32C-163 (27) 06/29/2015 10:19 4135877815 KITCHENS PAGE 02/04
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r Name:
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A:s
6241B2t1 OK TO FINAL
onstrltctax,asmaaNan,Removal and Haul Away ss s3o sc
Ramwvf e+M4inJ n untertops,tabmm.axf e0plor"s.nwpet vanxy,and batleoom 11M.
Haul away dame,
Silo arotaoHon
PW Box Gwreit In tall — 116.00
ustam Assembly ar Inrhtle8ttn f0.0o
NO CUSTOM A55FMRLY OR INSTALLTION 15 INCLUPPO
molding Installation 110.00
Elirctrical f2ee7.6o
ALLOTMENT FOR ELECTRICAI,WE WU.SCHEDULE A SITE VISIT FOR OUR f-1.HC:TRICIAN AND THEN
SUSMIT AN EXACT QUOTE IM ELECTRICAL WORK.
1AF ARE REQUIRED TO BRING T Ht,F.LECTRIrAL IN THE KITCHEN UP TO CURRI-N if C(aDES.
umbag "s".34
IrWO Worm sink wttaucet.within 3'ul exIWV"on(ntstefler Drovides shun tiff,trap+mwl valves as needed)
Install garbage disposal
Ird"I vanlry sink end faucet
Instal Dlblshower vAIm prvl drain
frigod t01et
Ralat t011Ct fl9 W
A EREQUIRED ICI®RING THE PLUMBING IN THE KITCHEN AND BAi HROOM tIP TO CURRENT
CODES,IF IT IS DISCOVERED THAT EXISTING PI IIM81Nt,DRAIN OR VENT LINES ARE NOT UN TO
C:URRkN I CODES.Ti IERE WILL BE AN ADDITIONAL COST tOR THAT 1AMX.
pliance Instaaaban SAD
and Beene ah In kske t1 10.09
)rywWl Wart Is PiYiling 117311.20
Path d"all from new een:KA al work
muonal Charga(k applicable) $3,766.40
Install new crown mnld'exj in"re unit
Instep 8 roolactime)wwxfcxw%
Plumbing
Pkime Building perms foes,if listed,on.ndy ewimitod. By signing mis r form tfls customer o9rMx In{lay** �a9
nix.prrmO fees accessed for this pr pest.Arry AilkXe'nre Ix4wm:n II ie e6tkttated tae arltl die aCtlNl acccssod fee
will be colnt*nl Inter or refunded to Ste Customer.
cad Sale Work PrAwcex
Asbestos may Ix:(axxeM In a horse bulk between 1949 and 1990 and 1 had Paint mAy Iw.Pnmo-vit Ina home
bulk before 1978,Additional chxr9t%may occur it the ouslomer does not oisoosa of product per F mlrral [7
Maildw of Lead Safe Practices.
raj Notes on the Project
ON RARE OCCA810Aw1 ADDITIONAL NORK IS DISCOVERED AFTER A PROJECT HAS RTARTFI3,THE CUSI OMkR
AORkAS R I/AT THIS ESTIMATE at VALID ONLY FOR THE WOHK US TO AND THAT ANY ADDITIONAL V"K THAT
I8 DJSWVFRFD AF nbR r HE PRCrdECT HAS BEGUN THAT WAS EITHER ANSUD ON THE ORWINAL 510 OR
AMSES DUE TO UNFORESEEN GIRDLAlaTANMIs WILL RkSULT IN ADDITIONAL CHARGES THAT MURTAF PAID
FOR BEFORF THE WORK CAN BE Gt7MPLE'ED.
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Wi d 02999LR999L << Lo S00dX3 50;tL Lo-LO-SW
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,M4 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plttmbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le ibly
Name(Business/Organization/individual):
Address:
City/State/Zip: ��� Phone
Are you an employer?Check the appropriate box:
Type of project(required):
1.7 I am a employer with employees(full and/or part-time).* 7. ❑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 am a homeowner doing all work myself.[No workers'comp.±^sur_nL-.reouired.]t
4.❑I am a homeowner and will be hiring contractors to conduct all worx o ^y ,v
.:my prcpe . I r11 10 F-1 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
p netors with no employees.
12.❑Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.n R f re
These sub-contractors have employees and have workers'comp.insurance.: _°/
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
14. Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box 41 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.
'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 isproviding workers'compensation insurance for my entp/ovees. Below is thepolicy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: 1,5�7�o 2__ Expiration Date: L /f�
Job Site Address: / &�9 ::City/Statc/Zi
Attach a copy of the workers' compensation policy declaration page(showing the policy number and - ation date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine p to 51,500.00
and/or one-year imprisonment,as well as civil penaitie�,iu the form of a STOr"ORIC ORDER and a fine of up t^5250.00
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 certi and snnaltie�f_perjury that the information provided above is true and correct.
Sicm atur � 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. Cit}f mvii Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
e�
Contact Person: Phone#:
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:
The debris will be transported b
Th :N Y
debris will be received by:
The
Building permit number:
r
Name of Permit Applicant
Date Signature of Permit Applicant
City of Northampton
Massachusetts
4° f DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 ss ti?�
1'yy X71
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 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 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
1, 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
- Office of Investigations
_ 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 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. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ 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.❑ 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.
tHo meowners 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,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. Lie. #: 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 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 certify under the pains and penalties ofperjury that the information provided above is true and correct.
Signature: 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
6. Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder: f/ c/�i �1 i'/.L. �
�
License Number
�
Addr s Expiration Date
Signature Telephone
9. Re istere Home lm r"vement Contractor: ` Not Applicable £
Comoa6v Na ��-� Registration Number
A s Expiration ate
Telephon
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
Or Doors I]
Accessory Bldg. ❑ Demolition ❑ New Signs (0] Decks t0 Siding [0] Other[0]
Brief Description of Proposed P A 1� V VV
Work: rV1®1�17)lV� ✓ I�/n/�a't/`� Cl ��,,�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a if New house an'i:or.addition to existing housing; co�T+p9ete the foilowincL.
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 fioor 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,_ —�ej A 1,1Nd3d�� , as Owner of the subject
property w
hereby authorize lf2idArb
to act on my behalf, in mat elative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized
Agent here y dec are that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed u the p ins and penalties of perjury.
1 1�
Print N
i nature of Owner/A nt Date
. ,
Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomptete Information
Existing Proposed Required by Zo
This colunin to be filled in by
~,
Building Department
Lot Size
Setbacks Front r-
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved L
#of Parking Spaces L--j
(volume Location)
A. Has a Special Pennit/Yariance/Fimbng ever been issued for/on the site?
NO 0 DONTKNOY C) YES 0
IF YES, dateissue6 �
IF YES: Was the permit recorded at the Registry ofDeeds?
NO ��/��
DON7KNOYY 0 YES 0
—=-
IF YES: enter Book i Pag and/or Document#
�� ��
B. Does the site contain abrook, body of water orvvetiands? NO �=��� DONTKNOY/ �~� YES �~/
IF YES, has 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 pnoperty �� ��� 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 0
IF YES, describe size, type and location: � ]
E. Will the construction activity disturb(clearing, gradingexcavation,or filling)over 1 acre oriait part ofa common plan
' that will disturb over 1 acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
- Depa meat use onl�r
of Northampton Status of Permit
B. llding Department Ctrrta GutlDnvetay Perini
� 16 2015
^ 12 Main Street SewerlSepticAyairabilrty _
Room 100 Waterllfe7iAaatlabllity
Electric,Piumging&Uas lnsarQ m ton, MA 01060 Two Sefs of Structural Plans
NcrthGmpton,PAA J10b0 p
4.
p one 3-587-1240 Fax 413-587-1272 PIoflSite Plans
Other 5;pecify _
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
ffice
1.1 Property Address: This section to be completed by o
Map Lot Un
,� ;.Zone Overly District
Y
Elm St District .i CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
� � Q
Current Mailing Addr-Af yy� y�f
Telephone
Signature
2.2 Authorized A ent:
Na in Current Mailin ddress:
Sig ature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building P-n v/ -„v v , � (a)Building Permit Feb
2. Electrical (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+5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector'of Buildings Date
File#BP-2016-0066
APPLICANT/CONTACT PERSON HOME DEPOT AT HOME SERVICES
ADDRESS/PHONE 5 RIVERVIEW DR NORTH PROVIDENCE02904(401)935-2633 Q
PROPERTY LOCATION 23 RANDOLPH PL tj!r 0
MAP 32C PARCEL 163 000 ZONE URC(105)/WP(53)/
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 KITCHEN SINK,REPLACE VANITY,TOILET&SHOWER&3
REPLACEMENT WINDOWS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 101342
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
o . io ela _
� ! /� A
Sig re 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.
Aao�7
23 RANDOLPH PL ti:r' BP-2016-0066
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C- 163 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2016-0066
Project# JS-2016-000118
Est. Cost: $22000.00
Fee: $143.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 101342
Lot Size(sq. ft.): Owner: TANSEY JOEL G&KYRIAKI GOUNARIDOU
zonin :URC 105,/WP(53) Applicant: HOME DEPOT AT HOME SERVICES
AT: 23 RANDOLPH PL 111
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 O Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON:711712015 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE KITCHEN SINK, REPLACE
VANITY,TOILET & SHOWER & 3 REPLACEMENT WINDOWS
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 7/17/2015 0:00:00 $143.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner