17C-322 form for the purpose of enabling or supporting the work of competing project contractors without the permission of,and compensation paid to,VHI. _
----,
mss
City of Northampton
Building Department
Plan Review
212 Main Street
Northampton, MA 01060
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ACCESS COVER UVi.:.1:. ELECTRICAL FA44EL_-
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5�CHESTNUT STREET PROPOSED
E� SI;�LE:SEE VIEW SFIEI:TNUMBER
`�'aIIey h�or�e Improvement, Inc. �(.' - ---
340 riverside Drive-, PO Box 60621,Northampton, M,4 01062 DATE.
Office Phone n the eb at "f522 Fax
co KRISTEN AND ANDREW MUNSON D1,AWNBY:S.G.
,_Find us on the web at: t.twLU.VaIleuHomeImprovement.com
City of ylorthampton 212 Main Street, -Northampton, MA 01060
Solid Waste Disposal Ai-fida>>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 waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work:
The debris will be transported by: -aLVA .
The debris will be received by: �.
Building permit,number:
Marne of Permit Applicant 4
C�aTe Signature of Permit Applicant
f
The comjwonweal,-A of
eparaa eat o i du,� �iad cci eiYats
flce oyest` ons
i T=ji 600 Washington Street
-- ,; Boston, MA 02111
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): C� �:��
Address: _�
City/State/Zip: A' `C�l _CICC _ CC) hone#: �� - ��oL`�� 22,
Are you an employer? Check the appropriate box: Type of project(required):
1. I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub-contractors 6. F-1 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 8. Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.t 9. Building addition
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 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.F] Roof repairs
insurance required.] ; c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Otber
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
I 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 area are employer that is providing workers'compensation insurance for nay employees. Below is the policy and job site
my"Ormadon.
Insurance Company Name: v A b, �, 011_
A i a
Policy'#r yr-Self-MIS. a .- , a ems-
Job Site Address:_ CKa ► 56_\.� City/State/Zip: ()/e (L ka LO 1D(0,--_'
Attach a copy of the workers' compensation popcy declaration page(sbewinb the pol—icy nunnbe4 and expix aW oa date).
Failure to secure coverage as required under Section 25A of i`viGL 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 fof w riled to the Officc of
Investigations of the D.1A for insurance coverage v rification.
I do hereby certify e g the pains a-ldpenalti�,a perjury that the information provided above is true and correct
14 1,
Signature: ^��V"l�r'; e�� °�i>">r/1,y`'� Date:
arniciaz use±n alai Do YIL T,a�1 its 7n th25 L2 r�?Z,.t0' c mt ae93d 6v `7 dy* ' 9 9n o r�rriaa4 �?
�1 iS
ep
City or'i`m)vn: Pea */ tcea e R �
Issuing Auto Lty (c,Lrcte one,): n
�I r.r_,G%ra%k of Llez'kkh 2.Mu`"'ff g Deparg aiehu' -3. i%r 7 i own C erk 4.Eieetrficai Inspevwr S. PLa.E��bLag inspector
if 6. Othl er $R
Contact Person: Phone : ii
SECTION B-CONSTRUCTION SERVICES
3,1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: n S'W--°--C mcl' —, (� �
License Number
.,
Address Expiration Date
signatufef 111 Telephone
9.`Redistered'Home Immrovemenf Contractor Not Applicable ❑
Company Name Registrationj�/Number a�61 A "1`7
Address Expiration Date
Telephone ) ���� ��
SECTION 11®-WORKE=RS'COMPENSATION INSURANCE AFFIDAVIT(IVI.G.L.c. 152, 25C(�
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...... ❑
The current exemption for"homeowners"was extended to include Ow,ner-aceurnbed DvreNftigs of one(1) or two(2)families
and to allo:F✓such homeowner to engage an individual for lace who does not possess a license,ura-, dad th&t the cw°tier acts
as suPervgcor.C'.R 7gt➢., Sixth Edition
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 eueh work rnerformed under f e buP&Pff�?erM t_
As actin6 Construction Suuen1mr Vournre:.gence can the ic)b site will l P�Pn,.,ra t fi-n ,4 to h ndupon
n- -- - _-, .....e, lam.
cornplttion 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 undersigaaed"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 3-knata?re
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) C-7r Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding[®] Other(d)
Brief Description of Proposed
Work:_ gL� �� OLAT r— 6AS-46 V_F ' kO STktj rP.A L Amv
Alteration of existing�-She roo Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement 'Z� Yes No
Plans Attached Roll
6a.if New.house`and or addition to ex1.stin cwnb]efe the follow ing•
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. t Private well City water Supply iic Tank C y Sewer
SECTION 7a-014JMER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
r��n r.
T
hereby authorize- ��Oci X-ct_k
to ac=behalf, bs relative to work authorized by this building permit application.
IZI1 Lf � i
Signature of Owner Date
as Ot+vr,erlAuihorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
€ be�ief.
Signed under the pains and penalties of perjury.
Print Name
I
j Signature of o k1ner!A V
777 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
E'
Building Height _...._,
Bldg. Square Footage % _...._.
Open Space Footage
(Lot area minus bldg&paved
arldnQ)
#of Parking Spaces _:._..._
_.......
volume&Location) '._.._._.._._.__... .............. __ .__-.:_.--................_.._._ __ . _.':...-......_...:.. ....._-___--
A. Has a Special Permit/Variance/Finding ever been issu for/on the site?
NO 0 DONT KNOW (D Y 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of eeds?
NO 0 DON'T KNOW � YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of wa r or.wetlands? NO 0 DON'T KNOW 0 YES 0
IF YES, has a permit been or need to e obtained from the Conservation Commission?
Needs ro be obtavned Obtained (: � , Date (issued:
C. Do any signs exist on the prope ? YES NO 0
IF YES, describe size, typed location:
D. Are there any proposed char ges to or additions of signs intended for the property? YES NO
iF YES, describe size, #e and location:
' ui iro�.v J.�uc:uue! al.t 1/ �r ulvw V 1V1ca!!t!`U,.UIaW(tt� U;CUCV=L[UH, Ui MIR!Llj UVCI 1 al.lo UI IS it 0aii UI d GiSl•C&CIC)it Ui GYI
that wilt disturb over 1 Ore? YES 0 �0 .0
j
IF YES,then a Northampton Storm Water Management Perl lit fron the DPW is required.
Department use only
City of Northampton Status of Permit:
` B iiding Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
DEC C' 201 Room 100 Water/Well Availability
No hampton, MA 01060 Two Sets of Structural Plans
o�ru, 13- 87-1240 Fax413-587-1272 Plot/SitePlans
:ows
r!P,A M,rrJ-MAGmGo Other'Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Prop a rty Address:
This section to be completed by office
J �- -- Map Lot Unit
"ofencg, Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name n) Current Mailing Address: r
Telephone
Signature
2.2 Authorized Acfent:
Name(Print) Current Mailing Address:
Signature
Telephone
SECTgO7 3-E` ^IY EATr D CC STRUCF o O Q 00--1371-7
i
tram Es i "azed,ClSC(D0Irar 5)to
be UfifCiai Use Only
completed by permit applicant
1. Building 23 (b (a)Building Permit Fee a
2. Efectricai r `1 (b)Estimated Total Cost of
Consiruciion from '6
pliiiiibitlq rte— ( S,uiNdpmg PCrprgph Fee
I
4. Mechanical (HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) q Check Number '
This Section For Official Use Only
Diiilc iig Perr pit Nlurnber: Date Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2016-0821
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE01062 (413)584-7522
PROPERTY LOCATION 58 CHESTNUT ST
MAP 17C PARCEL 322 001 ZONE URB000)/
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: FINISH BASEMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
BuildinU Plans Included:
Owner/Statement or License 106006
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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
i Delay
-�
Si re of Bui mg Of cial 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.
58 CHESTNUT ST BP-2016-0821
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-322 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate,,,orv: renovation BUILDING PERMIT
Permit# BP-2016-0821
Project# JS-2016-001387
Est. Cost: $24800.00
Fee: $161.20 PERMISSION IS HEREB Y GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 106006
Lot Size(sq. ft.): 9016.92 Owner: MUNSON ANDREW&KRISTEN
Zoning URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT. 58 CHESTNUT ST
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.1212212015 0:00:00
TO PERFORM THE FOLLOWING WORK.FINISH BASEMENT
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 12/22/2015 0:00:00 $161.20
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner