36-213 (10) City ofNorthampton 212 Main Street, Northampton, MAO 1060
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: 33 ,B i r~h Love
The debris will be transported by: PepLnb1j'(- We,sf
The debris will be received by: K uob i;c lnl(���
Building permit number:
Name of Permit Applicant Phil bec"IA11"eu do.at.e Itr) IdVInenf
ILL 15
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
kv 600 Washington Street
Boston,Mass 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
�, Phil Beaulieu&Sons Home Imp.,Inc.
Name(Business/Organization/Individual): 217 Grattan Street,Chicopee,MA 01020
Hl REG#100073 Exp.6/8/16
Address: CSL#CS62638 Exp.6/13/17
Alain Beaulieu
City/State/Zip: PH:(413)592.1498/Fax:(413)594.6008
Are you an employer?Check the appropriate box: Type of project(required):
1. ❑ I am an employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part time).* have hired the sub-contractors 7, ❑ Remodeling
2. ❑ 1 am a sole proprietor or partner- I fisted 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] 5.0 We are a corporation and its 10. 0 Electrical repairs or additions
3. ❑ 1 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]; c. 152,§ ](4),and we have no 12. ❑ Roof repairs
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.
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.
1 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:� �,�� I ILQ
Job Site Address: ") City/State/Zip: C��'
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 covera e verification.
I do herby certify u t and penalties of perjury that the information pr ided /ove is true and correct
Si nature: Date: / G(>
Print Name: Phone#: y�
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 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: Not Applicable ❑
Name of License Holder: Phil Beaulieu&Sons Home Imp.,Inc.
=s 217 Grattan Street,Chicopee,MA 01020 — License Number
HI REG#100073 Exp.6/8/16
CSL#CS62638 Exp.6/13/17
Address Alain Beaulieu Expiration Date
PH:(413)592.1498/Fax:(413)594.6008
Signature elephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Company Name &_ Phil Beaulieu&Sons Home Imp.,Inc. _
® 217 Grattan Street,Chicopee,MA 01020 Registration Number
HI REG#100073 Exp.6/8/16
Address CSL#CS62638 Exp.6/13/17 Expiration Date
Alain Beaulieu
PH:(413)592.1498/Fax:(413)594.6008
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 ermit.
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,StateAnd Local Zoning f Al-d State of Massachusetts General Laws Annotated.
Homeowner Signa re
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 [p Siding[0] Other(O]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition xistin housina, complete the followin :
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, c fit, \P V"\G��li����l as Owner of the subject
property
hereby authorize P(�JVvy�
to act op my behalf,in al matters relative to work authorized by this building permit appli ion.
�� / /",//J
Si ature of Owner Date
i as Own uthorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best ge
and belief.
Signed under the pains and penalties of perjury.
Print Name
1 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
'Ihis column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&payed
(volume&Location)
A. Has aSpecial been issued for/onde site?
NO 0 DON'T KNOW tv 0 YES
|F YES, date isaued:| !
IF YES: Was the permit recorded at the of Deeds?
NO �� DONTK�W YB ��
~��
IF YES: enter Book and/or Document#|
B. Does the site contain a brook, body of water ��nr�etiand�� NO �~/ DON'T KNOW YES
IF YES, has a permit been or need to beobtained from the Conservation Commission?
Needs tpbeobtained »�� Obtaned »�� Date
! �� ------'�
v~� ' x~� ' '
C. Do any si � �� ��gn�� ��onihepnoper�y7 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 0 NO 0
IF YES, describe size, type and location: '
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre urieb part ofu common plan
that will disturb over 1acre? YEGK ) NO K )
�� ~�
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
ors 77 r
City of Northampton
Building Department � b
212 Main Street
2015 Am
j Room 100
nePr o�r>u o r i� a N hampton, MA 01060
NQR'HA CON,M,%i,
.587-1240 Fax 413-587-1272
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
Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
co
Nam Print) Gy��1�---- Current Mailing Address:
Telephone
ignat re
2.2 Authorized Agent: Phil Beaulieu&Sons Home Imp.,Inc.
217 Grattan Street,Chicopee,MA 01020
HI REG#100073 Exp.6/8/16
Name(Print CSL#CS62638 Exp.6/13/17
Alain Beaulieu
Signature PH:(413)592.1498/'Fax:(413)594.6008
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
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) 1 117100 - lCheck Number d
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
33 BIRCH LN BP-2016-0768
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-213 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
C'c�tc or, ROOF BUILDING PERMIT
Permit# BP-2016-0768
Project# JS-2016-001288
Est.Cost: $17100.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group PHIL BEAULIEU & SON HOME IMPROVEMENT 062638
t.ot Sizc(sq. ft.): 213008.40 Owner: MCMANON ANNIE
ZonimU: Applicant: PHIL BEAULIEU & SON HOME IMPROVEMENT
AT. 33 BIRCH LN
Applicant Address: Phone: Insurance:
217 Grattan St (413) 592-1498 Workers Compensation
CHICOPEEMA01020 ISSUED ON.121712015 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE 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 si nature:
FeeType• Date Paid: Amount:
Buildin'u, 12/7/2015 0:00:00 $40.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner