24A-177 (4) City of Nioithampton 212 Main Street, Northampton, M-A 01060
Solid haste Disposal A-Hdavit
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 1, S 150A.
Address of the work: '? `ecli- Oc(C�'h
The debris will be transported by:
The debris will be received by: �0,-HfA i
Building permit number:
Dame of Permit Applicant V
Date Signature of Permit Applicant
P�"y C„ifl'.co >6fl'C�F'GG'•G�GG�: t,� 1_„.;Svy"e�.>��y���'
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ARrgNeant Infor m9flon Please Pent Legibly
P
bale (Business/Organization/Individual): \ Ck,�,i L�fi r'` �` �!1 0 0\13''a e 4- D 1�
Address: `��
City/State/Zip: (?f .VI C `hone#: �4 -<�E)
Are you an employer? Check the appropriate box: Type®f project(rewired):
1. <. In a ern to er vvitll �% 4. ❑ I am a general contractor and I
p y have hired the sub-contractors o. ❑ New construction
employees (full and/or part-time).
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 ❑ Building addition
com .itasura�?ce.t
[No workers' comb. insurance _ _ p ,0 6—: E,_--_c_, __
J. I VH e are a C®r�7oraLl®fl and ILS I a .�� LL Ea r4 CPL i trcaea e r aet�nLEL LIl� p
required.]
officers have exercised their 1 L Plumbing repairs or additions
�.® I am a homeowner doing all work ® g p
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] ; c. 152, §1(4), and we have no
employees. [No workers' 131-1 Other
comp.insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy infonnatiion-
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 arts an employer that is providing workers'compensation insurancefor my employees. Below is the policy and job site
information.
Insurance Company Name: � '�,� �; �"►� ` ►`C%
� 1
Policy#or Self-ins. Lic.#: �'3 �J C, 02- 1�� Expiration Date:
Job Site Address: City/State/Zip: tC11GlbC�
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 er u that the information provided above is true and correct
I do hereby certify rt the pains and penalti��� P Jay ,f p
e
lip �gy �
Simature 1pk` � G f��'`�° pJ�!>��"`� Date:
Phone#: `�� ��
Qfjllcihl use only. Ado not write in this area, to be completed by city or town official
!I
c.,IlE�'ibn�ei vain: n icn iirir,. he�yr�e,rr
Issuing Authority(circle one):
a. Board of Health 2.Building Department 3. City/Town Cleric 4.Electrical Inspector 5. Plumbing Inspector
ii
6. Other
a_C Uact Person:
SECTION S-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: \_ -1 Not Applicable ❑
Name of License Holder: ��P ll �C\\ C"C ®(0 05100 ULQ �� �4�� �en d License Number
?.0 . ct l22 116
Address Expiration Date
Signature � Telephone
9 Re lste•ed'H (meam ioveme nt Not Applicable ❑
Company h e Registration Number
Address Expiration Date
Telephon,*)- s�-� Zz
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 07"ner-cccLnied Dwe'Ungs of one(1) or two(2)u nflies
and to allow such homeowner to engage an individual for hire who does not possess a license,proAdled that the ovIrter acts
as=Rerviser.CAIR 790 Sixth Edition Section 1083.5.1.
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 Berson who constructs more titan one house in a fwo: :ear'neriod shall not be consieered F homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official. fat he/site shall be
regpotrsible for Fill such worts Derf®rmed under the buadjUZIMER11
As acting Construction Sut2ery1sor your presence on the j ob site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be ad-,sed that v ith reference to Chapter 152(Worl ers'Compensation) and Chapter 153(LiabUity of Employers to
Ent ployees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,JQu n?aT be liable forperson(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 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 forlon the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
E•!0 DO€ 7 KNOW C) YES
IF YES: enter Book Pages and/or Document#
B. Does the site contain a brook, body of water or wetlands?. NO C DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
.Needs to be obtained Obtained 0 , Date 6ssued _.-.
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:
7:. lVIEE the CUnSirUCliUi activity disturb (Ciccir g,Grnufng, cCcVctiOn,Or frr ng,over.i acre-or is r?{of CpmnCn plan
that will disturb over 1 acre? YES f\f 0 0
IF YES, than a Northampton Storm Water Management 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 [0] Decks Siding[0) Other[CQ
Brief Description of Proposed
7
Work: /1/1
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a,.:K New house and oP addition to exietincl housing, foiG ►ihq,:
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? ,� ll
d. Proposed Square footage of new constructio7 / `Dimensions
e. Number of stories? (((((VVV
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 well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
l � as Owner of the subject
property
hereby authorize W 6,`SQn b , « �1
` "V�6 T lr xe<-c),1p_(
to act behalf,in a otters relative to work author' ed by this building permit application.
Si, re of Owner Date
as Owner/Authorized
f
--,,cent liereb�i d ,.,iare.Thal utc Ct�iiiciei5 ci�d Ii'=.'v.�i��t� ^c.n the rorego!nq appffcan ra
on are true and accurate,'to the best of my knowledge
I "
'
and bs"i .
Signed under the pains and penaitias of perjury.
i Print Name Q
1
Signature of Owner/Ag2ff ��a
'Department use only
C ' of Northampton Status of Permit
c��Q Ong Department Curb C*ut/Driveway Permit
U X01 12 Main Street Sewer/Septic Availability
e p�� Room 100 Water/Well Avallability
Northampton, MA 01060 Two'Sets of Structural Plans
phone 413-557-1240 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 /%,S CT
1.1 Property Address: his section to be completed by office
Map Lot Unit
Zone Overlay District
Elm 5t.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
y
oh n �_ o oo
e(Print) Current Mailing ddress:
f ��t 1
Telephone
ignature
2.2 Authorized Agent: G\sOn sh• , �
�OM �n1<�ra�ervter�� ��� Q-o,b� 1�0��1 , q�orencc- --(4 ono(02.
Name Print Current Mailing Address:
X13-���-`15Z2
zignat e Telephone
SECT=3-ESTIMATED CONSTRUCT IOM COST,G
Item Estimated Cost(Dollars)to be Official Use Onfy
completed by ermit applicant
1. Building (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) 0 0 G Check Number
This Section For Of•6scial Use Only
E Building Permit t��:mber: Date
r:
I
Signature:
Building Commissioner/inspector of Buildings Date
307 PROSPECT HGTS BP-2016-0408
GIs#: COMMONWEALTH OF MASSACHUSETTS
MM:Block: 24A- 177 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-2016-0408
Project# JS-2016-000641
Est. Cost: $5000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 106006
Lot Size(sq. ft.): 18992.16 Owner: HACKMAN JANET T
Zoning:URA(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 307 PROSPECT HGTS
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:912412015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 7 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 Sisnature:
FeeType: Date Paid: Amount:
Building 9/24/2015 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner