29-370 (4) City of Northampton 212 Main Street, Northampton, Na 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 CL_
The debris will be transported by:
The debris will be received by: V
Building permit number:
Name of Permit Applicant
�2 \�
Date Signature of Permit Applicant
\ The Commonwealth of Massachusetts
• i,u �_ Department of Industrial Accidents
l ���y
A-- r 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: �jAb
City/State/Zip: Phone
Are you an employer? Check the appropriate box: Type of project(required):Z�
1.M I am a employer with � 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. New construction
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 or me in, capacity. employees and have workers'
g Y P h'• 9. ❑ Building addition
[No workers' comp.insurance comp. insurance.t
required.] 5. ❑ We are a corporation and its ME 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 i
employees. [No workers' 13.9 Other i�U)a4t on
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 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: POOR ?- Ql_ LAA-L')L)4D_06f 6 COUP-
Policy#or Self-ins. Lic.#: �J<Jo60,Z O Expiration Date:
a � � l I(
Job Site Address: 37 City/State/Zip: F(ot ZnC e 01OW-
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 r2cation.
I do hereby certify „ the pains a.Id penalti. • perjury that the information provided above is true and correct
Signa 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 S-CONSTRUCTION SERVICES
81 Licensed Construction Supervisor: \_ _+ Not Applicable ❑
Name of License Holder:.. t�1t_°� 1 (\\ CT ®to dJw
License Number
P.o c�c�a� �ore�ncr !�a o o b2 ct 22 l 1
Address Expiration Date
5ignatur 71, Telephone
1 Re isteied Nome m roVemenf Contractor,-- Not Applicable ❑
Company a X Registration Number
Qz R)N �1 �O�PX�CL O\0(02-
Address Expiration Date
Telephone���"Cx�� c522
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.:.... ❑
l . ® i�Qw e d
The current exemption for"homeowners"was extended to include Gyrner-Gecupied Dwelfl6�s s_of one(1) or two(2)kmk1lies
and to allow such homeowner to engage an individual for hire who does not possess a license,pray jded that the owner acts
as snpervisor.CAM 980, Sixth Edition Section
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-gear 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 shalt be
responsible for all such work performed tinder 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 persons)
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 Sionature
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:.,-. - R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved -
parking)
#of Parking Spaces _......:
_.
Fill:
volume&Location ._._.,_...... ..................,.._.....__..._._: .....,__-_._.._.._.._...._.....__._._...._.___.__..._1
A. . Has a Special Permit/Variance/Fi din ever been issued for/on the site?
NO 0 DON'T KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW 0 YES 0.
IF YES: enter Book Page: and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW (D YES 0
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 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(cleantrig,grad fn) c"CcVat{On, Orf;lifrlgJ CVG'r'; 3Cr?Or'. Et NBrt of 2 GOmnfOn pla n
that will disturb over 1 acre? YES 0 NO-
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding] Other
Brief Descri Liono Pro sed A. trSrC � i 10��l '"G.�11t11ash l�;� ya� f:GFGt� Ir1S�trGL��-
Work: Si�S - M fi IZ -
Alteration of existing bedroom Yes IV, No Adding new bedroom Yes _ N
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.if New house and or addition to existing ho Using, co4inl2fete 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 ACCENT OR COnN,TRA}C�T9OR�APPLIES FOR BUILDING PERMIT
as Owner of the subject
property
hereby authorize w P-% g b\�\7'4 t?} ,�� �kOnn<-TM F- y6 if1` L
to act on my behalf,i V II matters relative to w6rk autho ' ed by this building permit application.
signal ner date
1, 1�°` �� �`�1 e �t>��ti' �yt�s , " C1G- as Owner/Authorized
Agent hereby declare that the statEmerEts sand info.rm.„anon on the foregoing application are true and accurate,to the best of my knowledge
and beiiai.
Signed under the pains and penalties of perjury.
Print Name
Signature of Own gent Date f
tc7i rr, (5Ttijj Uf XD"):`14U1nVt0r1T
DEPARTMENT OF BUILDING XSPECTIONS L, 5
212 Main Str•eel . Municipal Building Yip
Northampton, MA 01060
LOUISHASBROUCK BUILDING PERMIT FEES Phone: (413)587-1240
BUILDING COMMISSIONER Effective July 21, 2008 Fax: (413)587-1272
DEMOLITION $ 20.00 ACCESSORY STRUCTURE
$ 35.00 PRINCIPAL BUILDING—Residential
$200.00 PRINCIPAL BUILDING-Commercial
*NEW CONSTRUCTION $ .50 per square foot for 1't floor
.30 2nd floor
.20 " 'A floors,attic,basement,garage
STRUCTURAL ALTERATIONS IN ALL USE GROUPS
$6.00 per thousand dollars of estimated cost or fraction thereof,
with a minimum fee of$55.00
$25.00 WOODBURNING STOVE
*NEW ACCESSORY STRUCTURES one hundred twenty(120)square feet and over
$ .20 per square foot with a minimum fee of$25.00
*NEW ACCESSORY STRUCTURES under one hundred twenty(120)square feet
$25.00 per inspection
*SWIMMING POOLS $30.00 for above ground
$60.00 for in-ground
*SIGNS&AWNINGS $30.00
*DECKS $50.00
REPLACEMENT WINDOWS $35.00
SIDING&ROOFING
Residential $35.00 per structure
Commercial $55.00 min.per structure OR$6!K of estimated cost
TENTS $25.00
*ZONING REQUEST FORMS $15.00 (includes home occupation registration)
REISSUE OF LOST PERMIT $25.00
CERTIFICATE OF ANNUAL INSP. $100.00 (minimum)
Temporary Certificate of Occupancy $25.00
PERMITS REQUIRING ONLY 1(1)INSPECTION WILL BE A MINIMUM OF$25.00;ALL OTHERS WILL
HAVE A$50.00 MINIMUM. PERMIT FEES SHALL BE PAID TO THE ORDER OF THE City of Northampton
AND SUBMITTED,WITH THE COMPLETED PERMIT APPLICATION,TO THE OFFICE OF THE BUILDING
INSPECTOR. WORK STARTED WITHOUT PERMIT IS SUBJECT TO DOUBLE NORMAL FEE.
!! NO CASH -CHECKS OR MONEY ORDERS ONLY !!
*Filing deadline is 12:00 pm(noon)on Wednesday.
Department use only
...... ity of Northampton status'f Permit-
j uilding Department Curb Cut/Drk\v ay Permit
u 2 8 > �� �n 212 Main Street Sewer%SepticAvadability
Room 100 WaterNVell Availability
Electr, . F r rthampton, MA 01060 Two Sets of Structural Plans
phone. 587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify `
d
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1
This section to be completed by office
PropertyAd�d ��
3 /7 Address:Au--4i in C -c-le Map Lot Unit
t'3�211(L MA o i o(o;t Zone Overlay District
Elm St.District CB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Ja(4 o elm e lla khe 3'7 Atchn G r-cle. Flonen e M i-o)w
Name(P t) Current Mai in Address:
M4 IS °3�0 - 371
Telephone
ISIgnature
2.2 Authorized Age t:
l cjw%-N 6hi-F.-�te;ft 3qc) Rwecside Mtn oIo[pa
Nam Print) Current Mailing Address:
Sign ure Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building c�v (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=0 +2+3+4+5) V C) Check Number
This Section For Official Use Only
Building Permit Number. Date
Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2016-0104
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522
PROPERTY LOCATION 37 AUSTIN CIR
MAP 29 PARCEL 370 001 ZONE
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&AIR SEAL
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included:
Owner/Statement or License 060300
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOJ�MATION 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
mol' 'on Delay
Signature of Build' g 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.
37 AUSTIN CIR BP-2016-0104
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-370 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2016-0104
Project# JS-2016-000186
Est. Cost: $4500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 13111.56 Owner: MATCHETT JACQUELINE K
Zoning: Applicant: VALLEY HOME IMPROVEMENT INC
AT: 37 AUSTIN CIR
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.712912015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL ATTIC INSULATION & AIR SEAL
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 7/29/2015 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner