37-022 (20) This plan is the proprietary work product of Valley Home Improvement,Inc.(VHI).It is delivered for the limited and exclusive purpose of supporting the contract bid of VHI,and customer agrees that the elements of this plan shall not be republished or presented in any
form for the purpose of enabling or supporting the work of competing project contractors without the permission of,and compensation paid to,VHI.
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Valley Home Improvement, Inc. BEN GREENWOOD SCALE:SEE VIEW SHEET NUMBER
340 Riverside Drive, PO Box 60621, Northampton, MA 01062 DATE:
Office Phone 413384.1522 Fax 413.585.0820 BASEMENT BUILD OUT DRAWN BY:S.G. 6
Find us on the web at: www.VallewHome Improvement.com a. ��
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Boston, IAA 02111
ter. ass.govl di a
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ADRUeant Inform2flon Please Print Legibly
Name (Business/Organization/Individual): \+(( �, �',t+�, �` '�1� On 104116 ;`7''Ai'len4-
Address: VCkV-C—
City/State/Zip: hone#:
Are you an employer? Check the appropriate box: Type of project(required):
1. I am a employer wi�lr 4. ❑ I am a general contractor and.I
employees (full_and/or part-time). re
have hid the sub-contractors 6. ❑New construction
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
[No workers' comp. insurance comp.insurance.? E
required.] ]. �V e are a corporation and Its ��:.� s 1 uv_aa iCp aaab vt aeae.eac Wiia
Plumbing officers have exercised their 11. airs or additions
I am a homeowner doing all work ® g re P
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.
1 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 nay employees. Below is thepolicy andjob site
information.
Insurance Company Name: �j '��� C. ` 's,� J'1 e G r6i P
Policy#or Self-ins. Lic.#: 00`0 i)1:5 C,6 012- 1 Expiration Date:
Job Site Address: \3 Ve✓\ �\u r - Vjjl_�_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 rification.
I do hereby certify the pains a 4d penalties perjury that the information provided above is true and correct.
�
Signature: p�, l i �. � / ,. Date:
�2
Phone
Official use only. Do not write in this area,to be completed by city or town official I
c5 f , , . .74�y L
Issuing Authority (circle one):
L Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 3.PiumbiLng Inspector
S.Other
Conitaet Persona: P'horce#:
City ofNorthampton 212 Main Street, Northampton, MA. 01060
Solid Waste Disposal Affida>>it
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 haste disposal facility, as defined by MGL c 1 f 1, S 150A.
Address of the work: j°l
The debris will be transported by:
A (&AAO-Q,�Q The debris will be received by: L
r
Building permit-number:
Dame of Permit Applicant r-
Gate Signature of Permit Applicant
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:_
License Number
2-62D �Ocrex
Address Expiration Date
- � .
Signat Telephone
9.'Redistered Home Improvement Contractor. Not Applicable ❑
SIr5 �-, 60 5SV-3
Company Name .' / Registration Number
®
Address Expiration Date
Telephone ELIA C~ -D
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 Exeml2flo
The current exemption for"homeo-,hers"was extended to include Owner-oceu lgled 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,iDrovided that the awrier acts
as cuperwisor.CM- .R 780, SIT-th 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 Fie/she shall be
resgonsible for all such work performed under the hij1ding permit°
As acting Construction Su nervisor 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) l/'-1I Roofing ❑
Or Doors M
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [Q Siding[0] Other[C j
Brief Description of Proposed p
Work: �( A1�Si � T � DKS M 1120T , ADD �C/L �4� � Wt) V t(CTL1 A 1,
Alteration of existing bedroom Yes No Adding new bedroom Yes No N A� CS
Attached Narrative Renovating unfinished basement -Yes No
Plans Attached Roll
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, � - �� � ,as Owner of the subject
property
hereby authorize ' ' =�1�Y1[ y'
to act on my behal in all matters relative to work authorized by t is building permit application.
f � )
i
Signature of Nwner 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
f and belief.
i
Signed under the pains and penalties of perjury.
Print Name
/& h / / Z�)'1
Signature of Owner/ e 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
volume&Location) _.._...._.. ._......_._- .....:._... _ ._..__..... ......... __.... _.._...._ _.-..,..._.
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO (D DON'T KNOW 0' YES 0
IF YES, date issued:
IF YES: Was the permit recorded at;the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page and/or Document#
r
B. Does the site contain a brook/body of water or,wetlands? NO } DON'T KNOW 0 YES 0
IF YES, has a permit beeyi or need to be obtained from the Conservation Commission?
Needs to be obtained/ 0 Obtained , Date Issued:
Y g /� property? O 0
C. Do an signs exist on he YES � ..._.. N
IF/any e ize, type and location:
D. Are oposed changes to or additions of signs intended for the property? YES 0 NO IF e size, type and location:Yi a�uv�w UistUlu (GicaVSVlu,yi661i19, C.a:aVaLibit, UP tIIill4)uvci i aU.UV"is re pari(J 8 G'irriSV�iiUf�UI81`i
that er 1 acre? YES O NO ,0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
C4, of Northampton Status of Permit:
2 B iiding Department Curb,Cut/Driveway Permit
C0 212 Main Street Sewer/Septic Availability
c `_-
Room 100 Water/Well Availability
No hampton, MA 01060 Two Sets of Structural Plans
' 587-1240 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
This section to be completed by office
PropeMrty Address:
�� 1 , `C7ti �•�?r^ -CJ��t�,�.` Ct� Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
—G-i- ! / Telephone
Signature
2.2 Authorized Agent:
Vl �! PC) 3cK boba
Name Print
( ) Current Mailing Address:
Signature Telephone
SECTION 3-ESTWATED CONSTRUCTION COSTS
item Estimated Cost(Dollars)to be Ofi'ociai Use On'ty
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical a 5c��> (b)Estimated Total Cost of
i Construction from 6
3. Plumbing _11500 gr?ildir gl Perrralt Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+ 3+4+5) 30 000 Check Number
This Section For Official Use Only
Building Permit N Date umber: Issued:
i
Signature:
Building Commissioner/inspector of Buildings Date
File# BP-2016-0750
A I'll LI CANT/CON TACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE01062 (413) 584-7522
PROPERTY LOCATION 19 MT LAUREL PATH-600 FLORENCE RD
MAP 37 PARCEL 022 000 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
T_ypeof Construction: FINISH PARTIAL BASEMENT,ADD 1/2 BATH
New Construction
_ Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 077279
3 sets of Plans/Plot Plan
I'l IF FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORM TION 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
D° "10 lition y
S re of Building Official 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
o1'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.
19 MT LAUREL PATH-600 FLORENCE RD BP-2016-0750
61S COMMONWEALTH OF MASSACHUSETTS
Map:Block: 37-022 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Cate�or,: renovation BUILDING PERMIT
1'12 BP-2016-0750
Project# JS-2016-001252
Est. Cost: $30000.00
Fee: $195.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
i.ut 'Si l(2 (ice Owner: ESPINOLA MARTIN V C/O BEN GREENWOOD
Applicant: VALLEY HOME IMPROVEMENT INC
AT. 19 MT LAUREL PATH - 600 FLORENCE RD
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.121212015 0:00:00
TO PERFORM THE FOLLOWING WORK:FINISH PARTIAL BASEMENT, ADD 1/2 BATH
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:
i2ugh: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
NIN' OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
13uildin,t 12/2/2015 0:00:00 $195.00
212 Main Street, Phone(413) 587-1240, Fax: (413) 587-1272
Louis Hasbrouck—Building Commissioner