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17C-055 (3) i THE COMMONWEALTH OF MASSACHUSETTS Board of Building Regulations and Standards Home Improvement Contractor Registration Program Registration No: One Ashburton Place,Room 1301 Boston,lVLA 02108 Effective Date: �,J9, Application for Registration as a Home Improvement Expiration Date: Contractor or Subcontractor-MGL Chapter 142A,780 CMR R6 (PLEASE READ BOTH PAGES CAREFULLY) Date Processed: 1. BUSINESS NAME: A.119111_1 L—)-d bLl - kA-1( C a�.�✓�.� �` c Print the name in which the applicant is conducting business (SEE INSTRU TIONS) 2. Mailing Address: Z S tnn t�,P/ ( tt ) Area Code Telephone Number 3. City: �,i c r.�, State: +M c,_ Zip: (0 1 0;L 4. Street Address(if different): (Print street name and number,a P.O.Box is not acceptable for address)City State Zip 5. Applicant type: L"J Individual 11 DBA [I Partnership [I Trust El Private Corporation El Public Corporation ❑Limited Liability Partnership ❑ Limited Liability Corporation Please Check One (See instructions regarding enclosing a city or town registration under DBA or"fictitious name"law.MGL c 110,§5 8 6) 6. Federal ID Number: Z- t/- 6 c t 5 (see back) 7. Number of Employees (See instructions) S. Have you registered previously under this law? If so,under what? Name: Registration No: a 9. Individual responsible for Home Improvement Contracts: q,4_6 ar (See instructions) Last First MI Social Security No 10. Title of individual responsible for Home Improvement Contracts: n .;;:;; �A �- �,A) t 1 1_ Does the applicant or responsible individual hold any other epnctniction relater)state city,tnw licences or registrations? 10 Yes No Type of License or registration Issued By License or Expiration Date Name of License Holder registration number 12. List all partners,trustees,officers,directors and major owners(10%or greater of ownership)of an applicant partnership or corporation below. Use additional paper if necessary. (See instructions below) Check here if you wish to receive an application for additional ID cards for key persons. ❑ Last I First I Middle Initial Title in Applicant Business %Owner Address 13. Is the applicant claiming exemption from the registration fee?(See instructions) []Yes [� o 14. Registration fee enclosed:$ at' ° (see note#1,of instructions) Guaranty Fund fee enclosed:$ (see note 92,of instructions) If necessary,include two separate certified checks or monev orders-one marked"Registration Fee';one marked"Guaranty Fund". See instructions for the fee amounts.Make all certified checks or money orders payable to"Commonwealth of Massachusetts". PERSONAL OR BUSINESS CHECKS WILL BE ACCEPTED BUT WILL REQUIRE AN ADDITIONAL TEN(10)DAYS TO PROCESS. Pursuant to Massachusetts General Laws Chapter 62C§49A,I certify under the penalties of perjury that I, to my best knowledge and belief have filed all state tax returns and paid all state taxes required under law. 4 1 t) Signature o plicant or applicant's representative Title held with applicant Date A false answer to any question in this application constitutes grounds for suspension or revocation of the applicant's registration. ANDREW T. WALSH JR. DBA 1375 ATWAL CONTRACTING 9 FOREST AVE 2 53-716812118 GREENRELD,MA 01301 Date 7 PH 413-475-3137 Pay to the Order of ( ,1 L a Vli�.l, y�e� 1 �cti �n`l �i<<c�.SE', S $ x p tru Dollars FLORENCE SAVINGS BANK 85 MAIN STREET,FLORENCE,MA 01082 r N For NIP 1: 2 L I8 ? I688i: 19 80 44 ? 2 ? Ill' L375 � � �11rlassacStusrtts = DEPARTMENT OF BUILDDTG INSPECTIONS INSPECTOR 212 Main Street • Municipal Building Northampton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction sup .�7Sor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends 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 home owner." The building department for the City of Northampton wants any person(s)who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before backfill). sonotube holes (before pour) a rough building inspection(before work is concealed) insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work(electrical, plumbing& gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location 4 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 �„ sv www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): �/1 i� 1 �C `�y._ G. t.11 col. Address: a Sv.vi,tw%,C. City/State/Zip: SA(-. OL011 Phone.#: Lf 13— r Z- -4 Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction � e loyees(full and/or part-time).* have hired the sub-contractors 2.LB"l 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.$ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 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 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. lContractors 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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip:' 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 afire 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 coverate verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature• c f �T Date: 3 d! U _ Phone#: —1 (_� 5- 1). 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: f 1 SECTION 8—CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: (— �, O License Number �( mac✓e � �- �-ti-c. �����,.��f�l St �v�c, , C� 13 iJ � 1 �.��l �©�- Address Expiration Date Signature Telephone . .o. a Not Applicable ❑ 9 Rea�stered Ho"fine Imoro/Gvemefn�t'Contractor P e,Q- 8.,4-L�COY e'U'' 1 Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GL.c.152,§2SC(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...... ❑ 11:, ,Homes Q��ne>��:� emu�ion 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) r/� Roofing ❑ Or Doors F-1 Accessory Bldg. ❑ Demolition New Signs [O] Decks [0 Siding[[--3] Other[O] Brief Description ofPr4pos(�ed Work: Q_e- ,,,5_L �u�.���aw t� n�i e S, l (� B ��u�:�'t ��('ale S�,n .�.✓ j (o(�✓ -� Alteration of existing bedroom Yes k--- No Adding new bedroom Yes Y No Attached Narrative Renovating unfinished basement Yes rte No Plans Attached Roll -Sheet sa.if:New i ` tionse.,an4d_ortldi"tion to ezist�n '-housn com�iet thefof(own : a. Use of building:One Family Two Family Other b. Number of rooms in each family unit: n Number of Bathrooms c. Is there a garage attached? h J - C",-"�,eJ d. Proposed Square footage of new construction. Dimensions e. Number of stories?a, 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 %)gcQutitu.Jt Li 3,rc.Jt ki c11-►IR-0 3 as Owner of the subject property hereby authorize /°T�[� �Q,�� L'_"J k t on �ela'lf, in all matters relative to work authorized by this building permit application. c-r Sign re of er Date as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application apppllication are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Pnnt N me Zo Sig toe o 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 Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces A. Has a Special Perm it/Vahuncu/Fndi ever been issued for/on the site? � ��� NO �~��� DON7KNOVV YES �~� IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO K @ D E �� IF YES: enter Book Page and/or Document#� { ^�/ B. Does the site contain a brook, body of water orwetlands? NO x_��� DON'T KNOW ��y YES IF YES, has permit been or need to be obtained from the Conservation Commission? Needs tobeobtained «.��~\ Obtained v~_�� Date� ' �� C. Do any signs exist on the prope�y? 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 0 NO /D" IF YES, describe size, type and location: | / E. Will the construction activity disturb(clearing,grading, .nr filling)over 1 acre nris it part ofo common plan that will disturb over 1acre? YES � } NO �� IF YES,then a Northampton Storm Water Management,Permit from the DPW is required. ' A ;'� Department use only, fir, City of Northampton Status of Per¢ ifij$ � a — -- Building Department �T !; 2r2 Main Street SeiNer e ya -- -�— _ Room 00 Wafec�lJU'eltat�aEtllty � v � z' 0 Northampton, MA 01060 aSe s otStruc�urak � s pQon ( 13-587=1240 Fax 413-587-1272 ri�te1a � ` , t t , ,mow APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE.INFORMATION 1.1 Property Address: This rsection to be completed by office Map Lot U1. Zone Overlay,Distract Eliot SL Distract dr- ,cCB Distract - SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED;AGENT '` 2.1 Owner ofp.Record: / 9+ (� I ) / `f / U I[; {"�Gt Lt ce c /L ? FYP `�: C�G�-,�� 1 Cf�" C In FS} v u S .I I Qt/eyl Lk_ ✓Ll 61 . Name( Ptl Current Mailing Address: LI13 -- .5 94 51 Telephone Sig 2.2 Authorized Agent: Ati ^. Sln J- _ tt 't d1 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 (a)Building Permit Fee boo. 60 2. Electrical (b)Estimated Total Cost of ' -Construction from.,6 3. Plumbing G o p Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) v�.L p Check Number This Section For Official Use Only Building,Permit Number. Date'; Issued: Signature: Building Commissioner/inspector of Buildings Date File#BP-2007-0915 ` APPLICANT/CONTACT PERSON ANDREW T WALSH JR ADDRESS/PHONE 2 SUMMER ST EASTHAMPTON (413)522-7795 Q PROPERTY LOCATION 168 CHESTNUT ST MAP 17C PARCEL 055 001 ZONE URA 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:_REMODEL BATHROOM(REPLACE SINK,PLUMBING/TILE SHOWER/FLR New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 082029 3 sets of Plans/Plot Plan THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFPRMATION 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 Elms Street Co sion Signature of Building Official 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. BP-2007-0915 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category: BUILDING PERMIT Permit# BP-2007-0915 Project# JS-2007-001485 Est. Cost: $8000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ANDREW T WALSH JR 082029 Lot Size(sq. ft.): 16509.24 Owner: MANSEAU PATRICK M& Zoning: URA Applicant: ANDREW T WALSH JR AT. 168 CHESTNUT ST Applicant Address: Phone: Insurance: 2 SUMMER ST (413) 522-7795D EASTHAMPTONMA01027 ISSUED ON:41412007 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMODEL BATHROOM (REPLACE SINK,PLUMBING/TILE SHOWER/FLR 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 4/4/2007 0:00:00 $50.001376 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 168 CHESTNUT ST BP-2 915 GIS#: COMMONWEALTH OF MASSACHUSETTS ME:Block: 17C-055 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category: BUILDING PERMIT Permit# BP-2007-0915 Project# JS-2007-001485 Est. Cost: $8000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use GrojM ANDREW T WALSH JR 082029 Lot Size(sg. ft.): 16509.24 Owner: MANSEAU PATRICK M& Zoni:a: URA Applicant: ANDREW T WALSH JR - -- AT: 168 CHES !NU-1 S i' Applicant Address: Phone: Insurance: 2 SUMMER ST (413) 522-7795 () EASTHAMPTONMA01027 ISSUED ON:41412007 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMODEL BATHROOM (REPLACE SINK,PLUMBING/TILE SHOWER/FLR POST THIS CARD SO IT IS VISIBLE FROM THE STREET + 'Ins pe for o'lhunbing Inspector of Wiring D.P.W. Building Inspector Ynderground: Service: Meter: Z Footings: Rough: Rough: q110 Jd`7 House# Foundation: L Driveway Final: Final: Final: / Rough Frame: 0/< /�! Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insu;adoin: Final: Smoke:, Final: OK THIS PERMIT MAY BE REVOKED BY THE ITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. / Certificate of Occupancy Signature: - FeeType• Date Paid: Amount: Building 4/4/2007 0:00:00 $50.001376 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo