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31C-002 (6) i THAYER STREET JOB CU k e h ASSOCIATES, INC. SHEET N0. OF 8 Coates Ave. South Deerfield, MA 01373 CALCULATED BY DATE (413) 665-4018 Fax(413) 665-1142 www.thayerstreetassociates.com CHECKED BY DATE SCALE r C)A r 1-1 X'-',�2, Lo a rd ,4 v�: y A/cr� kztJMp��1A O!D & O wat�Ti-�.0Lp K d E-iecte, heake �r Fay i i i I _J ,Z/ N �tiJ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): C (Tt rQF'T ��`�\1��` Jlnc Address: c C CX7tta City/State/Zip: �' Phone#: L.J J " Are Vu an employer? Check the approp ' to box: Type of project(required): 1.Erl am a employer with aCj 4. ® I am a general contractor and 1 6. ®New construction employees (full and/or part-time).* have hired the sub-contractors 2.0 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. insurance comp. insurance.$ required.] 5. ® We are a corporation and its 10.® 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 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. 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: C Policy#or Self-ins. Lic. #: 1 �X fP `)['�c CD�� Expiration Date: 10- [tp J ,/�A Job Site Address: y y Wycfr 14 VG City/State/Zip:/V Or'��/t 1-112 t OM,/�tiT Q l D 6� 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 gainst the violator. Be ad ' ed that a copy of this statement may be forwarded to the Office of Investigations of the IA for insura ag cover en ication. I do hereby c under t and p ties o ry that the information provided above is true and correct. Si nature: Date: cq - /-a " s Phone#: �1�3' COl CD 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#: ! | ! | | | � � | ! | |/ � ! / � � ' | i ! � | � | i | 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: L� � �Va Ord 14 of No 4haimp �qo M o 10 6 a The debris will be transported by: Avs i Rbl j o �fsC�rrs GGS- o a a The debris will be received by: /4c/.s LT) ff Building permit number: Name of Permit Applica Ufrh oil Tar k K orb Date Signature of Permit Applicant ! | | ' / | i | ' | i | | ! SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 13 Name of License Holder: V/e-rnpsn Karr; !m �o'4 C'<-, n cA License Number at e1 114U -Czx 'D c -er Id IW14. 013 73 ct- 06- 116 Addr Expiration Date << yi -S- 4/01 Signature Telephone 9. Reglsteretl Home lmarbvement Contractor: Not Applicable ❑ 7-ha -er S f rce �- /�5S oG u 1 ?81 (`): 5 Company Name Registration Number 3' Coa{Cs v-e- eef/-`��lf�l,1VV 0/373 c:�- 1-7--1-1 Address Expiration Date Telephone&l)66S-41 017 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....... Er 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 � | | i | / � | | | / | / 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 Other[� Brief Description of Proposed Re—n(a«'SGueraf bu.feJ"Cva wIndawf, r+,o and relolaee poor srstCA �H Work: Lowrr Icvel ;h btSeorca1� rC egoue o(d holic bash Eu1I h44h Jbase- w►rKt� Alteration of existing bedroom Yes t/ No Adding new bedroom Yes ✓ 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 ORS CONTRACTOR APPLIES FOR BUILDING PERMIT I, Yoe rr y L, oA C4 as Owner of the subject property hereby authorize 1/7!r Pt o 1A r r 'K A o h to act oainy behalf, in all matters relative to work thorized by this building permit application. Signature of wner Date I, V C rho tj 14 a r K �0�'( as Owner/Authorized Agent hereby declare that the state ents and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under th ains and penalties of ped VC oN Print NaWl Signature of Owner/Age t Z Date | / i i | / ! | | | | / | ! | ' i 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 w �, 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 ® 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 © DON'T KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO 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 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? YE: O NO 1 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. i i � i i I I Department use only �1 '6 -"' ity of Northampton of f ilding Department CurbCutlDrivewayPermit 212 Main Street SewerlSeptic Availability Room 100 Water/Welt Availability '. ampton, MA 01060 Two Bets of Strut turat�PiansY � G`' phone 413-587-1240 Fax 413-587-1272 PlQtlsite Plins I' q� Y&s �* a ©Iher�?peCtlyz; d y 6 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 y� wo ed /4✓G Map Lot Unit N o Y 4 L.X a lAl p t o y , / r'A - d (0( zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: e1 orry Coke-ill q V bi and A-uen Norq ka wi74-b hr )A0i0a Name(Pri t Current Mailing Address: sys - Telephone Signature 2.2 Authorized Agent: �j V t°r� ti d rr "n y �Ca' e5 4VC S, ��6��c��/�i9 0873 Name(Pri ) Current Mailing Address: y�-3 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building le,en-4;1. — (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of l �� Construction from 6 3. Plumbing -3 �. _ Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = 0 +2+3+4+5) 7 3 DO Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date ! . | | . / ' ! | � | | | | | | | | | � / ! ' i | ! � ! | i / | | | � i � | ' | i � | / . i | � | ' 48 WARD AVE BP-2016-0803 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 3 1 C-002 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category: renovation BUILDING PERMIT Permit# BP-2016-0803 Project# JS-2016-001344 Est.Cost: $17300.00 Fee: $112.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THAYER STREET ASSOC INC 045159 Lot Size(sq. ft.): 50529.60 Owner: COHEN PERRY zoning: RR(78)/WP(59)/URA(28) Applicant: THAYER STREET ASSOC INC AT. 48 WARD AVE Applicant Address: Phone: Insurance: 8A COATES AVE (416) 665-4018 Workers Compensation SOUTH DEERFIELDMA01373ISSUED ON:1211612015 0:00:00 TO PERFORM THE FOLLOWING WORK.REPLACE BASEMENT 1/2 BATH W/FULL BATH & 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 Signature: FeeType: Date Paid: Amount: Building 12/16/2015 0:00:00 $112.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner