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29-283 (10) City of 11ortha.mpton 212 Main Street, Northampton, _1V-A 01060 Solid 'Waste Disposal A.jfida�fit 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 b,e disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 1 11, S 150A. Address of the work: The debris will be transported by: \Jall!t,E HCM(f —�mc�rr��zme.�nfi The debris will be received by: t-aN Rz�J t n-q J Building permit number: Dame of Permit Applicant 1 ;0&4A Hcne- -Ir'Ro Date Signature of Permit Applicant ae Q.o➢HE nonweairn of 1ut&ssacau-sen-s Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.naass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): � Address: X-).f City/State/Zip: `Q,(,P_ Qe, \ r Y one:#: Are you an employer? Check the appropriate box: Type of project(required): 1.M I am a employer with 19 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 ca P aci n• employees and have workers' 9. F-1 Building addition [No workers' comp.insurance comp.insurance.t 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 11.0 Plumbing repairs or additions myself. [No workers' camp. right of exemption per MGL 12.❑Roof repairs insurance required.] i c. 152, §1(4),and we have no employees. [No workers' 13. Other (iU 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. lam an employer that is providing,workers'compensation insurance for my employees. Below is the policy and joh site infrrmaii0n. Insurance Company Name: 1f �' � L t1( Policy#or Self-ins. Lic.#: U�JCJ 0 Expiration Date: Job Site Address: �,1�1 ' S City/State/Zip: t'�C �'x1CC�, MA oidv,�_ 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. f do l4erehy ce�r : q _ie pains a;-€l pe�alti �4 perjp%ry that the i vrinationt provided above is trvse and correct, Signature: /,�` 1 ,i/ t-�i Date: J AS- F� ciai uEe on Fyn. Do not ivrite in this area,tc he comtlleted ley city or Eaw,K,0137cial City err Tawas. P'ermft/License# - i Issrr.rrng Authority (circte one): I_Reard of Health 2 Building De-Pz tment 3. CftylTf oy n Clerk ^._71ect-ri-eal lnspee°tar S.Mnmtfni-1-Inspector a. Other i Contact Person: Pone#: SECTION&-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:- � ®(0 bSCO UL�k, t , I�W-V_ j,4��p�,n.�en�� L License Number ?.o -6cy-- 'a 0\0 bl R[22 116 Address Expiration Date Uk SzZ. Signature Telephone Not 9;Re isfei ed a m rovement Contractor., ° : Applicable ❑ Company Ndne Registration Number Address Expiration Date Telephone�� �'��2Z 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...... ❑ The current exemption for"homeowners"was extended to include DyiTLIE nos of wile(1) or two(2),ar dies and to allow such homeowner to engage an individual for Dire who does not possess a Lcense,proFpded that the OITMer, 969 as superviser.CMIZ 780, Sixth Edition Secgan 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 accessary to such use and/or farm structures.A person whoa constructs more than one home fn a two:fear 12erio€Il 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 buildisru 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,.xrith 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 ma7 be 1Hable 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. Homeovimer Sisiggtur e 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 LotSize _. ....__....... ........._ ...:._.,.......... Frontage ........ ._......._._.._.._...._... _.. _...__.... Setbacks Front Side L:'..-...-- R:<.._._._....: L:'....,._,..... R:...........i Rear _.. .. Building Height Bldg. Square Footage w..._.._.... % ., Open Space Footage ° (Lot area minus bldg&paved parking) # of Pal-king Spaces _..,._._ Fill: volume&Location) A. Has a Special Permit/Variance/Fi din ver been issued for/on the site? NO Q DON'T KNOW YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW � YES �. W YES: enter Book Page: and/or Document B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? .Needs to be obtained Obtained 0 , Date @sued: 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:. P, ��lil the CUEISirUCtion aCiiViCy di3t1�[o lCiearirGl,grain c Vaion, or f,![ing,over acre or iS it Pan of a r_,'orl-tn on Mall 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 C] Addition [7 Replacement Windows Alteration(s) Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [M Siding[01 Ot er qtr Self. CT 'c, 166+al e Veit tr so e ic- ct) 9,� re cdllvlc� nt Brief Description of Propq�ed c J Work: R i j)Cafne-f 12-� —-- Alteration of existing bedroom Yes No Adding new bedroom Yes _N Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 64.'&f New,:ho or aadlt!6.n..to 6.xisting i ousinlq, C' Ofti�e e,h ffd11*�wtcap: 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 1. 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. 1. Septic Tank City Sewer Private wall City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERN41T 1 /)(,1Y nez- �lvC07-) as Owner of the subject property rr hereby authorize�e\50n SW, ��i } Af,rA t �CO3�--( )V7 Zn C- to act on my behalf,in all matters relative to work author' ed by this building permit application. Signature of Owner �J Date w�- as Owner/Authorized Agent hereby deciare that the statements and rfo-mation cr,the foregoing application are true and accurate,to the best of my knowledge t .:gnu bviiaf, Signed under the pains and penalties of perjury. Print Name Signature of Owner! nt Date ti71 ry gitj- of Xurl4aluvtjorn s �jj �tQQ88E1C!JLIgP(t2 �i. ``y DEPARTMENT OP' BUILDING, INSPECTIONS 3 212 Main Street . Municipal Building Northampton, MA 01060 U S HSBRULO AOCK 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 1St floor .30 " " " 2 n floor .20 Y,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 City of Northampton Status of Permit : , . Building Department Curb Cutibni e ay Permit 212 Main Street Sewer%SepticAvailability AUG -T NIS 't Room 100 Water/1Nell Availability Ndrthampton, MA 01060 Two Sets of Structural Plans phone 4')31587-1240 Fax 413-587-1272 Plotlsite Plans OtherS N: pecify 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 Pei e�xs l � Map Lot Unit Hor-ence Ni cl o� Zone Overlay District Elm St.District CB District SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: lC'ombe- 0Cetse 1 �. Name(Print) Current Mailing Add ess: 3� - - - 4, Telephone Signatu e 2.2 Authorized Agent: NeAson Sh t-N l co 340 IRNer tc IX. H"-e e iA ©t&o: Name(Print Current Mailing Address: eA Sign ure Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building Via . ozv (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=(1 +2+3+4+5) p�c^j() Check Number This Section For Official Use Only Building Permit Number. Date Issued: Signature: Building Commissioner/inspector of Buildings Date File# BP-2016-0161 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062 (413)584-7522 PROPERTY LOCATION 4 PENCASAL DR MAP 29 PARCEL 283 001 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 INSULATION,AIR SEAL&WEATHERIZE New Construction Non Structural interior renovations Addition to Existing Accessory 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 INFgRMATION 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 Dem iti Delay nature of uilding 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. 4 PENCASAL DR BP-2016-0161 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29-283 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-2016-0161 Proiect# JS-2016-000267 Est. Cost: $2000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 060300 Lot Size(sq. ft.): 12806.64 Owner: SLOCOMBE DONNA L Zonine: Applicant: VALLEY HOME IMPROVEMENT INC AT. 4 PENCASAL DR Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.81712 015 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL INSULATION, AIR SEAL & WEATHERIZE 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 Sijjnature: FeeType: Date Paid: Amount: Building 8/7/2015 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner