38D-007 (2) 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: P 0�11'rl�'
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant �, ��
Date Signature of Permit Applicant
The Commotiwealtle ofMassael[usetts
$a Department of M dustrial Accide[tts
1 Congress Street,Suite 100
13ostort,MA 02114-2017
>'tnuw.[uass.gos/ilia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED«'I HI TIIh PERNin"rim. mi rIIORITY.
Applicant Information Please Print Legibiv
Name(Business Organi/ation�hndividuai):A&J Home Improvement, Inc.
Address: 60 Washington Ave.
Cite/State/Zip: South Hadley,Ma. 01075 Phone #: (413)467-1500
Are rat an elnplocer?(A eck the appropriate bus:
Type of project(required):
I.E✓ I atn a cmplover%kith 8 emplovees(full and'or part-lime)."' 7. Q New construction
2.n I arty a sole proprietor or parinership and have no enipio)'ees%corking for are in 9. Relnodehng
any capacity.[\o%corkers"comp.insurance required.]
9. ❑Demolition
3.F"�I ant a honteon ner doing all%cock m)'.self.[No%corkers'comp.insurance rcquired.l
10 Building addition
d.�1 ant it honreomicr and%kill be luring contractors to conduct all pork on my property. I%%'ill
ensure that all contractor,either haw%corkers'courpansation insurance or are sole I L EJ I',lectrteal repairs or additioIs
proprietors%%'ith no etnnlo)cas.
12.Q Phnnbing repairs or additions
5.rJ l ant a general contractor and I have aired the sub-contractor,listed on the attaehcd sheaf. 1 3.F-/I lZoof repairs
'Ihcsc sub-contractors have emplocees and have%corkers'comp.insurance.:
(iFl 1F'e as n corpor:vtion and its officers have excrciscd their rieht of esanyriion per:%KiI•c. 1=1. Other
152.§1(4),and%ca have no entplovices.[No%corker;'comp.insurance squired.)
":xn'applicant that checks box A must also fill out the section belo%%Showing their%%orkcrs'cmnpensation policy information.
Homco%cners who submit this affidavit indicating the)'are doing all work-and then hire outside contractors must submit a nenc affidavit indicating such.
=Contractors that check this box most attached all additional sheet sho%cing the traffic of the sub-contractors and.state 1%11011c],or not those entities have
emplo)aes. If the sub-contractors have employe—,they must provide lhcir %corker.'comp.police number.
I ant an employer that is providing workers'compensation insurance for my enllple�yees. I3eloN'is the policy and,job site
information.
Insurance Company N<une:Chartis
folic%•#or Self-ins.Lic. #i:WC003796174 Expiration Date:05/11/{2-016 i
Job Site Address: }l �`��lc 5 S) City/State/lip: /
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration (late).
Failure to sedge coverage as required un(ler MGI•C. 152: §§'25A is a criminal violation punishable by a fine up to$17500.00
and/or one-year imprisonment,as well its civil penalties in the form of a STOP WORK ORDER and a tine of up to$250.00 a
day'against the violator.A cop} of this statement may he forwarded to the Office of Im'estigatiows of the DIA for insurance
coverage verification.
1 do hereby certify under the pains(ovd renyhies of perjury that the hifitrmation provided above is true and correct.
Signature: �
Phone;:(413)467-1 0
Qfjicial use only. Do not write in this area,to be completed by city or town o/icial.
City'or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2. Building Department 3. Cityfrown Clerk 4. Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone 0:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable❑
Name of License Holder: I'1 4\Ch'C .' J�l Esc Y� /&j t/ J
License Number
r� ti U/Q 7S
0- h, -�Oo
A dresss,� '� Expiration Date
✓r �- .S zu
nature Telephone
9.Registered Home improvement Contractor: Not Applicable ❑
CompanyName 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....... lRT" No...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or ftvo(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 tine to tune,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 F� Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [[--3] Decks Siding[o] Other[Qj
Brief Description of ro osed ` ((��
Work: p ph t f�Sh VVI' K Lrri
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 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
I 00-A M (6 17 as Owner of the subject
property _
hereby authorize �4 - �['h[�.0-�•ti�T-�
to act on my be alf, in all matters relative to work autho zed by this building permit application.
-2—In f",�6A' ]_�5 _Qod.
Signatu a of Owner Date
S as Owner/Authorized
Agent hereby declare that the statements Jnd information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and enalties of perjury.
AV_)r
4
Print Name
Sign re of Owner/Agent Date
I
'`
ri LJAN 1� � Department use only
Ity of Northampton status of Permit:
tt -ilding Department Curb Cut/Drivew ay Permit
t 212 Main Street sewer/septic AvailabilitRoom 100 WaterNVell Availability
c�ECnaNS N hampton, MA 01060 Two sets of Structural Plans
87-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
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
C ka- I-es �'rtxn�j Map Lot Unit
Zone Overlay District
✓V Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: i
Name(P i ) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Pun#) Current Mailing Address:
Signature Telephone
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= 0 +2+3+4+5) S Check Number
This Section For Official Use Only
Building ermit Number: Date
g Issued:
Signature:
Building Commissioner/inspector of Buildings Date
17 CHARLES ST BP-2016-0942
GlS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38D-007 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categoa: ROOF BUILDING PERMIT
Permit# BP-2016-0942
Proiect# JS-2016-001596
Est.Cost: $5800.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: A & J HOME IMPROVEMENT INC 101017
Lot Size(sq. ft.): 7492.32 Owner: MICHAK DON J&CAROL L MACCOLL
Zoning: URB(100)/ Applicant. A & J HOME IMPROVEMENT INC
AT. 17 CHARLES ST
Applicant Address: Phone: Insurance:
60 WASHINGTON AVE (413) 467-1500 O WC
SOUTH HADLEYMA01075 ISSUED ON.112612016 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 Signature:
FeeType: Date Paid: Amount:
Building 1/26/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner