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17C-264 (4) 94 NORTH MAIN ST BP-2016-1337 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C-264 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-2016-1337 Project# JS-2016-002303 Est. Cost: $1734.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THE ENERGY STORE 106024 Lot Size(sa. ft.): 11325.60 Owner: ANDRIKIDIS CHARLOTTE zoning: URB(100) Applicant. THE ENERGY STORE AT. 94 NORTH MAIN ST Applicant Address: Phone: Insurance: 31 OLD ROUTE 7 SUITE 200 (888) 840-6641 WC BROOKFIELDCT06804 ISSUED ON.•5/18/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC & RIM JOIST 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: FeeTvpe: 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-2016-1337 APPLICANT/CONTACT PERSON THE ENERGY STORE ADDRESS/PHONE 31 OLD ROUTE 7 SUITE 200 BROOKFIELD06804 (888)840-6641 PROPERTY LOCATION 94 NORTH MAIN ST MAP 17C PARCEL 264 001 ZONE URB(I 00) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid (45&t) Building Permit Filled out Fee Paid Typeof Construction: INSTALL ATTIC&RIM JOIST INSULATION New Construction Non Structural interior renovations Addition to Existin2 AccessoStructure 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 INFO RMATION PRESENTED: _Je!!_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 lay �e Signature of Building CIfficigi— 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. ECEiVED City of Northampton status Of Permit Department use only Building Department Curb CuUDdveway Permit MAY i 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability, �M NO IN Northampton, MA 01060 Two Sets of Structural Platte ku01 ho 1,6 413-587-1240 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 P�roperty�Afddress: KaAi4, This section to be completed by office GI `� o(4 S�. Map Lot Unit Zone Overlay District� lv(fAce. , Mik CSI o (62 Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: r,6(-1A& Name(Print) Current Mailing Address: I 2— ((s Telephone Signature 2.2 Authorized Anent: C S 'Po box KI ShkField MA 61M Name(Pri t) Current Mailing Address: X175 204- 452S Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit 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) Li . Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date ,, r..,. �� ��*.'� '.r i r 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 Spjeciat Permit/Variance/Finding ever been issued for/on the site? NO t:J DONT KNOW O YES O IF YES, date issued: IF YES: Was t e permit recorded at the Registry of Deeds? NO DONT KNOW © YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 6 DONT KNOW Q YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained © , Date Issued: C. Do any signs exist on the property? YES ® NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO d 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 O 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 I Alterations) Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [0 Siding[p) Other[C3] Brief Description of Proposed 11 (�` Work: Av CLL,a U aU jonl OF 04 c- CLr 111- `S-�- Alteration of existing bedroom Yes / No Adding new bedroom Yes �No/No Attached Narrative Renovating unfinished basement Yes 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° ( set A y t to ki J.S property as Owner of the subject I hereby authorize Y►f is �Gt� to act on my behalf,in all matters relativb to work authorized by this building permit application. (cw 040 /b/1� Signature of Owner ` Date I' as Owner/Authorized Agent hereby declare that the,, sand information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pain and penalties of perjury. Print Name aa Signature of Owner/Agent Date S v SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: V 1C-a+sos10 (t)b 2 y License Number PD �vx IRI , h�ac AA DI257 _ Address Expiration Date Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Fntr Z re n 8 3c12 Company N e ul Registration Number S► OU R-� -7 brook-EeU CT o b .e q 9110118 Address Expiration Ddte Telephone ggg goo- L I 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 buil ' g permit Signed Affidavit Attached Yes....... V 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,fndustrial Accidents ' Office of-Investigations 600 Washington Street Boston,MA 02111 www.mass.govfdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Ififorilsatioll _ Pit-me Priv{_I euibl l3ITie (business/Organization/individual): D �. �., _ Address: Phone#:.._— ; $fid Are you an employer'?Check the appropriate box: � Type of project(required): 1.�Y,.l 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. ❑Now construction 2.❑ I am a sole pioprietor 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. EJBuilding addition [No workers'comp,insurance comp.insurance. required.] 5, ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11 Q Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL insurance required.)t c. 152,§1(4),and we have no 12. Roof repairs employees.(No workers' 13. Other { n comp. insurance required.} J (1 *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infortnatim. I Homdowners who subrnit 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-contractars and state whether or not thost entities have employees. If the subcontractors 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 irtformatian. Insurance Company Name:_ Policy#or Self-ins.Lie.#: y( ��ll�� �q Expiration Date: --lob 7 Joh Si(c..Addre _... _ CitylStatel2ip: ({,�'l 0)0 Attach a copy of the workers'cornpertsation policy declaration page(showing the policy number and expiration date). Failure to secure coveial e as rcyuired ttndet Section 25A of MtA c. l S2 cart lead to the imposition of eritnn of penalties or.- lineup :xfineup to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the formor, gTop iyopy <JRDr-R and a tut; of up to 5250.00 a clay against the violator. Be advised that a col)v of this statement may be forwarded to tete Office of Ir?t�csitn:titons of(lie 1014 for insurance c overage vt.rificat-irm, I do hereby ce '_ der the#&Vs and penalties of perjury that the information provided above is true and correct+ Si*tiattyrt� Date: [6. trot r+'rfte rr; thisarca,to Gc comtrir'excfrt < tt'or 1QtvnofJ,ty or Town: Perntit/License # uing Authority(circle one): Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Otherntact Person: Phone#: 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: 1V. Ma-i-a flowvv�, The debris will be transported by: do Y The debris will be received by: Building permit number: Name of Permit Applicant 5 � b Date Signature of Permit Applicant OWNER AUTHORIZATION FORM rlk JP-A a (owner$ ) cww ofto PmWty located at r�l (Propady Address) (ProPedI► ) hereby authorize---0- zv� (Su an authorized subcontractor for RISE Engineering,to ad on my behalf to obtain a buMM permit and to perform work on my property. Owner's Signature City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS p�, � 212 Main Street • Municipal Building s o Northampton, MA 01060 s �� Property Address: I "1 p Contractor Name: f G r Address: rD City, State: �h e-M e 1 t� 5 12 5 7 Phone: 2� . Property Owner Name: �� �� � i l Address: "I' City, State: `1` �&C--nc&T 1"1 010(0(L (contractor) attest and affirm that the building l intend to insulate does hot have any open air (knob and tube)wiring in the spaces to be insulated and that f have provided the property owner with a copy of this affidavit. Contractor signature Date 5 �