30C-058 (3) 376 FLORENCE RD BP-2016-1159
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30C-058 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-2016-1159
Project# JS-2016-002003
Est. Cost: $5000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VICTORY ENERGY SOLUTIONS LLC 108212
Lot Size(sq.ft.): 61419.60 Owner: MIZULA ROSALIE S
Zoning: URA(100 /�95)/ Applicant: VICTORY ENERGY SOLUTIONS LLC
AT. 376 FLORENCE RD
Applicant Address: Phone: Insurance:
1 HARTFORD SQ SUITE 206 (877) 306-4483 O WC
NEW BRITAINCT06052 ISSUED ON:4/6/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL ATTIC/BASMENT INSULATION
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 4/6/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File# BP-2016-1159
APPLICANT/CONTACT PERSON VICTORY ENERGY SOLUTIONS LLC
ADDRESS/PHONE 1 HARTFORD SQ SUITE 206 NEW BRITAIN06052 (877)306-4483 Q
PROPERTY LOCATION 376 FLORENCE RD
MAP 30C PARCEL 058 001 ZONE URA(100)/WSP(95)/
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: INSTALL ATTIC/BASMENT INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 108212
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO" ATION PRESENTED:
pproved 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
D ay "
Sign e of Bui i ici 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.
IV Lj--
City of Northampton �
77p7orthampton,
Building Department
212 Main Street w
F � x
Room 100 '
'
thampton, MA 01060
phone 413-587-1240 Fax 413-587-1272 ' r�
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
3r4, F)o rc w. R-& Map Lot Unit
VAZone Overlay district
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: �y� j f
1 /�A��a ,° �'(aA' — VLA. �rt(� I" Af Name(Print) _.L. �.h5 ',n _�, Current Mailing Address: '
Telephone
Signature
2.2 Authorized Agent:
rt 15 � -hlln-�r " MA
Name(Print) — Current Mailing Address: 1
_ $�I I - �(lir,Of 0 2-7 {2
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building A5,owi (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=(1 +2+3+4 +5) =� Check Number s4/0 6
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
I
Section 4. ZONING All Information Must Be Complete . Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size I
i
Frontage
Setbacks Front
Side L.�._._ _,� R:i_
Rear ro
Building Height
Bldg. S e Footage
Open Space Footage % _
(Lot area minus bldg&paved
parking)
��—
#of Parking Spaces �•_-
Fill:
volume&Location) €
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW YES 0
IF YES, date issued:`
IF YES: Was the permit recorded at t Re istry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page and/or Document#i
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained ® , Date Issued: l
C. Do any signs exist on the property? YES i NO
IF YES, describe size, type and location. ;
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO 0/
IF YES, describe size, type and location.
E. Will the construction activity disturb(clearing,grading,'e avation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors II]
Accessory Bldg. ❑ Demolition ❑ New Signs (o] Decks [M Siding[I=] Other[
Brief Descrip i n of Proposedi U"I d4-i:-6Y�
Work:
Alteration of existing bedroom Yes '/ No Adding new bedroom Yes V/
Attached Narrative Renovating',unfinished basement Yes _ No
Plans Attached Roll -Sheet
6a:If:New Muse'alnd or addition to exists housin om lete the followin
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?x /A
d. Proposed Square footage of new construction. N Dimension
e. Number of stories?
f. Method of heating? A FirIlplaces or Woodstoves Number of each
g. Energy Conservation Compli c Maisscheck Energy Compliance form attached?
h. Type of construction /
i. Is construction wi in 100 ft.of we ands? 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 HEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING P RMIT
Q/Cbz-as Owner of the subject
property
hereby authorize d L( I( 1 �1'0 r t d d 0
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I ► I[1 �� d��l�l (�Ci t41
,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 under the pains an enalties of perjury.
1O 1
Print Name
Signature of Owner/Agent
g Date
i
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: fir
Not Applicable ❑
Name of License Holder: �(�,(� 1 c,y � i 4 � (�
' �� t � License Number
Address Expiration Date
Signature 7 Telephone
9� etilstered Hom lmoroyi)ment Contractor Not Applicable ❑
�,(Jo r U Ear r S '
Company Name J I Registration Number
1 +.1ar ��dwr( �-
Address
� - Expiration Date
Telephones 77' 306-
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDA IT(M.G.L.c. 152,§25C(6))
Workers Compensation Insurance affidavit ust be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildp* g permit.
Signed Affidavit Attached Yes....... No...... ❑
11. - Home.C)wner 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� 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 homg 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 Officials 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
The Commonwea4h of Massachusetts
In Department of I dustrial Accidents
Office of I i vestigations
1 Congress S reet, Suite 100
t
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit,: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name (Business/Organization/Individual): t (1
Address: f CU ,
City/State/Zip: � Phone #: �- 3
l'
Are u an employer? Check the appropriate box: Type of project(required):
1.LJ I am a employer with ,.30 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. E]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. E] Demolition
working for me in any capacity. employees and have workers'
insurance.$ 9. E] Building addition
comp.[No workers' comp. insurance p•
required.] 5. ❑ We are a corporation and its 10.E] Electrical repairs or additions
3.❑ I 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 ❑ oof repairs
insurance required.] t c. 152, §1(4),and we have no f
employees. ',jNo workers' 13. Other /C i
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: Y
Policy#or Self-ins. Lic. #: /`3(n C0'-C-5 Expiration Date: I
Job Site Address: 3% I (' �� 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 under the pains Mpenalties of erjury that the information provided above 's true and correct.
Si nature: - n n
Date:
Phone#: Soo o - lcl s3
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#•