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30B-106 (2) City of Yjorthampton 212 Main Street, Northampton, lV1A 01060 Solid 'Waste Disposal Affidavit In accordance of the provisions of MGL c 40, 554, 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 1 1 , S 15OP,. Address of the work: (ob.. Mr l+Dn Si. V' The debris will be transported by: �O)Ieo Hcme- --L,r,orrsa The debris will be received by: \)O164 ReCcAc]t 11�I Building permit number: Name of Permit Applicant MAW Shl-W14"W19i F OMLJ rffieM -�— Date Signature of Permit Applicant Yom ° -.6mmonwea€fF't? of le2assuckriitseze5 - -- _ Department of industrial Accidents Off ice of Investigations 600 Washington Street Boston CIA 02111 www.mass.gov/dia Workers' Compensation Insurance A.ffldavit: Buflders/Co ntractors/Llectricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: `-�G City/State/Zip: Vhone#: j-- Are you an employer? Check the appropriate box: Type of project(required): 1.[, I am a employer with 19 4. ❑ I am a general contractor and I employees (full and/or part-time). have hired the sub-contractors F1 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 g, ❑Demolition working for me in.any capacity. employees and have workers' 9 F]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, §l(4),and we have no r17 ( / �� employees. [No workers' 13. Other 1U fQa- comp.insurance required.] *Any applicant that checks boe#1 must also fill out the section below showing their workers'compensation policy information. fi Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractofs 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 ornot those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providin.wot leers'compensation instarancefbr stay employees. Below is the policy anal joh site information. Insurance Company Name: & ` p Policy#or Self-ins. Lic. (E�U5C~z Expiration Date: Job Site Address: L p R t[6n, 'St, Ap+, i City/State/Zip: Fl o(onC e .NA 0104,q,— Attach a coley of the workers' compensation po'Ucy declaration page(showing the poUcy 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 Brae up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOIC 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 D1A for insurance,coverage verification. -1 o laerehy cerr,,�fy t d *tiepaains a',�d pets^iti�.4 perja�ty that the it�ortwati®tr pa®�iared wlsove is t€�e and correct 7 Signature: d1 W/ Date: Official use only. Do not w rke in ibis aFea, io be cotnznletaal by city or tow,n of ciaI - -- C �I ity a��T¢E��. eeanee P'erzm:,�t.IL # Issuing Authorflty(circ)e one): f,Beard of Health 2.B d dinb Det.ar,tment 3, City/T m3m Clerk 4�Ezectrucal l nsDectc�r 5 �1��hSrv�I�.Gp€ctor d.Other Contact Person: Phone#: 1 SECTION S-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: t\L°� � � ®(0 b-21co 'f114 �4�Q�-o.�e��rti� ,�� License Number c�1-22-116 Address Expiration Date &IL& -Old/ ij« Signa ure Telephone Not Applicable 9 Registered HomeIniproyemenf a� Company Wafme Registration Number Qb l Address Expiration Date 1 Telephoneq�6 c� 3�az SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c.152,§25.C(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...... ❑ lie s Tj ion Weer Eiem The current exemption for"homeowners"was extended to include or two(2)families and to allow such homeowner to engage an individual for bire who does not possess a license,PQIM fd'!ed that tTr e o�i�°n 2 ets as 02erA90r t:RIP,9100 Slith Ecution Section 198:3.8.1. lDefirition 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 wbo constructs more than one horse in a two-rear Lser•iod shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official. that he/sire shall be res o Lsible for all such work Laerformed Lender the building tnermit. As acting Construction Supervisor your presence on the j ob site will be required fi•om time to time,during and upon completion of the work for which this permit is issued. Also be ad-,ised that-with reference to Chapter 152(Workers'Compensation) and Chapter 153(L iabidty of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you trray 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. HomeGwner SiSnatLLre 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: .._._... L'..... R: Rear _. Building Height _...._... Bldg. Square Footage ,.,._....,. % __.._.. Open Space Footage ° (Lot area minus bldg&paved _...... _._,' arkina) #of Parking Spaces Fill: _..._.... .._ _- . volume&location _,_._.,_.:.........___........... __..,__..__.__.... ..._.___._.._.:_.__...._.. ._._..___.__.._ :_...._._ ___..-_-_-_•--__-_ ..' A. Has a Special Permit/Variance/Fi dina ver been issued for/on the site? NO T DON'T KNOW YES Q IF YES, date issued:_�...._.._.._........_....._._ • IF YES: Was the permit recorded at the Registry of Deeds? E lO DONT KNOW 0 YES lF YES: enter Book Pager and/or Document# B. Does the site contain a brook, body of water or wetlands?. NO DON'T KNOW () 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 suns 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. �l`lil the CGf SiPLCitlii ce vity disturb (cle=iilk ,G1-j c e-va ion,orT,lif�5y�over acre or is n C?:t of a cO�trnoni purl that will disturb over 1 acre? YES �1 NO IF YES,then a Northampton Storm Water N42nagement 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 [❑] Decks [❑ Siding[0]ns tC- other[� Brief Des ription of Propo ed air ► II'�S$J Q.. e—5II.S W n1 faCed i ! Fri Il'1� aj1 1'1E'.tA) Work: -aYV�.t t CICjflC� Alteration of existing bedroom Yes No Adding new bedroom Yes NN Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.If Neer house-and or edditiean to existing hest gilq. 66,Mpi d the fna6 ik;i�g: 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. 1. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COIZPPL€TED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,- as Owner of the subject property 1 hereby authorize)_ \Son 6 � �Q�,`^Cc+ �� l i �6 �rt`�� c lrt C_ to act on my behalf, in all matters relative to w6rk author' ed by this building permit application. See -firs 1 e_ i sm e/ ll S Signature of Owner J Date 01,�+ � as OwnerlAuthorized Agent hereby declare that'd-,e Staten erEts_ndinfo,'mation on the foregoing application are true and accurate,to the best of my knowledge of id 3vii6f. Signed under the pains and penalties of rerjtlry%. Print Ware Signature of er/Agent Date v rtQtI$$r1C!�U$elt$ �� , DEPARTMENT OF BUILDING, INSPECTIONS 1 212 Main SLreeL • Municipal Building Yil°ui\, Northampton, MA 01060 U S HSBRLO AOUCK 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'�floor .30 " " 2"d 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 1 q"Oing Department Curb CuUDnveway Permit- AUG -12at5 212 Main Street Sewer/SepticAvailabili;ty a ; a Room 100 Water/Well Availability + N-01"f�tJ pton, MA 01060 Two Sets`of Structural Plans J -587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify z- 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 6(' gg�� "t Map Lot Unit �T' i Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: the reSe� 8�rc h end +, l Rorence RA-owva Name(Print) Curre4 Mailing Ad S /3 - -a� 1 Telephone Signa r 2.2 Authorized Agent: Neg&n "S A&646 Hwie T,wrov�rc1- 340 Rtvex-s t ck-'Dr. 1 f)orexiee ,t.�.�-aj�, Name(Print) Current Mailing Address: ' �- ,19� q 13 - 534 - 75a s- ignature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building �j J 00o j �O (a)Building Permit Fee c.� 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) J Q©(j. 6-To Check Number This Section For Official Use Only Date Building Permit Number. Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2016-0160 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 60 MILTON ST MAP 30B PARCEL 106 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildinp,Permit Filled out ( . Fee Paid Typeof Construction: INSTALL INSULATION AIR SEAL&REPLACE BASEMENT DOOR 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 INFORMATION 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 geDelay TTl� Signature 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. 60 MILTON ST-APT 1 BP-2016-0160 GIs#: COMMONWEALTH OF MASSACHUSETTS MW:Block: 30B- 106 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category: INSULATION BUILDING PERMIT Permit# BP-2016-0160 Project# JS-2016-000266 Est. Cost: $1000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 060300 Lot Size(sq. ft.): 7797.24 Owner: BIRCHFIELD THERESA M Zoning: URB(100) Applicant. VALLEY HOME IMPROVEMENT INC AT. 60 MILTON ST -APT 1 Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON. TO PERFORM THE FOLLOWING WORK.INSTALL INSULATION, AIR SEAL & REPLACE BASEMENT DOOR 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 Sisnature: 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