOO Lli 571c, mS ,ON,O _T41,e/4L(� w FI A, �.,,.; z , u EGs sTA/iP ?'�PrC�pAS I MA w� RA�,ci�uG Haydenville SOB c-�t�P,s�',y�es / �xcsTi.�G. Go�yQ�T�orOS' Woodworking & Design, Inc. SHEET NO. F/PmpT /�o�C OF [y P.O. Box 1070, Amherst, MA 01004 CALCULATED BY �'/! DATE Phone (413)665-7402 Fax (413)665.8602 www.haydenviliewd.com CHECKED BY DATE ff SCALE i `,.... n 7-o PRODUCT 201-1 1Sinale SAeNS1205-11PaWl - The Commonwealth of Massachusetts a Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant information: Lance Hodes Please PRINT legibly Business/Organization Name: Haydenville Woodworking& Design, Inc. Address: P.O. Box 1070 City/State/Zip: Amherst, MA 01004 (413)665-7402 Are you an employer? Check the appropriate box: Business Type(Required): 1. X I am an employer with 6 employees(full 8. Retail and/or part-time)* 2. 9. Restaurant/Bar/Eating Establishment 3. I am a sole proprietor or partnership and have no employees working for me in any capacity. 10. Office and/or Sales(incl. real estate, auto, etc.) [No workers' comp. insurance required] 11. Non-profit 4. We are a corporation and its officers have exercised their right of exemption per c. 152, §1(4), 12. Entertainment and we have no employees. [No workers' comp insurance required]** 13. Manufacturing 5. 6. We are a non-profit organization,staffed by 14. Health Care volunteers,with no employees. [No workers' comp. insurance required] 15. X Other_Construction 7. *Any applicant that checks box#I must also till out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers' compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company name: A.I.M. Mutual Insurance Co. Insurer's Address: 330 Whitney Ave. City/State/Zip: Holyoke, MAO 1040 Policy # or Self-ins. Lic. # WMZ8006257012015 Expiration Date: 7/6/2015 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 $250,000 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D1A for insurance coverage verification. I do hereby certify under thepains andpenalties of perjury that the information provided above is true and correct. Signature Date 9/11/14 Print Name Lance Hodes Phone# (413)348-2733 Official use only. Do not write in this area to be completed by city or town official City of Town: Permit/license# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Licensing Board 5.Selectmen's Office 6.Other Contact person: Phone# SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: t/ Not Applicable ❑ Name of License Holder: /9 V C �� S GS'O y T e`1/Y License Number 4A le p EA" 0<00 2 i o liG l/S Address Expiration Date 3 1/9 —02 733 Si ature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ w©oA�o�Gli�t1G D�'"SiG-�tJ ,�iVG // o 1 - Company Name Registration Number .S Y0 -OV 4, .So c�T/j/,06�c`,e�/E�,,O./�1/� o 137.? 4! /3 Address Expiration Date Telephone 4113 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....... 2-' 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 [Q Siding[0] Other[0] Brief Description of Proposed o^cv Pvrn#A AFovc.,toSEA --- i fovT e 1b Work: Oif l G/Ao of& ;?A1A 1W(r 1, 131,14,4 4,LC7—A c.e N A i jlea , NO &77P4-C-7-w? k *000t 19W 77 c-I ,07— 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, t✓`S as Owner of the subject property he by authorize tic E Woo=4s t act on my behalf, in all matters relative to work authorized by this building permit application. Signature of O er Date Em I, G_.4 Svc.c ADES as Owne Authori en ereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge nd belief. Signed under the pains and penalties of perjury. 1./4ivc,C �oDES Print Name Sign a 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 Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW O YES O ..... ... . . ....... . .... . IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO GDONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained 0 Date Issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO O--- IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading,excav on, 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: f Building Department Curb Cut/Driveway Permit i 2 `i 212 Main Street Sewer/Septic Availability j L Room 100 Water/Well Availability R N hampton, MA 01060 Two Sets of Structural Plans Electric Fi a--%1 echo s Plc y�hq 413- 87-1240 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 3G /°mn► a ro7 7—.r r4c e-- Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ` �p r G 4.-0'3 / s e ra oS Na (Prin /,' Current Mailing Address: X �/`'°' Telep�n.3 :r6:6— 7g 38 Signature 2.2 Authorized Agent: /V A.'C ,M 40 4F 0. 4?0 A to 7 U /�,�r�i t,rs f /r 0 10 0 Name(Print) Current Mailing Address: Alta igna re Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted by ermit applicant 1. Building � 00 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) /V 5. Fire Protection 6. Total=0 +2+3+4+5) 2f Y7 00 Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0281 APPLICANT/CONTACT PERSON HAYDENVILLE WOODWORKING&DESIGN INC ADDRESS/PHONE P O BOX 1070 AMHERST (413)253-3229 PROPERTY LOCATION 36 POMEROY TER MAP 32A PARCEL 233 001 ZONE URC(58)/SC(42)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiny,Permit Filled out Fee Paid Tvpeof Construction:_RENOVATE FRONT PORCH New Construction Non Structural interior renovations Addition to Existing Accessory Structure Buildine Plans Included: Owner/Statement or License 044314 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF0ION 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 Demolition Delay Si re o B i ding 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. 36 POMEROY TER BP-2015-0281 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A-233 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-2015-0281 Project# JS-2015-000542 Est.Cost: $4900.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HAYDENVILLE WOODWORKING & DESIGN INC 044314 Lot Size(sg. ft.): 23348.16 Owner: CHRISTAKOS PETER G&DEBORAH S Zoning. URC(58)/SC 42Z Applicant: HAYDENVILLE WOODWORKING & DESIGN INC AT. 36 POMEROY TER Applicant Address: Phone: Insurance: P O BOX 1070 (413) 253-3229 Workers Compensation AMHERSTMA01004 ISSUED ON.911512014 0:00:00 TO PERFORM THE FOLLOWING WORK.-RENOVATE FRONT PORCH 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 9/15/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner