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38B-212 (5) 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: 16 �6 1(2L)Iaj The debris will be transported by: ACED CurL---z The debris will be received by: „fit t Building permit number: Name of Permit Applicant 4( ('t t.I cz _ ILA Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents z Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization'udividual): Address: 0/4 C40;-16k1F1t-)—V0 City/State/Zip: t IV Phone A6, Are you an employer''Check the appropriate box: Type of project(required): . I am a general contractor and I 1.❑ I am a employer with 1 _ ❑ 6. New construction employees(full and'or part-time).* have hired the sub-contractors 2.[ I am a sole proprietor or partner- listed on the attached sheet. 7. F1 Remodeling v ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' 9. F1 Building addition [No workers' camp. 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.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] + c. 152,§1(4),and we have no employees. (No workers' 13.❑ Other—____,_i___T 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 theft hire outside contractors must submit a new affidavit indicating such. =Contractors 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 polio^and job site information. Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration 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 a fine 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 coverage verification. I do hereby ce under th ins a d enalties of perjure,that the information provided a �o-rve/is true and correct. Signature: _._ --- — Date: 1 l[_�5 Phone#: ^d�� -- - -- - I — Official use only. Do not write in this area,to be completed bt,cih,or town official. Citv or•Gown: 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 Construction Su ervisor: Not Applicable ❑ Name of License Holder: �L e� 6u 1 CZ y 5 / License Number Addr Expiration Date 263 Signa r Telephone 9.Realstered Houlp Improvement c r: Not Applicable ❑ fi t,(-Go u 1 cZ %o C�� y Companv Name Registration Number 6L C+--�MEEPUQ 01696 Address 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.......A 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 F-1 Replacement Windows Alterations) Roofing ,�( Or Doors 0 Accessory Bldg. F-1 Demolition I"1 New Signs [0] Decks JM Siding[1--3] Other[E] Brief Description o#.Proposed Work: (�ArF h ry O ey. (ck r,D Alteration of existing bedroom Yes_c No Adding new bedroom Yes _ No Attached Narrative Renovating unfinished basement Yes _)L_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?a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, . /� ,as Owner of the subject property hereby authorize to act act o y behalf,in all matters relative to work authorized by this building permit application.ha A nature of Owner ate I 41-60 as Owner/Authorized Agent hereby declare 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. A(. � t�L/ Print Name _ Signature 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 filled 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 ® ONT KNOW Q YES IF YES, date issued: �l I IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW ® YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO W DONT KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained ® , Date Issued: C. Do any signs exist on the property? YES 0 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 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 ® NO P IF YES,then a Northampton Storm Water Management Permit from the DPW is required. a Department use only City of Northampton Status of Permit: Building Department Curb Cut(Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 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 /o "'5r-r i2Jlrr �z, Map Lot Unit Zone Overlay District Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name rint) Current Mailing Address: r✓ "'� Telephone Signature 2.2 Authorized Anent: { 4 'fitLFO QuIEL-- . 4-C,4�16V-FJECO R0,4Q .Name(Pri ) Current Mailing Address: 6R `1d&J- Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by rmit applicant 1. Building �Lori d (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of , 5 Construction from 6 3. Plumbing (%�0 Building Permit Fee 4. Mechanical(HVAC) �( 5.Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0889 APPLICANT/CONTACT PERSON ALLEN GUIEL ADDRESS/PHONE 63 CHESTERFIELD RD WILLIAMSBURGO1096(413)268-9200 Q PROPERTY LOCATION 16 FAIRVIEW AVE MAP 38B PARCEL 212 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT_APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin Permit Filled out Fee Paid Typeof Construction: RENOVATE BATHROOM V New Construction Non Structural interior renovations Addition to Existin Accesso1y Structure Buildiniz Plans Included: Owner/Statement or License 054248 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO TION 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 D Sign re of Building Officiftf 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. 16 FAIRVIEW AVE BP-2015-0889 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B-212 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-2015-0889 Proiect# JS-2015-001726 Est. Cost: $19000.00 Fee: $114.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ALLEN GUIEL 054248 Lot Size(sg. 1): 3615.48 Owner: WATERMAN PAUL D&DONNA L zonin : 100)/ Applicant. ALLEN GUIEL AT. 16 FAIRVIEW AVE Applicant Address: Phone: Insurance: 63 CHESTERFIELD RD (413) 268-920Q-0 WILLIAMSBURGMA01096 ISSUED ON:312612015 0:00:00 TO PERFORM THE FOLLOWING WORK.-RENOVATE BATHROOM (all work within footprint) 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 Denartment 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 Sisnature: FeeType: Date Paid: Amount: Building 3/26/2015 0:00:00 $114.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner