25A-120 (4) MIX Home Improvements Inc.
575 Granby Rd
South Hadley,MA 01075
Phone# 413-532-7603 NPHIINC@grnail.com 9117/2015 2013-202
Fax# 413-532-6435
Barbara Kuschka
Re.8 Sherman Ave
Northampton,MA 01060
a
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Cover all floors to protect during construction. 15,365.00" 15,365.00
Remove trim
Remove walls and ceilings to existing studs in the Dining room,Living Room
and Hallway.
Insulate exterior walls where needed.
Install new 1/2°sheetrock on all walls and ceilings
Install new trim where needed
Frame and Install trim from kitchen to hallway door
Remove and replace stair treads
All walls and ceilings will be prepped ready to paint.
Back Dining Room-Frame out and install French door
All permits will be applied for prior to work start
Remove all waste from site
t
Subtotal $15,365.00
Sales Tax (0.0%)
$0.00
Total $15,365.00
^I
City of Northampton 212 Main Street, Northampton, MA 01 060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: � S IBC'rrv)H i) kf
The debris will be transported by: L)M Q�C� 'cf x
The debris will be received by: cn1
Building permit number:
Name of Permit Applicant VwIE :fr'r QVc,-016I)t Inc
CI a 7 j /5 /
Date Signature of Permit Applicant
Em
• The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,Mass. 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/OrganizatiorAndividual): N .P. -
Address: 575 &zpinbq tJ
City/State/Zip:,—S.4Q aJ u (n5 Phone#: #/3-W a-_7(PD3
re you an employer?Check the appropriate box: Type of project(required):
1. I am an employer with 5 4. ❑ 1 am a general contractor and I 6. ❑New construction
employees(full and/or part time).* have hired the sub-contractors 7. ❑Remodeling
2. ❑ I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp.insurance.$
required] 5.❑ We are a corporation and its 10. [1 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 perm MGL
insurance required]t c. 152,§ 1(4),and we have no 12. ❑ Roof repairs
employees. [no workers' 13. ❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information.
tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contactors that check this box must attach 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: �1 �t f �►�51,�r'Ql ?
Policy#or Self-ins.Lic.#: D '4 Pe- y Expiration Date: 20-2015
Job Site Address: 2hc('mn Ave- City/State/Zip: N OOA f}I V�M { NA 000,
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 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby cert' d r the pains and penalties of perjury that the information provided above is true and correct.
Si nature: Date:
Print Name: NIC_RDI�S �G�'ERS Phone#:
Official use only Do not write in this area to be completed by city or town official
City or Town: Permittlicense#:
Issuing Authority(circle one):
1.Board of Heath 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�Supervisor: I Not Applicable ❑
Name of License Holder:- J v I,d (i-H S T 5 I W Lj 16
License Number
rp`lu) C--* )nb4 Rd � i.I--In calf'l t A)0 011)'7- oq I i a I z.0 i
Address —� —1 7 Expi tion ate
UI1 5'� � 7(n03
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
K�P• flarY1-c !2rL'>;i"m r-,n+ Z-,r - iLi�)O �
Company Name Registration Number
x`15 C� Y�bU 5•HQd If'i,l , ty)A oiu-76 C( 11 to 1 Lac)
Address i f Expiration Date
Telephone
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....... X 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 10835.1.
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 ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [❑ Siding Q]] Other[ER
Brief Description of Proposed
Work: 41-rip ('11fre,i+ !L)WL, InsAull oel.) e,'F►eejf-Cck-
Alteration of existing bedroom Yes Z�sl No Adding new bedroom Yes x No
Attached Narrative Renovating unfinished basement Yes -x_ No
Plans Attached Roll -Sheet
sa. 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, PQ M m K-sc h k , as Owner of the subject
property 1
hereby authorize ��i 1�• tt�l)1E }►1 �(�V�)�1�t1 Inc
to act on my behalf, in all matters relative to wok authorized by this building permit application.
si, V1 tc C®Y�
Signature of wner Date
I, t M E as Owner/Authorized
Agent hereby declare that the st tee ments 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.
N I't koW, fir:- cR_5
Print Name
%) 1Is
Signature of 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 O DON'T KNOW Q YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES O NO O
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 O
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 O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
Cj 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
o ampton, MA 01060 Two Sets of Structural Plans
- 87-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
A TION 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
Shef-0yin A G'c' Map Lot Unit
0 K4 NA 1-fl P�� ' l�110 1 Q 0 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
��R1��rR K'USC�)KC �`��� t�m r� Avg , ) IAkciryzo6rn MA
Name(Print) Current Mailin
��Address:,
13- Vii' 1 5718
IC 1h c�� iYT /�C: Telephone
Signature
2.2 Authorized Agent:
N.P. 6 R ba IRA S-�nJ,lp(4 ntcz-�
Name(Pr :
' t) Current Mailing Addres
X113-15:�a 71PQ3
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building C' (a) Building Permit Fee
l�
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) 1:!5 3b6 Check Number VW
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2016-0516
APPLICANT/CONTACT PERSON N P HOME IMPROVEMENTS INC
ADDRESS/PHONE 575 GRANBY RD SOUTH HADLEY01075(413)532-7603
PROPERTY LOCATION 8 SHERMAN AVE
MAP 25A PARCEL 120 001 ZONE URB(100)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinp,Permit Filled out
Fee Paid -1 d 1141
Typeof Construction: STRIP WALLS&INSTALL SHEETROCK&TRIM (J
New Construction �9
Non Structural interior renovations AIL
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 100481
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOR ION PRESENTED:
pproved 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
emoli io elay
Signature of Buildm Offi 'ial 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.
8 SHERMAN AVE BP-2016-0516
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25A- 120 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2016-0516
Project# JS-2016-000862
Est. Cost: $15365.00
Fee: $104.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: N P HOME IMPROVEMENTS INC 100481
Lot Size(sq. 1): 5183.64 Owner: KUSCHKA BARBARA J&JEFFREY P JOHNSON
Zoning.URB(100)// Applicant: N P HOME IMPROVEMENTS INC
AT. 8 SHERMAN AVE
Applicant Address: Phone: Insurance:
575 GRANBY RD (413) 532-7603 WC
SOUTH HADLEYMA01075 ISSUED ON.1011912015 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP WALLS & INSTALL SHEETROCK & TRIM
(FRAME & INSULATION INSPECTIONS REQUIRED
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 10/19/2015 0:00:00 $104.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner