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30B-109 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: 86 nto-I -s4- The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant 101-5-11!r Date Signature of Permit Applicant The Commonwealth of Massachusetts ----_ --- Department of Industrial Accidents !rte Office of Investigations I Congress Street, Suite 100 • :" Boston,MA 02114-2017 www massgov/dia Workers' Compensation I nsuranceAffidavit: Buil der s(Contractors/Electrici anslPlumbers Applicant Information r j Please Print Leeibly ` Name (Business/Organization/Individual): -�V S f Address: �o w f114- City/State/Zip: t► ," It f�i3yy Phone#: �� t�v� q 077 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. ❑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 [No workers comp.insuranoe 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 12.01toof repairs insurance required.]t c. 152,§1(4),and we have no employees [Noworkers 13.❑Other comp.insurance required.] *Any applicant that chedcsbox#1 must also fill out thesedion below stowing their workers compEnsation policy information I 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-contradorshaveemployem they must providetheir workers'comp.policy number. 1 am an employer that is providing workers compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: LI ��d y�b1 )L i��tJ�•'^`t Policy#or Self-ins.Li^c.#: WC,;L' 3�s 60 Expiration Date: Job Site Address: 7S M f `=✓t 1 d' City/State/Zip: ��lu+t �3 /t]A 060 Attach a copy of theworkers 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 certify:undderthe ins and Penalties of pedury that the information provided above is true and correct. Signature: c Date: Phone#: 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 Construction Supervis�or: i/�,,� Not Applicable !j Name of License Holder: 45-t6- ^ re r �� tl o O� 96 License Numbe-2- d Add LM Expira ion Date Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ! Company Name Registration Number Address Expiration Cate �,w w-AA h Telephone q1 �� y 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 b ilding 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 building 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 171 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[0] Other[E j Brief Descriptign_of Proposed, Work: "&'50 S ti Y+.�r �v`f �� ✓ t,/�`�. S L�3 Alteration of existing bedroom Yes �i' No Adding new bedroom Yes 1Q No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 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, T� l es C�'. L �° To Ss as Owner of the subject property /f hereby authorize to act n my behalf,in all matte relative to work authorized by this building permit application. Signature of Owner Date 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 Name Signature f Owner/Agent Date 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 0 DONT KNOW 0 YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW Q YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW © YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO Q 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 Q NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. e.�.�.,.�..-•r� E.i F Y�@$ �'- S .oF irl �.. � t. ,.r A • � � �n 2 Ri of Northampton Status of Permit: Department use only Building Department Curb Cut/Driveway Permit 5 2 Main Street Sewer/Septic Availability Room 100 Water/Well Availability, pJectric,Plumbing&Gas Ins mpton, MA 01060 Two Sets of Structural Plans tNortnam to -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: This section to be completed by office M Map Lot Unit L� Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(P. t) Current MTailing Address: L_' l'/ Telephone Signature 2.2 Authorized Aaent: Fr Ile, C Alp.* St Name(Print) / Current Mailing Address: Signa re Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 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=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 80 MILTON ST BP-2016-0461 GIs#: COMMONWEALTH OF MASSACHUSETTS Map.Block: 30B- 109 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category ROOF BUILDING PERMIT Permit# BP-2016-0461 Project# JS-2016-000758 Est. Cost: $7500.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JUSTIN FELLOWS 106686 Lot Size(sg. 1): 68824.80 Owner: GROSS TERESA L Zoning URB(100)/ Applicant. JUSTIN FELLOWS AT: 80 MILTON ST Applicant Address: Phone: Insurance: 220 NORTH ST (413) 824-6279 ERVINGMA01344 ISSUED ON.101512015 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SH I NGLE ROOF 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 10/5/2015 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner