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24A-142 (2) 39 ROE AVE BP-2016-1335 GIs#: COMMO WEALTH OF MASSACHUSETTS Map:Block:24A- 142 ITY 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-2016-1335 Project# JS-2016-002301 Est. Cost: $1696.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THE ENERGY STORE 106024 Lot Size(sq. ft.): 8015.04 Owner: LADD JENNIFER zoning: URA(100)// Applicant: THE ENERGY STORE AT. 39 ROE AVE Applicant Address: Phone: Insurance: 31 OLD ROUTE 7 SUITE 200 (888) 840-6641 WC BROOKFIELDCT06804 ISSUED ON.5/18/201¢0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL ATTIC DORMER 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 5/18/2016 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2016-1335 APPLICANT/CONTACT PERSON THE ENERGY STORE ADDRESS/PHONE 31 OLD ROUTE 7 SUITE 200 BRO�KFIELD06804(888) 840-6641 PROPERTY LOCATION 39 ROE AVE MAP 24A PARCEL 142 001 ZONE URA(100) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATIOIN CHECKLIST ZONING FORM FILLED OUT ENCLOSED REQUIRED DATE Fee Paid SM Mra;5 Building Permit Filled out Fee Paid Tvneof Construction: INSTALL ATTIC DORMER INSULATION New Construction Non Structural interior renovations Addition to Existing Accesso Structure Building Plans Included: Owner/Statement or License 106024 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF MATION PRESENTED: k'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 s, 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. Department use only City of Northampton Status of Permit 1 3 2016 Building Department Curb Cut/Driyaway Permit 212 Main Street Ss%ertSepft Ay OM OF SLRDM NVEMONs Room 100 Water/Well Awliebil 010°° Northampton, MA 01060 TWO Sets of Structural Putts phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Spy dfy APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENQVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office G Map Lot Unit � /�I (,w) Zone Overlay District VU n I MA ` U Elm St District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: - I Cr ennli rir L-GC� -I n v� an - 00 Name(Print) Lae Current Mailing Address: a_ Cl. T_ Telephone r� Signature 1-113 113 2q� -- 5 toG (Q 2.2 Authorized Agent: Name(P' t) J Current Mailing Address: �— I-7S 209- L 5bi:T Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by.2ermit 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=(1 +2+3+4+5) 2 3 Check Number This Section Fo Official Use Only Building Permit Number: bate Issued: Signature: Building Commissioner/Inspector of Buildings Date Y 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/Finding ever been issued for/on the site? NO 0 DON'T KNOW ® YES Q IF YES, date issued:' IF YES: Was the permit recorded at the Registry of Deeds? NO © DON'T KNOW ® YES O IF YES: enter Book Page and/or Document#' B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained O , Date Issued: C. Do any signs exist on the property? YES Q NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES o NO Q 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 ® 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) ElRoofing ❑ Or Doors C[ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding[D] Other(D] Brief De cription of Proposed Work: mei' iC. a�e. S. Alteration of existing bed om Yes No Adding new bedroom Yes No � � wl Attached Narrative Renovatin unfinished basement Yes No Wl Z'f" 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? Firleplaces 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 P RMIT I' as Owner of the subject property hereby authorize f C�os- to act on my behalf,in all matters relative to rk authorized by this building permit application. 9 Signature of Owner Date 1' r as Owner/Authorized Agent hereby declare that th statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed and a pains and penaltiesZZ . .S 9 Print Name Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su ervisor. Not Applicable ElName of License Holder:- 10(0()()—1 License Number mpr Ad s Expiration Date —" Signature Telephone 9 Renistered Home Improvement Contractor: Not Applicable ❑ C( ,- Companv Name RegistrationNumb r 8 Io 1 Address Expiration D to 01 E-T wo Telephon 6� �qV SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affid94it must be completed and submitted with this application.Failure to provide this affidavit will result in the denial of the issuance of the bui ing permit. Signed Affidavit Attached Yes.......N1 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 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 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 Commonwealth of Massachusetts Department of In4lustrialAccidents r c Office of Investigations I Congress Stree4 Suite.100 Boston, MA 102114-2017 www mass gov/dia Workers'Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): )�—:-n 6- Address: ! C1 City/State/Zip: CT N&L 'hone#: 8 L4 0 Are ou 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 8. ❑ Demolition working for me in any capacity. employees and have workers' insuralnce. 9• ❑ Building addition con [No workers' comp. insurance p• 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 1 L 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 � � R17A employees. [No workers' 13. Other �p(�( 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. Y%C, �Insurance Company Name: OLD LQ, AV Policy#or Self-ins. Lic. #: (G N(AVq L 6, Expiration Date: G U Job Site Address: `�_)9 �Oc nVPS City/State/Zip: r4kCWn on Q� 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 IA for insurance coverage verification. I do hereby ce fy u •,s a d penalties o erjury that the information provided above is true and correct Si ature: thepa Date: q Phone#: 11'15 2.0 11— 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#• City of Northampton p 1212 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: Ea T-,Qee- pvel The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant Date Signature of Permit Applicant AThe Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 g� www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: 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 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 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' 9. Building addition [No workers' comp. insurance comp. insurance.t required.] 5. F1 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.❑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 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. lContractors 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: Policy#or Self-ins. Lic. #: Expiration Date: 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 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 and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 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#: -- City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS y. 212 MaiNorthaampton MunicipalBuilding r (� Property Address: j� e/dry Contractor Name: S Address: I City, State: � �r "fLU t 01=7 Phone: Property Owner Name: (i� Address: J� City, State: ( Y U(c� d 1, (contractor) attest and affirm that the building I intend to insulate does not ave any open air (knob and tube)wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavi Contractor signature Date Ilk 1 ' r� i' I OMER AUTHORIZATO1 FORM :�lAwA co+ s OwAer of the FW*Wcubd at i .t� {$1ibC01 *1 an aWhmt d a bcm*attorfor RISE Ekomech toactonnryboWtDobtidnabAft pamd and tDpod=wixk 0n nw pmpaitljf. D