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30C-058 (4) 376 FLORENCE RD BP-2016-1397 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: windows replaced BUILDING PERMIT Permit# BP-2016-1397 Project# JS-2016-002409 Est.Cost: $5069.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const, Class: Contractor: License: Use Group: PELLA PRODUCTS, INC 096558 Lot Size(sd. ft.): 61419.60 Owner: KEHNE DEBORAH Zoning: URA(100)/WSP(95)/ Applicant. PELLA PRODUCTS, INC AT. 376 FLORENCE RD Applicant Address: Phone: Insurance: 155 MAIN ST (413) 772-0153 WC GREENFIELDMA01301 ISSUED ON.5/25/2016 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 4 REPLACEMENT WINDOWS 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 Simature: FeeType: Date Paid: Amount: Building 5/25/2016 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner RECE!_VED City of Northampton Status of Permitent use only Building Department Curb Cut/Driveway Permit MAY 5 r',`; d 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability DEPT OF SUILD;NG INSPECT orthampton, MA 01060 Two Sets of Structural Platte NORTHAMPTON,MA 01 &e 13-587-1240 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 S I(P eto rtn(S- Map Lot Unit o t c)V)'2— Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: t0z\por-a.h L ISE hnE, 37 0 Ptom-nLe Rat Name ted _ � Current Mailing Address: � 4 Telephone Signature 2.2 Authorized Agent: Pe U a ProC10 1n��11TnWu� rn55 1�� Mw1 �r�enFiP Ir��M(� vic:COL Name(Print) Current Mailing Address: �1r3- 173 - It5-1 x X17 Si Telephone SECTI N 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 d (b) Estimated Total Cost of Construction from 6 3. Plumbing 11 Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: 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 °o (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding been issued for/on the site? NO O DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Regis of Deeds? NO ® DON'T KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW �S IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO 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 0 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 Wis6ows [Alteration(s) Roofing Or Doors 1Z Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [❑ Siding[❑] Other[p] Brief DeAcription of Proposed Work: < , Alteration of existing bedroom© zges No Adding new bedroom Yes No '1� � ' S `k, Attached Narrative '31 Renovating unfinished basement Yes _�No Plans Attached Roll -Sheet 0_r_ ,, bCdfnaN"' 6a. If New house and or addition to existina 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 1, a b4(-C"l L. ^P'k as Owner of the subject property p herebyauthorize fbt0. `CCC��C•'`� 1n to act on my b half in 1 matters relative to work authorized by this building permit application. - - 5/iZ_ Xt Signature of Owner Date 1 +✓� �� ��� ?f� ' (1( \OM55 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 and penalties of perjury. TxkVo( BrD55 Print N e Signatur of Owner/Agenti Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Tkor Z(D-5`D C J oq( License Number Address Expiration Date 12 Si 9.Registered Home Improvement Contractor: Not Applicable ❑ V106 IH2 -ICI Company Name Registration Number S a0 "86 -� 2gitX Address Expiration Date Telephone 01X 1 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§ F7 Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuanceof the buildin ermit. 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.!U 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 buildinE 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 an Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature The Commonwealth of Massachusetts x -- Department of Industrial Accidents I Congress Street,Suite 100 - Boston,MA 02114-2017 kM www mass.gov/dia Workers'Compensation Insurance Affidavit;Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):Pella Products, Inc. Address: 155 Main Street City/State/Zip: Greenfield, MA. 01301 Phone#:413-772-0153 Are you an employer?Check the appropriate box: Type of project(required): L ✓❑I am a employer with 49 employees(full and/or part-time).* 7. E]New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in g. 2)Remodeling any capacity.[No workers'comp.insurance required.] 3.D I am a homeowner doing all work myself.[No workers'comp.insurance required.]+ 9. ❑Demolition 4.f_1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10[]Building addition ensure that all contractors either have workers'compensation insurance or are sole I Ln Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑✓ 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance,t 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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: Hanover Insurance Group Policy#or Self-ins.Lic.#: WHN-9399766-04 Expiration Date: 01-01-2017 Job Site Address: 31 U Floa-,g L-e . City/State/Zip: F(pr e n Lk Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer un a pains and pe rjury that the information provided t. above is true and correct. Signature: /C Date: 7 bu Phone#: Above 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 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: �)-7b F torencx. ezd F-Iure., c_e_ MO 0►ou,Z I The debris will be transported by: Qin-<<a Q-vdgc -S I nr, The debris will be received by: Pelta ProA(x 5 l(N(- 155 Nl(� 013 C)I Building permit number: Name of Permit Applicant V00, PCpc")c� kc' - k r eyor VsS Date Signature of Permit Applicant