22D-068 (4) 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 150A.
Address of the work: 8Z4)
The debris will be transported by: P-�nr
The debris will be received by: (i l bgw54,,,
Building permit number:
Name of Permit Applicant 0,1'6-
Date Signature of Permit Applicant
The Conuntinwealth of Massachusetts
Departtttent of Intlustrial Accitlentv
' M Office of Investigations
$ 600 Washington Street
t` t
" 3 Roston,M.A 02111
*yV 4 4k.4 iviviy.nut s.gorldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(13usirtesM(�)r anirattnr>rindividuat); ,�t 'Ire-
Address: Do /051-1
City/State/Zi : ,, a d Phone#:
P
Are you an employer:'Check theMppropriate box: Type of protect(required):
1.❑ 1 ani it employer with_ _ _....._. 4. ❑ lam a general contractor and I 6> ❑ New construction
r1ania ploy-ces(full and/or part-tine).* li ave hired the sub-contractors
2.b, sole proprietor or partner- listed on the attached sheet. T ❑ Remodeling
ship and have no employees "These sub-contractors lave S. ❑ Demolition
working; for ntc in any capacity, snap#ogees and have workers' g. ❑ Building addition
jNo workers'comp. insurance comp.insurance-
rcquircd.j 5. ❑ We are a corporation and its It).❑Electrical repairs or additions
3.❑ 1 ana a houacowner doing all work officers have exercise their l 1. Plumbing repairs or additions
n-iysell. [No workers°comp. right of exemption per MGL 12. Roof repairs
insurance required.[ �� c. 152 §1(.1).and we have no /
eniploNces. [No workers' 13 Other-j
camp.insurance required.j last
r`,1aty applicant that checks box-F1 must also fill out the sections below showing their workers'rontpensati nt Policy infkrrmation.
I loyteowtters wlw subnrit this affidavit indicating they are doing all wort;and then hire outside contractors mtLst submit a new aTidavit intheating such.
'C`nninrctom,that cheek this born musa attached ail additional sheet sttnsring the name of the sub-contractor,and state wdxdter or not those c;ntities have
employees. tithe sub-conliactots hair ernpttsyers,fliq must provide their woti:%W eoinp.ptahcy nurnha.
7 am an etnployer that lv providing tvy}rkers'cornpensatiorr insurance for my emplayeem Below h;the policy and joh silt:
in formation.
Insurance C"ornpany Naamc:
Polio=#or Self-ins. Lie,iE: __....._......_ ...... Expiration Date:
Job Site Address: ` �L'�C �� CitylStatc/Zip: .I to/t'1`1C-
Attach a cop)of the workers'compensation policy declaration page(showing the policy°number and expiration date).
Failure to secure coverage as required tinder Section 25A of MGL,c. 152 call lead to the imposition of criminal penalties of a
fine up to$1.500.00 a.nd/orone-year impnw.runent,as well as civil penalties in the form of a STOP WORD:ORDER and a Line
of up to S2500)it day-against the violator. Be advised that a cop)of this.statentent may be forwarded to the Office of
Investigations of the DiA for insurance coverage%crification.
I tit)hereby cerdit,under the pains rind penahies of perjurr that the information provided above is true and correct.
Phone
Official use only. Do not write:in thin area,to her completed ks,cit,or toivn official
Cite 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 Constructio/n�Suae`M/sor�/) / Not Applicable ❑
Flame of License Holder: C ` 10 �Jbz7
License Number
ddre Expiration Date
i -3yo_ t 3y
ure Tewptwne
8:Reoist�redlg Not Applicable ❑
Com6any Name If Registration Number
oq& 0 S/13/ �t 6
ddress Expirat oni Date
Telephone
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.......V11, No...... ❑
ll. . .�ome Owner E�empti�rn
The current exemption for`homeowners"was extended to include Owner-occuyied 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 born-owner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she sball be
recnnnsihle for ells 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 pennit.
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 apalicable)
New House ❑ Addition Replacement Windows Alteration(s) Roofing E]
Or Door 0
Accessory Bldg. ❑ Demolition ❑ New Signs [E3) Decks [Q Siding[0) Other
Brief Description f P p r. 1
Work:
Alteration of existing bedroom Yes__Z No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa:�f dew httlts+e=�tn+a�� �n�o�a[is�itir�fiuutan�l,a,�mple#e`�heft�llo�r�ns�:
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 PER
as Owner of the subject
property Wr
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I Nrf /�/ G(,�I ( as Owner/Authorized
Agent hereby aree'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.
Y WL& �I
Print Nam
Signs of OwnedAgent Date
Section 4. ZONING AR Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to he filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L. R: U R-;
Rear
Building Height
Bldg.Square Footage
Open Space Footage %
(Lot area minus bldg&paved
parkFng)
4 of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 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 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
0
C. Do any signs exist on the property? YES 0 NO 0
IF YES, 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 YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over I acre or is it part of a common plan
that will disturb over I acre? YES 0 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required,
City of Northampton � NN
�_.
Building Department ?ik �
212 Main Street r "� Writftyrg �
f 6 2014 ;►�,
i Room 100 �f'a�e>" e�A�ai� �
rthampton, MA 01060 > � � ��
lectr,c. ' phort6,41 587-1240 Fax 413-587-1272 iCttlSlte P ' `�£
r itt ti-
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� _.:_____- �1'•� ��_ ., mss-
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE 114FORMATHM
1.1 Property Address: This section to be contpletscl by ofllce
�Yj �IGli"��C�. � 1VIap Lot Urni�
.Zone C)verlay Distrlf
Elm St Diutrict ' CB Distract- -
SECTION 2-.PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: )
(AAA Lam er qb e,--Am
Name(Print) Current Mailing Address: ^ L/—
Telephone
Signature
2.2 Authorized sent: AQ
Nana' t) urrent Mailing Address:
01 . �o--
Si tune Telephone
SECTION 3.ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by rmit applicant
1. Building `fir r (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 J,44
6. Total=(1+2+3+4+5) � .7 Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
96 FLORENCE RD BP-2015-0665
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:22D-068 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Metal Chimney BUILDING PERMIT
Permit# BP-2015-0665
Project# JS-2015-001277
Est. Cost: $2502.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: CORY J MCGILL 107568
Lot Size(sq. ft.): 20778.12 Owner: WILMER KRISTEN
zoning:URA(100)/WSP(100) Applicant. CORY J MCGILL
AT. 96 FLORENCE RD
Applicant Address: Phone: Insurance:
P O BOX 1054 (413) 340-1392-0
WILLIAMSBURGMA01096 ISSUED ON.12116120-14 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL METAL CHIMNEY FOR EXISTING
WOODSTOVE
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 12/16/2014 0:00:00 $25.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner