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30B-063
City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street * 1P I'll 47��•v� Property Address: �`t' 4,1 Ve rs/J�-- -410 tie e . Contractor Name: Address: City, State: Phone: - II Property Owner /V /Name: ,.� k--Address: J 1 i ve rd V. City, State: 6 Y-e I, —5 A� � (contractor) attest and affirm that the building I intend to insulate does not have any open air (knob and tube) wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit. Con si ature Date 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: 4,1 VZ I-sI ' c L�Y�W The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 5y www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information P,eas,e Pr21DA L.ezib1- Name(Business/Organization/IndividuaI): / '(; Address:_ jq2 36.E /C W�.- City/State/Zip: 6� 1 ' 13t)l Phone-#: _ /� - �� 3 - 4/ Areu an employer?Check the appropriate box: Type of project(required): I. I am a employer with 4. [] I am a general contractor and I * have hired the sub-contractors 6. El New construction employees(full and/or part-time). , 2.❑ I am a sole proprietor or partner- listed on the attached sheet_ ?_ ❑Remodeling ship and have no employees These sub-contractors have &. ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.# 9. E]Building addition required.] 5. ❑ We are a corporation and its 20.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 I.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.R R f repairs insurance required_]t c. 152,§1(4),and we have no employees.[No workers' 13. Other /ns XLJ) 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 mustsubrita new affidavit indicating such. tConoactors 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. aQl�Insurance Company Name: /0 d,t.1 t na Policy#or Self-ins. Lic.#: 0 N 4-40 4l ;9\ Expiration Date: /%/1 Job Site Address: L;,M/4 eiver—Si� 6r. CityfState/Zip: ► /0 re-oc c 1`4_ 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 STOP WORK ORDER and a fate 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 Investi cations of the DIA for insurance coverage verification I do hereby cert�o under the pains and penalties of perjury that the information provided above is true and correct. nature: t Date Phone 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 G.Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction supervisor., ( Not Applicable ❑ Name of License Holder: �_ rn�J I 17/v ic" 7 License Number Addre Expiration Date `Z ch ,._ o Signahure Telephone 9.Reallstered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number 14 �J if Li/a41 Address Expiration Date 0I ,� 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 build ing_paprrilt. 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)wh own a parcel of land on whic a/she resides or intends to reside,on which there is,or is intended to be,a one or two family lling,attached or detac d structures accessory to such use and/or farm structures.A person who constructs more than a home in a tw year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Offici , n a fo acceptable to the Building Official,that he/she shall be responsible for all such work performed under the builds ermit. As acting Construction Supervisor your presence on the site 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(Yorkers'Compensation d Chapter 153(Liability of Employers to Employees for injuries not resulting in Death)of 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) M�u New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other p (LC !r ✓Nq `f i/ C.� a - Brief script n of Q�pos t t�/ po Brief — ase vo - ✓e n/► .rl �J 3� fi /�i�r'� ,.� /► Alteration of existing bedroom Yes No Adding new bedroom Yes Nom , Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa.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 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, /1(�/1(_6 / 7I r1 �-- as Owner of the subject property hereby authorize 1"S S to a n my behalf, in matters relative to work authorized by this building permit application. Sign ture of Owner Date 1 Y�C J S as Owner/Au orized ent reby declare that the statements and information on the foregoing application are true and accurate,to the best of my RF5Wedge and belief. Signed under s and penalties me Pr ___77? C_ Signatur of Owner/ ent Date Section 4. ZONING Alt 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 0 DONT KNOW a YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW 0 YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Wo DON'T KNOW 0 YES 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 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 Q 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 O NO 4 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only U City of Northampton Status of Permit: 'Iding Department Curb Cut/Drlveway Permit rep, 12 Main Street Sewer/septic Availaabbility " Room 100 Water/Well Availability hampton, MA 01060 Two Sets of Structural Plana N0jh7 bfp9 a ne 4 587-1240 Fax 413-587-1272 Plot/Site Plans +npton M,t 010 Other Specify_ APPLICATION TO CO TRUCT,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 q� Wi Map Lot Unit 7 D M Yi C' Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner r of l'i i C,h R-(.l Z, e nt) Current Mailing Adhd Telephone [� Sig re 2.2 Authorized A e ame rint) Current Mailing Address: Sign&m— Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building �j (a) Building Permit Fee 2. Electrical J� (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total= 0 +2+3+4+ Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File# BP-2015-1215 APPLICANT/CONTACT PERSON IDEAL HOME IMPROVEMENT INC ADDRESS/PHONE 142 BOYLE RD GILL01354(413)863-2128 PROPERTY LOCATION 294 RIVERSIDE DR MAP 30B PARCEL 063 001 ZONE URB(100) 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:_INSTALL ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 091207 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 D la s��s' Sign'l ure o uil ing 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. 294 RIVERSIDE DR BP-2015-1215 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 30B-063 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categ`oa: INSULATION BUILDING PERMIT Permit# BP-2015-1215 Project# JS-2015-002295 Est. Cost: $2116.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: IDEAL HOME IMPROVEMENT INC 091207 Lot Size(sq. ft.): 5880.60 Owner: ZINK MICHAEL&ANDREA DOEHNE Zoning: URB(100)/ Applicant. IDEAL HOME IMPROVEMENT INC AT. 294 RIVERSIDE DR Applicant Address: Phone: Insurance: 142 BOYLE RD (413) 863-2128 WC GILLMA01354 ISSUED ON.61512015 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION 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: FeeTvpe: Date Paid: Amount: Building 6/5/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner