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49-043 ME a0 I Da t cf,. S ab v Bar size roc? 'Lable rn Ralsett ve-viLn,:r plat Fornm v emu' Cn in ca'n: F1 81-01, —Ceiling Duct chase Jeffrey Bott Contracting Door 6'8"high 32 Pine Street Florence , MA 01062 Cennerazzo + Roy (413) 584-6251 Media Room Plan � r r � Na �o e°faro• �.r .` Ipy��s ��o�ors e�t �. �. e Sl �e WO 4 �'1 Rdo CZ7012 � rk,,�"5 S de.,, 1� i►, ��� er�oii. Ian Gaar�ao 9. 3IId its �Idi Q f 1r �lCe have e1ero'�se 1 o Rill 4u d teir Q Elecliic • �tll OI CXEI111JI10 11. r�paizs or ad-z ri Y ;� C Ilper MGL ' p1Lmbino Tepairs or adQYoM 1PSllT3IlC�1'?q "p ,, i C �_,�l(4),and we have no Roof repairs dons employees.Rio workers other cozy.insurance required,I `,nv apptica^,t that checK;Sex `I rratsi aiso ll out the section below snowing:heir workers,corrpensation aolicv irfor=tion. Homeowne s who submit this affidavit r dicatirg they are doirg ail work an'then hire outside contactors mist submit a new affidavit inicatirontractors that caec;this box mus atac ie3 an _sucadtional h. sheet showing the name of the sub-contactors and state whether or not those eadties have e^mloye�. If the sub-contMctors have enmiovees,they must provide their worc-^5'cot ip.policy number. I am an employer that isproviding worriers'compensation insurance for my employees Below is the policy and job sue information. lncuranC- f�Q-;:.nv\ig rne'� ' - C,.��i� Policy#or Self-ins.Lic,7:OCC 5c, b©O f&O 12-009 Expiration Date: (0 zs L7 Job Site Address: �Z- 1 (���'"�G �r�� ��( City'State/Zip: i✓ �B'��1/��o�t/ /I�i/ D/D�p 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?5A of vIGL c. 153 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-yeas irnprisonniem as well as civil penalties in the form of a STOP WORK ORDER and a fine o ur :o 3?f0.00 a day against the violator. Be advised that a copy of this statement may be for,-arded to the Office of Investigations of the DL4 for insurance coverage verification. f do hereby eerr,f6 tinder the pairs and penalties of perjury that the in�ormarion provided above is true and correct. �tgaa ur° Date. Z t Phone qf"icial use only. Do not write in this area, to be completed by city or town oJ1tcial Cin•or Town: PermiuLicense Issuing Authority (circle one): � ' ;ca! inspector ;°?u iin_Inpector Y.Electr1.Boa.d of Health ?.Buiicin� lepar.�:ent i*v Town L ler; 6.Other l P 0 e._ I Contact persoil: The Comironweal'th of Afassachse.-4-s D,.�Tarrmen! of Industrial.4 cciden!s 60011 ushington Street Boston, MA 02111 www.mass.-Ovldla 7,,'orkers' Compensation Insurance Affida-vit: Buildl-rs/Contractors,,'Electricians,Tlui-nbers dicant inforniation Please Print Leaffilv ae dress: 1p: -;State,,'Z' Phone—.,: ........... you an employer?Check the appropriate box: Type of project(required): 1 am a employer with ',' 4. [_J I am a general contractor and 1 6. ❑New consrrucM.on e=lovees(.fffill and/or pan-time). have hired the sub-contractors 7, 1 Remodeling I am a sole proprietor or partner- listed on the armched sheet. ,- f ship and have no ernolovees These sub-contractors have S. EJ Demolition emolovees and have workers* workiag for me in any capacity- 9. Building addition I-IN-0 workers'comp. insurance comp. insurance.- r ea c ett and I ors have )rk _5 W are a corporation and its e I 0•EJ Electrical rtpairs or additions t , I officers have exercised their 11.[]Plumbing repairs or additions I am' a homeowner doing all work right of exemption per MGL myself. ['-No workers' comp- Roof repairs - c.right §1(41),and we have no insurance required.] employees. [No workers Other co=.insurance required.] Any applicant that checks box#1 must also 411 out thesec"wi bei0wshoA-_n_2 rheir workers'con-wensarior policy irform2tion. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must subrM a new affidavit indicatffim such. n those e=ue rave Contractors that check this box must armc.!&d an addi-uorml,sheet showina the rzarre of the sub-contactors and state whether or not oe , s C,TMI0Y=- If the SUID-COMMCEOrs have eimloycts,they raust provide their woi1K_--s'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees: Below is the policy and job site information. Policv=or Seff-ins.Lic. #:OCC SO 0C)0,f&0 12-00* Ex-oiration Date: & -7 City/State.Zip: Al&'Atr4W!��110,tl ^ OIND Job Site Address: 14A Z-,( I 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 ol'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 o.^up to u'_50.00 a d---v against the violator. Be advised that a copy of this statement may be for-arded to the Office of Investigations of the DL',AA for insurance coverage verification. I do hereby cem:4-tinder the pairs and penalties of perjury thar the in,"ormation provided above is trite and correct Date- 2-1?LO? er ci U, Phone 0,rj,,cial use onli, Do rot write in this area, to be completed by ckv or town otj'iciaL Cin�or Town: Issuing Authority (circle one): e.9 t CiT II-Beard ofiHealzIlt 1 Building Depar= Inspector F!tunbip,21,1sn- ecio, 6.Other it Person: Phere ^ ` ' SECTION 8-CONSTRUCTION SERVICES 6.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holde License Number Sign e Telephone Company Name Registration Numbbr Coi Address Expiratidn Date 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. The current exemption for~hoozermzos'was extended minclude one(1) or mvo(2)taoUiev and m allow such homeowner mengage an individual for hire who does not possess ulicense,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 farnn 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 buildin2 permit. As acting Construction Supervisor your presence uu the job site will h eo,q"�un d from time mtime,during and upon completion o[the work for which this permit is issued. Also he advised that with reference to Chapter l52(Workers'Compensation) and Chapter lj3(Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable bmrpcmoo(o) you hire to perform work for you under this permit. The undersigned'homeovmzo,`certifies and assumes n:myouo@bUi{y6/rcumyliuocevid`the3tateBuildingCode'Cbyof Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature , '. / / � 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 _.," _.__.,"_ _ _ _._..,._ ._.,.yy... Frontage ��.._ k. Setbacks Front Side L. _ ` R. -. L::-,_. _ R.---Z i Rear Building Height Bldg. Square Footage Open Space Footage _, o --�(Lot area minus bldg&paved arkin _._. ._. #of Parking Spaces Fill: € volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? JON NO DON'T KNOW 0 YES Q IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book Page; 9 and/or Document#, B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued:€ C. Do any signs exist on the property? YES NO 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,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO POS IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5 DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors E] Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding [O] Other[p] Brief Description of Proposed P-'�1-415 Work: G �oir t'toN��CT�tt�t,ty— -'ido� Alteration of existing bedroom Yes No Adding new bedroom Yes �_No Attached Narrative Renovating unfinished basement _Yes No Plans Attached Roll -Sheet sa tf1N6W,„house F9ll4 addition`to exlsting'”Fiousin�ar°d`oint�lete the following: a. Use of building :One Family Two Family Other b. Number of rooms in each family unit: Number of Bathro s c. Is there a garage attached? d. Proposed Square footage 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 wetl ds? Yes o. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar flo below finished grade k. Will building conform to th uilding and Zoning regulations? No. I. Septic Tank ty Sewer Private well City water Supp SECTION 7a-OWNER'AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, �L✓I V1 2 O C n VZ O as Owner of the subject property hereby authorize - to act on my behalf, in all matters relative to wo k authorized by this building permit application. Signature of Own Date as Owner/Authorized Agent hereby d Clare that th 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. Print Name Q Signat e o O Agent Date Department use on kt • ' 140, f City of Northamptonerm�fi Building Department Curb��Dmewa� � � � 212 Main Street � . we► ` Room 100 VSrate I t � _ Northampton, MA 01060 �e S#rtctuNal`tns � k � , phone 413-587-1240 Fax 41 j 587-1272 s - r i APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Proaerty Address: Map Lot Unit 17- 1 JPA�-k tAi(t fZIAb zone Overlay District f�o 010 6 0 Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: e✓ivl Co �L LsZh �er Name(Print) Current Mailing Address: Telephone S g G- Signature O 2.2 Authorized Agent: tIlIx Name(Print) Current Mailing Address: POTCA�f Sign tur Telephone N-101 I SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 3 ) (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing t j� �.•�-� Building Permit Fee J 4. Mechanical(HVAC) ^ s 5.Fire Protection 6. Total=(1 +2+3+4+5) r7 00c> Check Number $" "L 4 U, M This Section For Official Use Only Date Building Permit Number. Issued: Signature: Building Commissioner/inspector of Buildings Date MEOW A File#BP-2009-0689 APPLICANT/CONTACT PERSON JEFFREY BOTT ADDRESS/PHONE 32 Pine Street FLORENCE (413)584-6251 PROPERTY LOCATION 729 PARK HILL RD MAP 49 PARCEL 043 001 ZONE SR(100)//WP/WSP II THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out zvr Fee Paid Y7 7v Typeof Construction: FINISH BASEMENT&ADD 1/2 BATH New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 053157 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF(— MATION 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 l !!! 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. BP-2009-0689 729 PARK HILL RD COMMONWEALTH OF MASSACHUSETTS GIs#: Map:Biock:49-043 CITY OF NORTHAMPTON -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Lot: Lot: -0 Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT. Category: Permit# BP-2009-0689 Project# JS-2009-001007 Est. Cost: $40000.00 Fee:Cost: $0 PERMISSION IS HEREBY GRANTED TO: Contractor: License: Const. Class: JEFFREY BOTT 053157 Use Group. Lot Size(sq ft.): 163829.16 Owner: CENNFRAZZ_O ALBERT&KEVIN ROY zoning:_S1t1100 !iWP/WS-?II Applicant: JEFFREY BOTT �.�. 7 EDIN S!/ L!ii r?rn ' • Phone: Insisr_ance: Applicant Address: 413 584-6251 Workers 32 Pine Street Compensation FLORENCEMA01062 ISSUED 0 N:21I112009 0:00:00 TO PERFORM THE FOLLOWING WORK.-FINISH BASEMENT & ADD 1/2 BATH POST THIS CARD SO IT IS VISIBLE FROM TIIE STREET Building Inspector Inspector of Plumbing Inspector of Wiring P.P.W. Underground;, ;LJ ( ice: Meter: Footings: �.:� /� Rough: �� <, House# Foundation: Rough: Driveway Final: Final:-5-- "{' 07 Final: Rough Frame f.( I Fireplace/Chimney: Gas: Fire De!iartrnent Insulation: 1 ^ rFinal: ' THIS PERMIT MAY BE REVOKED BY THE ITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULAT S. Certificate of Occu anc Si nature: FeeType' Date aid: Amount: Building 2/11/2009 0:00:00 $240.005239 212 Main Street,Phone(413) 587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo