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24C-183 (2) 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 property licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: SON Crf,SGen+ �"i �yr rhA 'on, HA otof� The debris will be transported by: ?f-Uk Prodoc z Inc. The debris will be received by: Fe-daL Qroct-c4S Inc. T 155 5V (-vw Pnclel , MQ ©1341 Building permit number: Name of Permit Applicant 'l�1ta Prod�c Inc_ &�16f 3ra5S Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents W Office of Investigations w d 1 Congress Street, Suite 100 Y ~ Boston, MA 02114-2017 M s�• www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Pella Products, Inc. Address: 155 Main Street City/State/Zip:Greenfield, MA. 01301 Phone #:413-772-0153 Are you an employer? Check the appropriate bog: Type of project(required): 1.© I am a employer with 49 4. Q 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. 0 Remodeling ship and have no employees These sub-contractors have g. n Demolition working or me in an capacity. employees and have workers' g Y 9. EJ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. E] 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. 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: Hanover Insurance Group Policy#or Self-ins. Lic. #:WHN-9399766-0021 Expiration Date:01/01/2016 Job Site Address: `�10q cm' c 2-fl JT City/State/Zip: Wo CA a4 .HA 010(al'7 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 certto under the payss and p ti f perjury that the information provided above is true and correct. Si nature: Date: a5 4 J Phone#: Above 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 Consdttctlon SuperviTs�or. Not Applicable 0 Mine of Mcanse Holder:1<e1 LAC 1 m ti CS-()q(;,552 License Number to Caear .r. S'� M Pt Oi'" 3 /1 /goal Address ' Expiration Date ",X-1005:111:51 9.Reolatered Home IrnywayetTiontQc 11,getor Not Applicable ❑ W10. Pro41JC-f{ InC Af C4/,( IA=S 1121S0 Company Name Registration Number to Georap S - Grca �i� it MR UtIol ColI holy Address Expiration Gate IAI zelephonetll3-773-1 1 s7 3 SECTION 10-WORIa W COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.162,§26C(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 buildin ernit. Signed Affidavit Attached Yes...... No..... ❑ 11. -Home Owner.-ExemudOn The current exemption for"homeowners"was extended to include Owner-occupied Dwellings fone(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,DMvided that the owner acts as supervisor.CMR 780. SYitb fiditiaa Section 1083.S.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 two-year period shall not be considered a homeawner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official.that he/she shall be respeasibte for all such work performed under the buNiea permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion ofthe 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"honwownW 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 apRE21��) i New House Addition F--j Replacement WIPdows Alteration(s) Roofing Or Doors 12, 1 i Accessory Bldg Demolition New Signs 10] Decks 10 Siding tC31 Other Brief Description of Pwpos'ed Alteration oi existing bedroom Yes Adding new bedroom Yes No Plans Attached Roll -5heet 6a.-If New house and or addition to existing housing, complete the following, ' d Proposed Square footage 01 new ccnstrl'ct�orl- C) �,r.,s h, Type of construction Depqi of basement or collar floo clowfinishocIrgrade VVill building conform to the Building and 7omriq regulations? Yes No SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT property to act ori my behalf.,in all matters relative to work authorized by Jits building permit appl,cation Signature of 0wrici Owe as Owner/At.ithorized Agent hereby decla're'lhat ttfe statements and information on the fore�going ap�piicjfion�areuue�and acc�urate,to the best of my knowledge ar�d belief. Signed under the pains and penalties of perjury, ! 1 Section 4. ZONING All Irdormatim Must Be Completed.Permit Can Be Denied this To Incmnplete Information Existing Proposed Required by Zoning This column io be fined in by Building Depwonent Lot Size Setbacks From Side L• R• U. Rear Building Height Bldg.Square Footage % Open Space Footage (tot arcs minus bldg&paved _ it Orparking Spam Fill: tivlamc&location A. Has a Speciat Permit/Variance/Finding er been issued for/on the site? NO O DONT KNOW YES a IF YES,date issued:'. IF YES: Was the permit recorded at the Regis of Deeds? NO O DOW KNOW YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook,body of water or wettands? NO O DONT KNOW V 'ES O IF YES,has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O . Date Issued: C. Do any signs exist on the property? YES O NO IF YES,describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO IF YES, describe size, type and location: -^ -�- E VIAR the construction activity disturb(clearing,grading, on,or fling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES,them a Northampton Storm Water Management Permit from the DPW is required. .^ ° ( ftrnent Use Only 6.0 City of Northampton 0�pejm'l Building Department Gas Availability Northampton, MA 01060 Two Sets off Structural Plans- phone 41 3-587-1240 Fax 413-587-1272 PlzwSite Plans 101her Specify- 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 Map Lot Unit '-111 olow Zone Overlay District Elm St.District-­­-­- GB District 2.1 Oviner of Record: 2.2 Authorized Agent: IL Estimated Cos,(Do!lws)to bf� Official Use Only t3)Suddin,g Perrmt Fee (o)Esmatc-r,-rotai cost of i ccnstructzr!from (6) g Permit Fee 5 Fire Protection 0 This Section For Official Use Only Building Permt Number Oat", Issued Signature Uwe 204 CRESCENT ST BP-2016-0282 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24C- 183 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: windows replaced BUILDING PERMIT Permit# BP-2016-0282 Project# JS-2016-000427 Est. Cost: $7447.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: PELLA PRODUCTS, INC 096558 Lot Size(ssq.ft.): 7013.16 Owner: DOUGLAS THOMAS JR& SHOSHANNAH WINEBERG zoning:URB(,100)/ Applicant: PELLA PRODUCTS, INC AT. 204 CRESCENT ST Applicant Address: Phone: Insurance: 155 MAIN ST (413) 772-0153 WC GREENFIELDMA01301 ISSUED ON:812812015 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL 9 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 Silznature: FeeType: Date Paid: Amount: Building 8/28/2015 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner