11C-031 (4) irce: 6.v1rerrea'rceVe"&Lre UJ 1vlussuLrecc�cee�
Department of Industrial Accidents
Office of Investigations
,. 600 Washington Street
Boston,NIA 02111
www.mass.gov/dia
�Varkers' Ce, peg sation Insurance Affidavit: Builders/Car tractGrs/`Electricians/Plumbers
Applicant Information Ple°a�se Print Legibly
Name (Business/Organization/Individual): ( �'L� }� k`` ),(2,-b�a`t��' tQV ° , � KA
Address: �HG ��.,;�Y`�'�[�� 3_
City/State/Zip: _ 0I Pho#: <�%%A` lCO 2Z
Are you an employer? Check the appropriate box: Type of project(required):
1.3, 1 am a employer with � 4. E] 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. Ej Remodeling
ship and have no employees These sub-contractors have g. E:] Demolition
working for me in any capacity. employees and have workers' 9 F� Building addition
[No workers' comp. insurance comp. insurance.1
n
required.] D. We are a corporation and its 1 a:i"dtrai ti, ano cr auurthja3
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 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no `�
employees. [No workers' 13.Ai Other In:S 1 CAAI Qn
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infonnation.
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 n:y employees. Below is the policy and job site
information.
Insurance Company Name: �V be u,
a
Policy#or Self-ins. Lic.#: (ACS D 0`J 02- 1 Expiration Date:
Job Site Address: / SC E'� 5 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 rrification.
I do hereby certify the pains a(d penalti, perjury that the information provided above is true and correct
Signature: (� >, '�' Date:
i
Phone#: �`"D—
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#:
l SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Sat ervlsor. Not applicable D
NAMe of Licen"Holder
.. e
Unwise Nuaitwr
. esS � l Expkiaticsra Elate Teiephorie
LA-
9,Register Home tan %yew M Cont ctpr � Not Applicable t l
�LP ,
Home- - e4 4nP�'1'r`
Ctarrt stn me Retgtsttabon Number
0 ?��rP�r"stde Dom. Ptoref ce MA ov ou.)- l7
Addre s !«xpiAn, to
i
tah �3
7,ilt
!
[jjST)O ! -NV{ARt ERS'CC MP MwA7tot+l IN t3t3ANCE EFdL9aL t7 Nid.C,t. . 1 2, 50{
Workers Compensation on In€urance affidavit natant be corn>leied Ord submitted with this application Failure to provide this affidavit w,41 result
€ in the denial of the issuance of the building permit
Signed Affidavit Attached Yes No -,. ,,
Home Owner ExeMption
l"Ple current cxeerraplion liir"hrkrr eininers"watt t-mcnJcd to itw1'2j l;aiaailie;
and tca aallo%ti ,u0i 11c}n};:akkvner to er?g.a c an indi%iJuaal for tl(ws nest p+ Nsv,s a license.tare}virlyd that the owiler"acts
Ieflnition of li art}e Baer, PCI- 'n t 4 i 0h€=k°w€1;1 p. 'xi of land ._ >. .a h --sides ides err -,=t nkh' M'idt°:,Ear, -Om°h ihc'rL'
2N,of :�,intendeu if,€cc ;a w i. ,t f'aM:
€a t. ,,a, .e:. : err€an whet r<ttt tzit t uarare tai tan eater t}rya aa:Pat t t}- r€}r terind%traitl tint t}e coosidered a homeowner,
stwt �'hall Submit to the lli.€Il lire tiftit et,on.,tiwn-i Je clnijbii:to(l-w Ruildi€tp(Kticiai that helsbe deal! tai
responsible for all such %N-Lorkprrfortned under alas t}aiite�in=ti€rata t.
is:ra tirt t,"trraittaart'sa}r Ott}eta cst r y,lur presvil c"n the oh mac ; ill lea:tai:+t,vd f`i°om tits}t to Britt.JieirM9 u416 a-10ta
of tl'ss'.'x4 t"sr�. iL 1` .+'?t€.;l)this,ltd,-`a?# t is i"'muc..
Also he deli iNcc ali a, v i?"i rt iCis°St,.' to aa3g`,* l.4Q 110 .a:*,l ta?t'��t� er S
'��4u lairs tt.a 1�`rlekzttt t�tar� tckr��a.a ut-tcics t1}€e;l�=vi�tait"
!`hc undersigned"hoi3avo ner"k 4rtilies and a �taita ,re ,n±tt,ihilit� 'kr'tumla(ian z �xilh the lloilding yodel t`its'tal-
Noitd?4n)j>I q1 Ordinances,,{`4AIC x"d 1-itch! /"nini l.,a .z81!.`s%a of ' as ai"hu" tv,tit-ner rl 1 :a1"k An}.`t,tti d'
}J!}arise wncr Sig atftire
`
New House F-1 Addition Replacement Windows FAIteration(s) El
Or Doors 0 1
Accessory Bldg, Ej Demolition New Signs (ril Decks [0 Siding[CO3 Oth r
Alteration of existing bedroom-Yes No Adding new bedroom Yes Na
Attached Narrative Renovating unfinished ba,-�me,)T Yes X No
Plans Attached Roll -Sheet
/
6a.1 New house and or addition to existing housing,complete the following,
a, Use of building . One Family-- Two Farndy___Ott1er_,'_
b Number of rooms in each family unit Nurnber 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 Nurritier of each
9 Energy Conservation Compliance, Masscheck Energy Compliance form attached?
h, Type of construction
j, Is construction within 100 ft-of wetlands?-Yes -Nci Is construction within 100 yr, floodplain Yes_No
I- Depth of basement or cellar noor below finished grade
k Witt building conform to the Building and Zoning regulations? -Yes- No ,
1, Septic Tank_ City Sewer Private well- City water Supply
OWNER$AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subje'l
Propefty
hereby authorize L
-sign.ature of Owner L/ Date
as Owner,.Autthorized
�ion o�'The foregoing applocati
Ager'�'Ie y(declate�Ihil �statt on ar 'true and accurate,to he best cf mv knowle,-
and belief
Section 4. ZONIN(,
All M101-1113111111 W,111 fie'C_11111ptc',,sd Pe,Twl C,31 b,Deloi >d 11t,P To lm,,mpl,1,I !Maly)as
I�.XislillL Requircd b-, Zoning
S-i'd-S R
Rid g, Nquarr Vootoge
)[ml'Space F(vow2c
I_11.0
'2'offlarkirw sp;jccs
A. Has a Special Permit Variancel Finding.ever been issued forion the site?
NO 0 DONT KNOW YES
IF YES, date issued:
)F YES: Was the permit recorded at the Registry of Deeds'
NO 0 DONT KNOW YES 0
IF YES. enter Book Page and/o, Document
B. Uoes the site contain a b!uok, bouy of watv. ui iiC)
IF YES, has a permit been or need to he obtained from the Conservation Commission?
el"N
Needs to be obtained 0 Obtained , {date Issued
Do �riysigiis exist ran tie pl'o'perty YES i NO
IF YE5, describe s;zzc, type ane location:
D. Are there any proposed changes to or additions of signs intended far, the property ? YES NO
IF YES, describe sire, type and location.
E:.. Mug!e corlSM jn-activity d!,*�,,,rt idea nng,gra,!,'a t;on w fAl;1a_!ove,I acre 0� 's 1!hart of a cmlnrnon Pian.
that wd"disturb over 1 acre li YES 01 NO
i� YES, -t'iTi a Norv"arrvivi sionw',.Natef fvlc.nagerne P,_'-frnd� the D. v,4 as recio4 -M
Titj.-uf Ya-ri4amptrl
' p
+
_ I x.
DEPARTMENT OF BUILDING INSPECTIONS
� o
jf 212 Main SAreel, . Municipal Building
Northampton, MA 01060
U S) SBRULOHAOCK 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"d floor
.20 " '/,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.
II NO CASH -CHECKS OR MONEY ORDERS ONLY II
*Filing deadline is 12:00 pm(noon)on Wednesday.
Department use only
y of Northampton Status of Permit:
SEP ilding Department Curb Cut/Driveway Permit
12 Main Street Sewer/Septic Availability
Electric, Piurnbing&Gas Inspections Room 100 Water/Well`Availabilit
Northampton,MA 01060
� ipton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plansf
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
:7 6towol f ;5-f. Map Lot Unit
L-,e CS Ufa3 Zone Overlay District
/
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Cf r Za.b 7 6*)/,y L ffd5 A4 otes�
Name(Print) Current Mai g Ad
� '-� - 7 �
Telephone
Signature
2.2 Authorize ent:
A(111W Pow -- Tfte( Jd1n A„wsk. . 6L,/-D e pr, Rgj-wc; W om&
Name int) Current Mailing Address:
�VL X13 a
Sip at re I Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building c) 00 (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) fry Check Number A
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2016-0337
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522
PROPERTY LOCATION 7 STOWELL ST
MAP 11 C PARCEL 031 001 ZONE URA(100 /H) B(0)/
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& WALL INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 108772
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO�ATION 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
i elay
!J
re J-BuilTing4Wial 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.
7 STOWELL ST BP-2016-0337
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: I IC-031 CITY OF NORTHAMPTON
Lot:-00 1 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2016-0337
Project# JS-2016-000546
Est. Cost: $3500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 108772
Lot Size(sq. ft.): 7361.64 Owner: PEREZ-MONTALVO JAMIE A&ELIZABETH APONTE-PEREZ
Zoning. URA(100)/HB(0) Applicant: VALLEY HOME IMPROVEMENT INC
AT. 7 STOWELL ST
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.911512015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC & WALL INSULATION
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 9/15/2015 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner