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31A-328 (2)
300 ELM ST BP-2016-1144 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 3 1 A-328 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2016-1144 Project# JS-2016-001970 Est. Cost: $6100.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JASM ENTERPRISES LLC 108517 Lot Size(sq. ft.): 5837.04 Owner: BRAND JESSICA zoning: URB(100)/ Applicant: JASM ENTERPRISES LLC AT. 300 ELM ST Applicant Address: Phone: Insurance: P O BOX 1276 (413) 427-5481 WC CHICOPEEMA01201 ISSUED ON.3/29/201¢0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL KNEEWALL & ATTIC INSULATION POST THIS CARD SO IT IS VISIBLE FROM THE §TREET 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 3/29/2016 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department useonly City of Northampton Status of Permit: wilding Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability MR `> 8 ZC's Room 100 Water/Well Availability N rthampton, MA 01060 Two Sets of Structural Plans 1) =,"- - __. phon4 41 -587-1240 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'I,n Map Lot Unit I V,, C- C3 � Zone Overlay District �f !f 7`U /T Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: IS-SIC0, 3rand Name(Print) Current Mailing Address: yr 7— 51/5— yc)�2 Telephone Signature 2.2 Authorized Acient: /G�l , J"41CSRa1Jc:� 6r ' .�/t �r Name(Print) Current Mailing Address: d113 SO/ 50/0 Signature Telephone SECTIO (MATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building / « (a)Building Permit Fee 2. Electrical f (9 (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) Check Number 1710 1 This Section For!Official Use Only Date Building Permit Number: Issued: Signatur . Building Commissioner/Inspector of Buildings 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 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/Fi i g ever'been issued for/on the site? NO 0 DON'T KNOW YES 0 IF YES, date issued:f IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW YES 1 IF YES: enter Book ` Pagel and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW A YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q , Date Issued: C. Do any signs exist on the property? YES 1 NO i IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0 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? YES Q NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. i SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ff— Roofing ❑ Or Doors E] Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [I] Siding[O] Other Brief Description of Proposed Work: 'ell� Tt}L' Alteration of existing bedroom Yes X No Adding new bedroom Yes /\ No Attached Narrative Renovating unfinished basement Yes _ No Plans Attached Roll -Sheet 6a.if New and or addition to existingg housin om`letetthe followin /y a. Use of building:One Family Two Family Other f+r U 1 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 PE RMIT i I, 11 Qr I S els ��35`� ` chi A C� a O_ caner of the subject property hereby authorize y � ZLC to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date as Owner/Authorized ized A ent hereb that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name ' Signature of Owne gent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: (f Is _ 1 o V 5 License Number � 2__ l0._.)s Address Expiration Date p6ncti i��d /VJ 4/3 301 '6010 Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ 10 SM til le,-Prises, Ct c- 166() 77// Company Name Registration Number 00 �36X 12 7 �1-2/-101, Address � Expiration Date C / bZ Telephone '�/3 30/ S^/© SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAWIT(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 farm structures.A person who constructs more than one hone 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 Loc oning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature The Commonwealth jMassachusetts C Print Form - Department oflnd iaCAccidents Office of Inve -gonion =! I Congress Sire t,Suite IOD Boston,MAD 114-2017 www.mass.gov/dna Workers'Compensation Insurance Affidavit:guilders/Contractors/Electrieians/Plumbers Appheast Information Please Print Legibly i1ASM Enter risos, LLC. Name(Business/Otgaeiiationitndividnel): p j Address: P.O. Box 1276 Ci /State/Zi : Chicopee, MA 01021 Phone#: 413-301-8010 Are you an employer?Check the appropriate box: Type of project(required): 1.® 1 am a employer with 10 4. Q I am a general contractor and I 6 Q New construction employees(full and/or part-time).'' have hired the Isub-contractors 2.Q I am a sole proprietor or partner- fisted on the atjtached sheet 7. ❑Remodeling ship and have no employees These sub-conp'actars have g. Q Demolition working for me in any capacity. employees and have workers' 4. Q Building addition j [No workers'comp.insurance comp.insurano.: required.] 5. Q We are a corporation and its ME]Electrical repairs or additions 3.Q I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions i myself.[No workers'comp. right of exemption per MGL 12.E]Roof repairs insurance required.]r c. 152,§1(4),and we have no Insulation employees.[Np workers' 13.®Other comp.insurance required.] •My applicant that checks box#1 must also fill out the section below showing thei f workers'compensation policy information. t Homeowners who submit this affidavit indicating they we ding all work and tbo hire outside contracts must submit a new affidavit indicating such. $Contractors that check this box must attached an additional shed showing the ram¢of the sub-oontractots and state whether or not those entities have employees. If the sub contractors have employees,they must provide their worker'corW.policy number. swaaaaa®se®nor I am an employer that Is providing workers'conipensadon insurajnce for my employees. Below is tke po&7 and fob site information. Insurance Company Name: Liberty Mutual Policy#or Self-ins.Lic.#: WC2 -31S-372772-014 Expiration Date: May 2, 2016 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 1r. 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one-year imprisonment,as well as civi�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 DTA for insurance coverage verification. I do here ce under!/i and oru t t t e in ormation provided above is true and correct Signafire: Date' Sept. 5 2015 _ Phone 413-301- 010 OJjrciat use only. Do not write in this area,to be completed by clty or town officiaL City or Town: Perlmit/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 City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of IVIGL 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: 366 61M s � IVO"A40P 17 The debris will be transported by: J 0SM ¢ry Cly The debris will be received by: uSJ 'a � Building permit number: A Name of Permit Applicant �ec-ne t 3" 25 - Dateature of Permit Applicant i Permit Authorization Form ATTN: Building Department Building Department Puchalski Municipal Building 212 Main St. Northampton, MA 01060 1, Jessica Brand , Owner of Elm 300 Elm Street Northampton, MA. 01060, Hereby authorize JASM �nterprises,LLC to act on my behalf and obtain building permitto perform insulation and / or weatherization work at 300 Elm Street property. Representative signature: - -- - p g Gate:'?� ,