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37-083 (7) MArv%VI Jos V F � s44 GV VT R s �q .3 Iq �97 �co r, Iti�{}z I�►�n }� Do,vbIt, 2 (e tr 2 )<9 s 4-u�s `7�8 1i�t�' K' YGNA I , i L i _ , , t/ 11 : -Llel ct,5 A"Pot P- City of Northamptdn ' Building Depai�tme�t Plan Review 212 Main Street hamp Nort ton. ?I 0 ' b `U c \ V i : • r/Gw 0 tr�,� 1'asS 1�� j i Aire_ Vt Sn S-Cf'-i- 4u vi g , 43 G V V T R Val apW �vl S Z t 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: 14144,✓ lktJ 6PJ6-S G �,rove- Z 1 The debris will be transported by: �05 n' 5 The debris will be received by: Building permit number: Name of Permit Applicant /�1�77,0 �-✓ ��s� Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of IndustrialAccidents u Office of Investigations 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Matthew West Address: 1438 Shelburne Falls rd City/State/Zip:Conway,Ma 01341 Phone#:413 588 4231 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 employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. 1 am a sole proprietor or partner- listed on the attached sheet. 7. n Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working or me in an capacity. employees and have workers' g Y p h'• x 9. F1 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 1 L❑ 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: Policy#or Self-ins. Lic.#: 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce ify nder the pains and penalties of perjury that the information provided above is true and correct Signature: �, -'— Date:6/26/2015 Phone#: 4135884231 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 7 8.1 Licensed Construction Sup.�errl �W/ w visor: � ] I Not Applicable ❑ Name of License Holder: MA h i'� F C 5T I✓S 0-7 6,Z-7 g License Number CQuy , w�, 013 I 031os— LzolJ0 Address I Expiration Date ygwZ�' W tit$ GV$ K Z3 l Signature Telephone g.Registered Home Improvement Contractor: Not Applicable ❑ IMF W\r-e,t-J F W-0-5�- 1 C6o (S'S- Company Name Registration Number 1 L13$ FK lt5 R� Co r\i.±x j PAA O !3 411 l Z II 1 201 ( _ Address I f Expiration Date Telephone ql l 5'0$ W 3) 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 buildine 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 Accessory Bldg. ❑ Demolition New Signs [O] Decks Siding[r-3] Other[1] Brief Description of Proposed J_ / ` Work:Ntt�J L+tktn =flthlCole&(� f , it / #-ktj k"i FLOrS, Rkjol--4ew,4,v "Jov,f, A( e a ,f 11 Alteration of existing bedroom Yes h No Adding new bedroom Yes A No Attached Narrative Renovating unfinished basement 'Yes Plans Attached Roll -Sheet u. 6a. If New house and or addition to existing housing. complete 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 AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, �� c c A) (l` ne%)P 11 as Owner of the subject property hereby authorize to act on my behalf, in all mdfters relative to work authorized by this building permit application. Hld'9401— 91 111 Signature of Om er Date 1 d& as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. �- Print Na e Signature of Owner/Agent l5ate 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 parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO © DONT KNOW ® YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DON'T KNOW MW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW VW YES 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 © NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES © NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only ity of Northampton Status of Permit: uilding Department Curb Cut/Driveway Permit i 212 Main Street Sewer/Septic Availability AUb L Room 100 Water/Well Availability, hampton, MA 01060 Two Sets of Structural Plans OWAiC,Plumbing&Ga 1 Northampton,udib 87-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: e- 0" [k S This section to be completed by office Z�rD 6�ov>� Si: 21 Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: I W g\0ee rJ d '.D##VC L L L' "w L��.d W.5 L 66 6rovt.st 1 �orvtctlV� Name(Print) Current Mailing Address: p(a 62 n q13 — 231— Z03Z hi AN,eU�. a I fJ l t�..t@ L Telephone Signature 2.2 Authorized Agent: OLS+- p 0. Y- 23,S7 Con VVta, e134J Name(Pri Current Mailing Address: ', w13-588 -YZ31 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building p 00 o. 0 o (a)Building Permit Fee 2. Electrical U (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) 3 8 COO . o d Check Number � This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File# BP-2016-0268 APPLICANT/CONTACT PERSON MATTHEW E WEST ADDRESS/PHONE P O BOX 235 CONWAY01341 (413)588-4231 PROPERTY LOCATION 266 GROVE ST-#21 MAP 37 PARCEL 083 000 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: RtMON ATE KITCHEN CABINETS COUNTERS FLOORS INSTALL REPLACEMENT WINDnW<&PATIO DOOR New Construction Non Structural interior renovations Addition to Existing- Accessory Structure Building Plans Included: Owner/Statement or License 078278 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO MATION PRESENTED: proved 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 emoliti elay 40r /A: ature of Buildmg f cial 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. 266 GROVE ST-#21 BP-2016-0268 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 37-083 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-2016-0268 Project# JS-2016-000412 Est. Cost: $38000.00 Fee: $247.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MATTHEW E WEST 078278 Lot Size(sq. ft.): Owner: O'DONNELL MAUREEN Zoning: Applicant: MATTHEW E WEST AT. 266 GROVE ST - #21 Applicant Address: Phone: Insurance: P O BOX 235 (413) 588-4231 CONWAYMA01341 ISSUED ON.91812015 0:00:00 TO PERFORM THE FOLLOWING WORK.RENOVATE KITCHEN(CABINETS,COUNTERS,FLOORS),INSTALL REPLACEMENT WINDOWS & PATIO 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 Signature: FeeType: Date Paid: Amount: Building 9/8/2015 0:00:00 $247.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner