02-026 (4) 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: FAr!�5- L�
The debris will be transported by: S'e- kip
The debris will be received by: ( l U �
Building permit number:
Name of Permit Applicant CsCy'�T
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
1 Congress Street,Suite 100
Boston,MA 02114-2017
M s www mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Le ibl
Name (Business/Organization/Individual): � CGS
Address: S15 ("�Tve t W-�7er/ C
City/State/Zip: ti Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑New construction
mployees(full and/or part-time).* have hired the sub-contractors
2 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
Nip 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.❑ I am a homeowner doing all work officers have exercised their I L❑ 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' 13.0 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: _
Policy#or Self-ins. Lic.#: Expiration Date: _
Job Site Address: 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 verification.
I do hereby certify"Ider the pains and pe We per' ry that the information provided above is true and correct.
Sign afore: Date: c4 —17
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 Supervisor: Not Applicable 0 Gt
Name of License Holder: ��O �s?c � � q 73p Z
License Number
Er���A-A, p- ►-t
Add res Expiration Date
gna ure Telephone
9.Realstered Home Improvement Contractor: Not Applicable ❑
r sz3OA01
Company Name Registration Number
Address 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....... ❑ 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 faun
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 D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[ Other[EK
Brief Descjlption f Pro osed ( r
Work: ` e,& �t f�vJ QYIcJ \ u{� C�1'� d\ Q1�1 cL/? Iv--
Alteration of existing bedroom Yes No Adding new bedroom Yes No Pe,/1 ie,
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
as Owner of the subject
property T
hereby authorize " ('01 \GLL-'w1
to act on my a If, in all afters(eilative to work authorized by this building permit application.
Signature Ap"Too Date
I, 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 uaider the pains and penal t s of perjury.
C;v� la.
Print Nam&. ner/Aaent 'Date
- Department use only �i
t k
City of Northampton Status ofPerm�t j _�
1ci= ;Iefi, w:_i�:e=..,;.1u:2°t]I��k'�_r
.hr.,_..._.r:!r�;::'u;;!!�;7::,-i
= 1710 Building Department CurfDri�eay Parmi#
212 Main Street SewerlSeptjcAuailall[ty ! IL r 3' s
.c.::.,.s.::F-r-_•�S"�a:<--,r�� �_..,nr iL_c?r}e�-�.:S9c
Fly.L.r-.4-;_iji!=i;!`iu == i_'Vic'°
Room 100 �Naterlll�fel�Rva:la6ilit r
DEPT.C'=n:. CSNG SN;r EGTlOiVi Y J d
NOR HNAPlCN,MA01C�0
orthampton, MA 01060 Tw.... of Structural PfaBsl _
�_._.r
phone 413-587-1240 Fax 413-587-1272 P[otlsi�ePlana;
I 4 7 I rl r'r' Il' t L
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE.INFORMATION.
r. _
isisect�orr;to='e_c.om e e -o
1.1 Property Address. �-
_....5_vl=: -
cu;3L _v_ 1- av:r-_—
Lo.tru=-
r
—\ T V .__v:.:—:.._��._.::-c,_c__:.,a.vc___gip:._.._..____�:.,_!_
-_—'lies?,i.-'..y---�_•_—_—_ _.__..__...__._
.__._.. .._ ._-.nr. ......
�...tni.
_Zo ' __ .:_
:�z_���.,
r.
SF.i'l�-v _
v..:r r
-_ Dlst[ICt :-�_..v,
Bc
SECTION 2.:-PROPERTY'OWNERSHIP/AUTHORIZED;AGENT:
2.1 Owner of Record:
Nam (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
3 7-6J
Name(Print) Current Mailing Address:
Slgna a Telephone
SECTION 3'-'ESTIMATED CONSTRUCTION COSTS. .
Item Estimated Cost(Dollars)to be Official Use Only
cam feted y permit app licant
1. Building 00 ('a) Building Permit Fee
2. Electrical (b) Estimated Total C"bst of
Construcfion'fram 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
3. Total=(1 +2+3+4+5) Check Number
This:Section For Official Use Onl
Date
3uilding Permit Number: Issued:
Signature:
w.
Building Commissioner/Inspector.of Buildings:';, ': Date
1�
File # BP-2016-0807
APPLICANT/CONTACT PERSON SCOTT CALLAHAN
ADDRESS/PHONE 33 WESTVIEW TERR EASTHAMPTON01027(413)320-6269
PROPERTY LOCATION 668 NORTH FARMS RD
MAP 02 PARCEL 026 001 ZONE RR(100)/WSP(99)/WP(50)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REMOVE WINDOW&FILL PATCH SIDING&INSTALL HARMON PELLETSTOVE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 97309
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved 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
Demolition Delay
Sig e o B 'lding 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
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.
668 NORTH FARMS RD BP-2016-0807
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 02-026 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catet(orv: renovation BUILDING PERMIT
Permit# BP-2016-0807
Project# JS-2016-001359
Est. Cost: $1500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SCOTT CALLAHAN 97309
Lot Size(sq. ft.): 47441 1.96 Owner: FERNANDEZ TONY
Zoning: RR(100)/WSP(99)/WP(50)/ Applicant: SCOTT CALLAHAN
AT. 668 NORTH FARMS RD
Applicant Address: Phone: Insurance:
33 WESTVIEW TERR (413) 320-6269
EASTHAMPTON MAO 1027 ISSUED ON.•1211712015 0:00:00
TO PERFORM THE FOLLOWING WORK.REMOVE WINDOW & FILL, PATCH SIDING &
INSTALL HARMON PELLETSTOVE
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 12/17/2015 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner