17A-158 (6) i
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DR N,wN Br VHI iValleLA Home Improvement, Inc.
I IR1.,115ED: 1 340 Riverside Drive, PO Box 60621,Northampton, MA 01062
6.2--l-14 I Office Phone 413584.1522 Fax 413.585.0820
I D,�e,'E: 1/20/2016,1
Find us on the ufeh at: un..vw.Walleyf�lomelmprovement.com
_ __
This plan is the proprietary work product of Valley
PATRICK RONDE>$U Home Improvement,lnc.(VHI),Itis
delivered for the limited and exclusive purpose of
53 FOX FARMS RD supporting the contract bid of VHI,and
customer agrees that the elements of this plan shall
FLORENCE, MA not be republished or presented in any form
1 O�^G for the purpose of enabling or supporting the worir of
competing project contractors without the
permission of,and rompansatrnn paid to,VHL I i
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plan Is the proprietary worl(product of Valley
DFiZANN 13Y: VHI Valley Home This Improvement Inc. PATRICK RONDEAU Home Improvement,Inc.(VHI).It is
delivered for the limited and exclusive purpose of
53 FOX FARMS RD supporting the contract bid of VH1,and
340 Riverside ?rive, PO PDX 60621, Northampton, MA 01062 JA customer agrees that the elements of this plan shall
16-23�.14 Office Phone 4135M.1522 Fax 41 FLORENCE, MA not be republished or presented In any form
53b5.020
for the purpose of enabling or supporting the work of
r,A T E: 1 X26/201 6 Find L15on the Loeb at: LLU-L(J.ValleyHomelmprovement.com 01062 competing project contractors without the
permission of and compensation paid to VHI.
........... ----------...... .. ............ ............. .......... ..............
--------
Depaa�rtme✓�A of Indaaso-idaad Accidents
0�3ITce of J ess iga sI Pis
600 Washington Street
—� Boston,MA 02111
_ = 14Jww.madss.gov1 dla
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 11 Please Print Le ibly
Name (Business/Organization/Individual):
i
Address: `��
City/State/Zip: �' `(D cc C) Phone
I--P_
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. ❑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'
[No workers' comp. insurance comp. insurance.t 9 Building addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.El 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 infonnation.
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 ant an employer that is providing workers'compensation insurance for nay employees. Below is the policy and job site
infiar`naEtion.
Insurance Company Name: C b"�C,` �,C au�cl-e _ rz�U!
C C;
1'chcy Ir it veil-iitu. .i—rr: ��w �: ,�"y � e _ Agitation.bate:
Job Site Address: _ 1j 7'l3� -Fay � City/State/Zip: Ekx&,,g(,f, H6LOJ&�2_
Attach a covey of the workers' compensation policy declaration page(shoi-ng the po�Ucy nu bWr and expi a:can date,).
Failure to secure coverage as required under Section 25A of iviGL 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 2nd a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be fort�Fgrded to the O f w-of
Investigations of the IDIA for insurance coverage v rification.
I do hereby certift i the pains a`�l penaltie' perjury that the information provided above is true and correct.
Signature: ��'�;!�?� • [�'� �!,�s+f����' Date:
of?Ccia!nse gn117. Do not wrIke,it this an ea. to ^c1"comlwlet y City 3?c6 49:2 c,�y`? ff
�?rev a�� a ng�A
U
City or Town: e'er */VLce sW# II
1.,,3acnY 6l ax Meiaky,w <. IDarnlaifig Depa`!ife.11lrru-exw 3. caeYi r uF%Vn, @.,heTk 4.m.gectricae k'gl5pee1Lt9r 3,PAUI59bing inspector
Contact Person: Phone
!I
Lily o1Nlortha.mpton 212 Main Street, -Northampton, 1AA 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 waste disposal facility, as defined by MGL c 1 ; 1, S 150A.
Address of the work: S3 Ci j
The debris will be transported by: ve ,,�}--
The debris will be received by:
Building permit.number:
Name of Permit Applicant A-;---
/z 4
Z'r///7 /'-- /A-
C
ate Sicnature of Permit Applicant
SECTION B.CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: � \ (1 'tW-ffVYYQt11
License Number
Address Expiration Date
Signa r Telephone
9.°Reeggi�ste_red Ho Improvement Contractor Not Applicable ❑
Corn pany Narne Registratiio�n{Number
Address Expiration Date
0\0d� 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....... CK No...... ❑
EX
The current exemption for"homeovimers"was extended to include Ow,ner°-ocmlled Dwellfugs of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,TSr o-,dded thg the owrber•Refs
Rs suoervicor•C'R 790. Sixth Ediitfo n .Feetior?R@ . . .�.
Definition of Homeowner:Person(s)who ovol 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 w bo constructs -more than one home in a Mo-year period s>ha➢1 not be considered a homeowner.
Such"homeowner"shall submit to the building Official,on a form acceptable to the Building Officials that he/she shall be
resnonsible for all each wort,Performed under the bllpdnnn6 12-ermrt
As acting Construction Sulaeniseir prom presence on the job cite Drill be rep„rrCA�°R— f—to h Pate;, b and upon
�-1 _: —
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 n.ay 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 V4rOPK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) -® Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [M Siding[0] Other[p]
Brief Description of Proposed p
Work: i�biflod hL
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 dr dditigh to ex!Stln houslnEd complete the folloIwE66:
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 citw Sswor Private wall City water Supply �
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
prcNet`1'
hereponmy }e
to �iin -
refa' e to work autho ized by this building permit application.
�,LCo
Signature of Owner 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
2nd be!isf. -
Signed under the pains and penalties of perjury.
Print Blame
Signature of O ner.Agen: Date
Section 4. ZONING Alt 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 o
(Lot area minus bldg&paved
_.
arkinO
#of Parking Spaces ..............
Fill:
(volume&Location) ............. ... _. -._. .._._ _.'....................,......__.-----•--
A. Has a Special Permit/Variance/Finding ever been ' s d for/on the site?
NO 0 DON"r KNOW YES
IF YES, date issued:!
IF YES: Was the permit recorded at the Regis of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body water or wetlands? NO 0 DON'T KNOW C) YES
IF YES, has a permit been or n d to be obtained from the Corserva "on Commission?
6veeds to be obtained ) Gbtainned (�� , Date Issued:
C. Do any signs exist on the operty? YES NO 0
IF YES, describe size, ype and location:
D. Are there any propo ed changes to or additions of signs intended for the prop rty? YES NO
IF YES, describ size, type and location:
...v w. Sr.0 —1i —1—V ul;cwv t uiaufiiy, c.ci;avcuu:t, uF Ldtlit�t)uvcl 1 aulc Ut to tt o iFLJI c i;UtiiMu i oiari
that will distu over 1 acre? YES 0 f\0 -0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
I Northampton Status of Permit:
ildl g Department Curb Cut/Driveway Permit
12 ain Street Sewer/Septic Availability
SAN 2 2018 R om 100 WaterMJell Availability
North m on, MA 01060 Two Sets of Structural Plans
±mil-1 0 Fax 413-587-1272 Plot/Site Plans
pEPi OF8�' oN,MAO�p60 Other Specify
NCHAM�T
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
33 JoX Fa.rni Za Map Lot Unit
Flo r-er2 CC— Overlay District
Elm 5t.Distract CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
P �bc,c� 1r"�. b3 c iCZ.-�►-r ' �lavj6rzct Ma oio6
N nn Current Mailing Address:
i�- r)�� 9k
Telephone
Telephone
Signature
2.2 Authorized A t:
--� 6oc Ocyo 80 F I4�eA rya aI 0
Name(Print) Current Mailing Address:
X113 -�g�j-7522.
Signature Telephone
SECTION -ECTRtftATED CCDRSTRUC-7 14 COSTS I
Era I
rr? i t.SLiiTf tcd CIC'SSC(uulVarS)i6 FiE Ull'iCtal Use Only
completed by ermit applicant
1. Building 2 7M (a)Building Permit Fee
2. Electrical ��v (b)Estimated Total Cost of
Construciion from '6
i 3. Plumbing —� I Eulld!Inco Perrn f Fete
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) 36 OZV Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
I
Signature:
j wilding Commissionerlinspector of Buildings Date
File#BP-2016-0948
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522
PROPERTY LOCATION 53 FOX FARMS RD
MAP 17A PARCEL 158 001 ZONE URA(100)
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: REMODEL FINISHED BASEMENT/PLAY ROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 106006
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORJ�TION PRESENTED:
L
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
Signature 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
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.
53 FOX FARMS RD BP-2016-0948
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A- 158 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2016-0948
Project# JS-2016-001605
Est. Cost: $30280.00
Fee: $196.82 PERMISSION IS HEREB Y GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 106006
Lot Size(sq. ft.): 28793.16 Owner: RONDEAU PATRICK D&KRISTA S
Zoning: URA 000)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT. 53 FOX FARMS RD
Applicant Address: Phone: Insurance:
P O BOX 60627 (413)584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.112812016 0:00:00
TO PERFORM THE FOLLOWING WORK.REMODEL FINISHED BASEMENT/PLAY ROOM
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 1/28/2016 0:00:00 $196.82
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner