41-008 (7) 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: J-
The debris will be transported by: 9 ► f `. ✓PC(c�.G�
The debris will be received by: c s�
Building permit number:
Name of Permit Applicant v e C
A
5-1-711 s
Date Signature of Permit Applicant
\ The Commonwealth of Massachusetts
Department of lndustrialAccidents
1 Congress Street,Suite 100
Boston,MA 02114•-2017
www mass.gov/ilia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le ibl
Name (Business/Organizatioii/rndividual): _1-e t »
Address:
City/State/Zip:6ke 1167a Phone#: ! 3 5 z 7
Are you an employer?Check the appro. it.box; Type of project(required):
1.Q I am a employer with employees(full and/or part-time).* 7. E]New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.7 I ant a homeowner doing all work myself [No workers'comp,insurance required.]f
10E]Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole I LE]Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑I ant a general contractor and I have hired the subcontractors listed on the attached sheet. 13.❑Roof repairs
Z, 7liese sub-contractors have employees and have workers'comp,insurance.$ 14.❑Other
Ge are a corporation and its officers have exercised their tight of exemption per MCiL c.
152,§€(4),and we have no employees.[No workers'comp,insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Honteoivners who submit this affidavit indicating they are doing all work and then 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,dtcy 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: _
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of investigations of the DIA for insurance
coverage verification.
I do hereby certify underW pains and p ties of perjury that the information provirleti ove is rue anr!correct
Signatur . _ Date:
Phone Official use only. Do not write in this area,to be completer)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#:
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u.sl.r.a„w�%d•� Sheet,
Prefix
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: r D�7 (�• 21 �'V-e57t-
License Number
(�12,jM&W-i14,0 617 RS
► n ��T
Address Expiratio Date
o
Signatu Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Nu ber
J2 -7 ;? S
Address Expiration Da e
Cc L / O Z Telephone�F l3
U
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....... ❑ 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 ❑ Replacement Windows Alteration(s) � Roofing El Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [❑ Siding[lam] Other[0]
Brief Description of Proposed fr j r I t
Work: (:,, LA 6) Cy-e-ca,J e l t-G�e o
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes X_No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building :One Family_K _ Two Family Other n
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached? l c 9�
d. Proposed Square footage of new construction. 6 H Dimensions l XZ
e. Number of stories? -.
f. Method of heating? lie Fireplaces or Woodstoves _Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction Wrej EiC.--,"
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 . S;-
k. Will building conform to the Building and Zoning regulations? X Yes No.
I. Septic Tank K City Sewer Private well 'K City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Y G (rt c, �f as Owner of the subject
property
hereby authorize C e ll Jtl'i,
to act o5,Ty behalf, ' all matters relative to work authorized by this building permit application.
SigdatukAf O er Date L '
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 e. [v
Print Name
Si ature of wner/Agent Da
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 r. G Inc 1CS c6--2, i i4c V
Frontage S y1, Cj ���, h._
Setbacks Front I/3 2� 10,2
Side L: G/ R:130 L R: 00
Rear �-
Building Height 2� Z
Bldg. Square Footage 225_. % 2.45'
Open Space Footage
(Lot area minus bldg&paved ( � �' /6,3 1 / 16�
parking)
11
L
#of Parking Spaces
Fill
(volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DON'T KNOW YES 0
IF YES, date issued:';
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW � YES Q
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 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q 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 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
D
Department use only
MR 2 12015 L City of Northampton Status of Permit:
" 2
Building Department Curb Cut/Driveway Permit
r.Ejeq,tric,,Plumbing&Gas Inspections 212 Main Street Sewer/Septic Availability
Northampton, VIA 01060 Room 100 Water/Well Availability_
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
I Other Specify_
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION I -SITE INFORMATION I
1.1 Pro pert Address. This section to be completed by office
V
"'j Map Lot Unit
//rr-e 2- Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 6 '/ed T>1"z
2.1 Owner of Record,
Y94 W Ci LA
Nari-k(Print) Current Mailing Address:
17 —
Telephone
Signature
2.2 Authorized Agent:
Rd t0e&&"-"qA'r
Name(Print) Current Mailing Address: X4
2 -7
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building A5) (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) 7,56
5. Fire Protection
6. Total= (1 +2+3+4+5) + 12 5; 9� Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-1030
APPLICANT/CONTACT PERSON SOVEREIGN BUILDERS INC
ADDRESS/PHONE 135 SOUTHAMPTON RD WESTHAMPTON01027 (413)527-8001
PROPERTY LOCATION 45 LOUDVILLE RD
MAP 41 PARCEL 008 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building-Permit Filled out J
Fee Paid
Typeof Construction: CONVERT GARAGE TO FAMILY ROOM&KITCHEN RENOVATION
New Construction
Non Structural interior renovations
Addition to Existing-
Accessory Structure
Building-Plans Included:
Owner/Statement or License 060176
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOR TION PRESENTED:
pproved 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
liti a
s- 7-IS
Signa 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.
45 LOUDVILLE RD BP-2015-1030
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 41 -008 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-2015-1030
Project# JS-2015-001964
Est. Cost: $125800.00
Fee: $750.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SOVEREIGN BUILDERS INCO60176
Lot Size(sq. ft.): 123231.24 Owner: BACIS PROPERTIES INC C/O RYAN GORMAN
Zoning: Applicant: SOVEREIGN BUILDERS INC
AT. 45 LOUDVILLE RD
Applicant Address: Phone: Insurance:
135 SOUTHAMPTON RD (413) 527-8001 Workers
Compensation
WESTHAMPTON MAO 1027 ISSUED ON:51812015 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONVERT GARAGE TO FAMILY ROOM &
KITCHEN RENOVATION
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 5/8/2015 0:00:00 $750.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner