17A-226 (2) THE FRONT OF THE DOCUMENT HAS A MICRO-PRINT AMOUNT BOX AND THERMOCHROMIC.ABSENCE OF THESE FEATURES WILL INDICATE A COPY.
75-16i8
919
INTERNATIONAL MONEY ORDER
Money Orders
co PAY TO THE PAY O Y T'HIS AMOUNT
CD ORDER OF:!
PACAR M ORDEN E UVQJ f (n4�
ORDEN DE:
MPORTA -51E BACK BEFORE CASHING'
? _
LO
.:
ROHM E FOR DRAWER/COMPRADOR,FIRMA DEL LH3RADOR i
M PURCHASE$BP SIGNING YOU AGREE TO THE SERVICE CHARGE AND OTHER TERMS ON THE REVERSE SIDE
ADDRESS:!
C) DIRECCION
—t Payable Through ISSUER/DRAWER: !.
—7 Citizens State Bank MONEYCRAM PAYMENT SYSTEMS,INC "
of Clara City
Clara City,MN TO AUTHENTICATE RU&CIRCLE -
PARA AUTENT)CAR R EBTREGAR EL COCULO
'.0914 &&. 18 ?t: LO 13 9563OB751x• 90 .
10. PLEASE PROVIDE THE NAME,SOCIAL SECURITY NUMBER,AND TITLE OF THE INDIVIDUAL IN THE CURRENT
BUSINESS THAT IS RESPONSIBLE FOR THE OVERSIGHT OF HOME IMPROV'EMEN'T CONTRACTS:
LrCC _
-
LAST FIRST SOCIAL/SECifkITY 4 TITLE
11. DOES THE APPLICANT OR RESPONSIBLE INDIVIDUAL HOLD ANY OTHER CONSTRUCTION-RELATED STATE,CITY
OR TOWN LICENSES OR REGISTRATIONS? YES NO
IF YES,PLEASE FILL IN INFORMATION BELOW. ATTACH ADDITIONAL SHEETS IF NECESSARY.
LICENSE TYPE ISSUED BY LICENSE/REG.9 EXPIR.DATE LICENSEE NAME
8 ( ctr C
12. LIST ALL PARTNERS,TRUSTEES,OFFICERS,DIRECTORS,AND MAJOR OWNERS(10%OR GREATER OF
OWNERSHIP)OF AN APPLICANT PARTNERSHIP OR CORPORATION,BELOW. USE ADDITIONAL PAPER IF
NECESSARY AND INCLUDE NEEDED PAPERWORK(SEE INSTRUCTIONS). PLEASE INDICATE BY AN"X" IN THE
LAST COLUMN THOSE LtiDn'IDUALS WHO REQUIRE AN APPLICATION FOR ADDITIONAL REGISTRATION I.D.
CARDS. USE ADDITIONAL SHEETS IF NECESSARY.
FULL NAME TITLE %OWNE$--. ADDRESS
13. IS THE APPLICANT CLAIMING AN EXEMPTION FROM THE REGISTRATION FEE AS A CSL HOLDER?
YES NO
14. REGISTRATION FEE ENCLOSED: $ GUARANTY FUND FEE ENCLOSED: $ �0.
PLEASE INCLUDE TWO(2)SEPARATE CERTIFIED CHECKS OR MONEY ORDERS,ONE MARKED "REGISTRATION
FEE" AND ONE MARKED "GUARANTY FUND." MAKE CHECKS PAYABLE TO "COMMONWEALTH OF
MASSACHUSETTS." PERSONAL/BUSINESS CHECKS WILL BE PROCESSED BUT WILL TAKE AN ADDITIONAL TEN
(10)DAYS.
I HEREBY SWEAR UADER THE P LIVS AND PENALTIES OF PERJURY THAT ALL LVFORIIATION CONTAINED IN THIS
APPLICATIONIS TRUE AND ACCURATE TO THE BEST OF:LIYK?VOWLEDGE AND UNDERSTANDING. FURTHER,I CERTIFY
PURSUANT .G.L. 62C,§49A, THAT I LIAVE FILED ALL 1�ECESSARYST_4TE TAX RETUR:'VS.
gnature Date
Title of Applicant or Business Representative (if registering as business)
THE COVLMONNVEALTH OF 1bLASSACHUSETTS
Board of Building Regulations and Standards For DPS Use OnIv.
Home Improvement Contractor Registration Registration No:
H One Ashburton Place,Room 1301
Boston,MA 02108 Effective Date:
Application for Registration as a
T Home Improvement Contractor Expiration Date:
or Sub-Contractor
MGL c. 142A; 780 CMR I10.R6
1. BUSINESS NAME:' C~/Z452;- APPLICANT PHONE 9:
2. MAILING ADDRESS: c j r )c%I,"0�,'
STREET CITY STATE ZIP
3. PERMANENT ADDRESS(IF DIFFERENT):
STREET CITY STATE ZIP
(PLEASE NOTE THAT P.O.BOX IS NOT ACCEPTABLE FOR PERMANENT ADDRESS.)AP
4. APPLICANT TYPE(CHECK ONE): 11 INDIVIDUAL D/B/A PARTNERSHIP TRUST
PRIVATE CORP. PUBLIC CORP_ L.L.P_ L.L.C.
(SEE INSTRUCTIONS REGARDING THE ENCLOSURE OF A CITY OR TOWN REGISTRATION CERTIFICATE IF D/B/A IS CHECKED)
5. SOCI_AL SECURITY OR FEDERAL TAX I.D.NUMBER:
6. NUMBER OF EMPLOYEES:
7. HAVE YOU REGISTERED PREVIOUSLY UNDER THIS LAW? I'ES ?/ NO
IF YES,PLEASE PROVIDE THE NAME AND REGISTRATION NUMBER IN WHICH YOU WERE PREVIOUSLY
REGISTERED:
APPLICANT/BUSINESS NAME:
REGISTRATION NUMBER:
8. A)ARE YOU CURRENTLY OR HAVE YOU EVER BEEN AN OFFICER,PARTNER,OR CO-VENTURER OF AN APPLIC T
'",'HO PREVIOUSLY APPLIED FOR REGISTRATION UNDER THIS LAW(M.G.L.C.142.4,)? YES NO
B) IF YES,PLEASE PROVIDE THE NAME OF THE APPLICANT AND NAME OF THE BUSINESS(IF DIFFERENT)AND
REGISTRATION NUMBER:
APPLICANT/BUSINESS NAME:
REGISTRATION NUMBER:
9. A)ARE YOU CURRENTLY OR HAVE YOU PREVIOUSLY BEEN EMPLOYED BY A REGISTRANT OR APPLICANT FOR
REGISTRATION AGAINST��W130//V0ISCIPLLNARY ACTION WAS TAKEN BY THIS DEPARTMENT?
L
YES /NO
B) IF YES,PLEASE PROVIDE THE NAME OF THE INDIVIDUAL AND BUSINESS(IF DIFFERENT)AND REGISTRATION
NUMBER:
APPLICANT/BUSINESS NAME:
REGISTRATION NUMBER:
f
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780C'vM 108.3.4 to
act as his/her construction supervisor. 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 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/footines (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 occupancv
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 pernit 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
Tile Co.nm Oil wealth of�IassacitIs etts
- Deparnr-neat of Indusnr.ai.-iccidents
Q-f ce OjOr.n vesti`arsons
_ 600 Mashlna ton Sr eet
Boston, 2VIA 02111
www.tnass.�ov/dia
VVorhers' Compensation Insurance Affdati,it: Builde rs/Contractors,rElectricians,rPlumbers
rmlicant Information Please Print Lesibl�
'NaMC- (Business/Organi:atiotv'Individual): � L�
Address: YD2�G( Sr
A-1:
City,State,Zip: (9/l�Gl � . Goo Phone
Are you an employer'Check the appropriate box: Type of project(required):
I.❑�Tain a employer with 4• ❑ 1 am a general contractor and I
oyees (full and/or part-t me)-* have hired the sub-contractors 6 ❑ `ew construction
2. a sole ro rietor or a-tner- listed on the attached sheet- i• ❑ Remodeling
P P P
ship and have no employees These sub-contractors have g- ❑Demolition
working for me in an Y pacity.
ca employees and have workers' addition
9. ❑Building
[No workers' comp. insurance comp. insurance.
requ 5- ❑ We are a corporation and its 10-❑Electrical repairs or additions
3.❑ I am a homeowner doing aI1 work officers have exercised their 11-❑Plumbing repairs or additions
myself. ['-,N-o workers' coma. tight of exemption per VIGL 12.❑Roof repairs
insurance required.] ' c. 152, §1(4), and we have no
employees. [No workers' 13.7 Other
comp. insurance required.]
*Am appiicant that checks box=Y must also:ill out the section below showing their worker'compensation policy infonnarion.
Homeowne s who submit this affidavit indicating they are doing all work and then hire outside contractors trust submit a new affidavit indicating such.
Contractors that check this box must arached 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 thepolicy and job site
information.
insti-anct Company Name:
Policy=or Seif=ins. Lic, r: 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 ender Section 25A of-MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORD ORDER and a fine
o:`up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLL fo insuranc°coverage verification-
I do hereby certify a the p s a d penalties of perjury that the in'ormation provided above is True and correct
Signature Date: '/08
Phone' <([3-
0fj:cial use only. Do not wrire in this area, to be completed by ciry or town ojjiciaL
City or Town: Permit/'License r
Issuing AuThority (circle one):
L Beard of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Phu-robing Inspector
6.Other
i -
i Coni2cr Persor:: Phone
SECTION S-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor I Not Applicable ❑
Name of License Holder: /1 CL (.1:.. + �•f+ � 2 'u
License Number
;dbress Expiration Date
Signature Telephone
L Reoistered Home Improvement Ganfractor Not Applicable ❑
:omoanv Name Registration Number
.ddress Expiration Date
Telephone
ECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT EM G.L. c._132s§25C(6})
+orkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
the denial of the issuance of the building permit.
aned Affidavit Attached Yes....... ❑ No...... ❑
1_ ..HOm
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. SLith 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-vear period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building OfScml,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 DESCPIP7ION OF PROPOSED WORK(check all aoolicabie?
I
New House [j � Addition Replacement Windows Alteration(s) C I Roofing E I
Or Doors �
Accessory Bldg. ❑ Demolition New Signs nj Decks F= Siding 1=1 Other[L71
Brief Description of Proposed
Work: � �'�/1<'4 )7/� 7c� t-ti! lY iNS l4 ���c=C�+ 1C c � �����'� � i1!/h���`/r► L
Aiteration of existing bedroom Yes v'No Adding new bedroom Yes No -`
Attached Narrative Renovating unfinished basement Yes
Plans Attached Roll -Sheet
6a. If IVew house andbr aciai idn td existing�iousing,�WtTlplete 4664 a6m-na, /Y
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? l
d- Proposed Square footage of new construction. Dimensiers
e. Number of stones?
f. Method of heating? Fireplaces or Wcodstoves Number of each
c. Energy Conservation Compliance. Masschecik Energy Compliance form attached?
h- Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. flocdpiain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will buildinc conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER:AUTHORIZATION: TO-SE COMPLETED==WHEAL -
OWNERS AGENT OR;CONTRACTOR.APPLIES FOR BU1tE11[+tC�PE M1T
I, Aviv z ,O ME K as Owner of the subject
prope.-Ly
hereby authorize Y� �C F= Cf� ll -/,—
to a •on my behalf, in all matters reiabve to work authorized by this building permit application.
G
Signature cf Owner Date
I as Owner/Authcnzed
?.gent hereby declare that the st-Cements and information on the foregoing application are true and accurate, to the test of my knowledge
and belief. Y
Signed under the pairs and penalties of perjury.
Fnnt Name
i
i
„,cnab_re,,f CwnedAg nt
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existinz Proposed Required by'Zoning,
TTiis column to b 'Ile in b�
par
Building De tment
L T S Z 7'.
o
LOT SiZ,-
Setbacks Front
Rear
Building Height
Open Space Footaae %
(Lot area minus bidg&paved
#of Parkinz Spaces
(volume&Location)
A. Has a Sp7zfal Permit/Yahance/Finding ever been issued for/on the site?
v~� x-�
NO \�� DONTKNOYY �,/ YES �_�
^ �
UF YES, date issued
IF YES: Was the permit recorded at the of Deeds?
NO K ) DO TKNOYY YE5
— [�� --------
IF YES: enter Book ` ` Pager and/or Document#' .
��
B. Does the �tecontain a brook, body of water orwetiands NO V�� DONTKNOYY �_� '�� v~�
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tobeobtaned y—� Obtained �-� Date .
' ^_� ' �~� ' ' L________.—_
C. Do aAysigns exist on the property? YES 0 NO
IF YES, describe size, type and iocation�
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~
on. or filling)over 1oo�or|a�po�oraoonm ��sn
that wiUdisturb over Iaoe? YES NO (3
|F YES,then-allorf6amPtbhSGo-T F,-W�ite—r Kfd-n5gemenfPehnit from the DPW isrequired.
�����
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street lSelwer/Septic'Availabliity I
Room 100 Water/WeltAvailability
f�orthampton, MA 01060 Two Sets of Structural Plans
phone
4.13-587-1240 Fax 413-567-1272 Plot/Site Plans
6 2U� Other'Specify
APPLICATION TO Q,O�STR CT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
F p y A
t SECTI'6' 'T. SITS 4r0R1Vf TION
This section to be completed by office
1.1 Property Address:
Map Lot Unit
Zone Overlay District
fa, Elni St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
(17
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS �Zi.C>C.: • V
Item I Estimated Cost(Dollars)to be Official Use Only
completed by permit aoclicant
1. Building (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= (1 +2+3+4---T+5) Check'Number
This Section For Official Use Only
Date.
Building Permit Number. Issued:
Signature:
--------- ---—._
building Commissioner/inspecto�_oT. u-omgs Date
File#BP-2008-1097
APPLICANT/CONTACT PERSON REECE CARAKER
ADDRESS/PHONE 246 NORTH ST NORTHAMPTON (413)584-3036
PROPERTY LOCATION 117 LAKE ST
MAP 17A PARCEL 226 001 ZONE URB
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: REPLACE PORCH FRAMING NEW ROOF&HANDRAIL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 85564
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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
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.
1'' r BP-2008-1097
CIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinc4 DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category BUILDING PERMIT
Permit# BP-2008-1097
Project# JS-2008-001621
Est. Cost: $2000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: REECE CARAKER 85564
Lot Size(sq. ft.): 20865.24 Owner: ZIOMEK ANN R&MARY ANN
Zoning: URB Applicant: REECE CARAKER
AT. 117 LAKE ST
Applicant Address: Phone: Insurance:
246 NORTH ST (413) 584-3036
NORTHAM PTONMA01 060 ISSUED ON:611212008 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE PORCH FRAMING, NEW ROOF &
HANDRAIL
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 6/12/2008 0:00:00 $50.00MO
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo