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City of Northampton
Building Department
Plan Review
212 Main Street
Northampton, MA 01060
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.\ The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
it
1 Congress Street,Suite 100
*7ae r- Boston,MA 02114-2017
1.0
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www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print I,e2ibly
Name(13u.sinc-ss/Organization/Individual): pluck A1hf.'( 11-
Address: igi ko.hra.du) RCk.
City/State/Zip: 1..4.4c1 S , 1f\ Phone 4: 64'3) 257 -SO/S
Are you an employer?Check the appropriate box: Type of project t required):
I.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6 EI New construction
employees(full and/or part-time).* have hired the sub-contractors
2I am a sole proprietor or partner-
A listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
workingfor me in any capacity.. employees and have workers'
Pa t 9. ❑ Building addition
[No workers' comp. insurance comp. instuance.
required 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.El 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 12.0 Roof repairs
insurance required.] + c. 152,§1(4),and we have no
employees. [No workers' 13Other o .CK
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers"compensation policy information.
+Hommwners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that cheek this box must attached an additional shay showing the name of the sub-contractors and state whether or not those entities have
employs. If the sib-contractors have a nplowes,they must provide their wnri:es'comp.policy number.
I am an employer that is providing workers'compensation insurance for m)'employees: Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lie. #: 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$1,500.01)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 A for insurance coverage verification.
I do hereby ce ' 11/
the i•' • ,:re s of perjury that the information protid/ed above is true and correct.
Signature: -- / Date: 6,/1 3/1 6
Phone#: (til 3) 2s-q- 3-OI3
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License #
issuing Authority Icircle one):
1. Board of Health 2. Building Department 3.City/ own Clerk 4.Electrical Inspector 5.Plumbing Inspector
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: 2)-( Hau,J eY,v,l(c R�
The debris will be transported by: net nib/k i
The debris will be received by: Glcr,c)ak
Building permit number:
Name of Permit Applicant frig
3 ll(
/
Date Signature of Permit Applicant
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
f xisling Proposed Required by Zoning
This column to be filled in by
Building Department
I c t Siic 15,00° Si -(T
Frontage /DO --
Setbacks Front 4/3
Side I.: i g R: 4 I.: I:
Rear 7.5-*
13uilding Ilci�t ht
Bldg. Square Footage c�
Open Space Footage °b
(Lo(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 DONT KNOW 0 YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO a DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O Date Issued:
C. Do any signs exist on the property? YES O N0
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 ( J�}
IF YES, describe size, type and location: X�
E. WII the construction activity disturb(clearing, grading, a ovation. 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.
1
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: L Not Applicable 0
Name of Ucense Holder: /'IArk I b r i C S FA- d 77(p,i S
License Number
sJ'g) kfl.hhJ RCA - LQead /�S l 4\ /O/2.3 //(0
Address t Expiratwn Date
(y,3) 257-so 1s"
Signature Telephone
9.Reoistered Home Improvement Contractor: Not Applicable 0
Company Name Registration Number
Address Expiration Date
Telephone
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 building permit.
Signed Affidavit Attached Yes No 0
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
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House [i Addition ❑ Replacement Windows Atteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg ❑ Demolition ❑ New Signs [Dl Decks [� Siding[DI Other[01
Brief Description of Proposed , ,,, �r`
Work: Cti,, c� /2x/6 �ck a j raw- (.-,( VGi s-<'_
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
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, I�uv, S� kq0n 0 5 , as Owner of the subject
property ,/�
hereby authorize fr1Ar k HI 6. ,0%
to act on y behalf, in all Natters relative to work/authorized by this building permit application.
0-1.^.-----....--- ,A...,---------)
Signature of Owner Date
I, I ' l c,,---k Al '`f , as O Authorized
Agent hereby declare that the stjtements 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.
ink 1bi^,gt1l
Print Name " -
Signature
4
M /L of Owner/Agent Date
zo1l "
t�Cr�
�s.y City of Northampton Status of Permit:
�� �Jo Building Department Curb Cut/Onveway Permit
4 / .cb <fe 212 Main Street Sewer/Septic Availability
yo\ o�. Room 100 Water/Well Availability
�, Northampton; MA 01060 Two Sets of Structural Plans
4sf phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
o
Other Specify
• •PLICATION 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
22 HA�dt(,V1Ile - RGI - Map C"() Lot Unit
Ni).ritA')(jwl pt��'1 , Al A Zone Overlay District
1 Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 1 Owner of Record: ��
Lo�;54- kat", ii.s 2)1 HA 06_0v 1IQ nU -
Name(Print) Current Mailing Address! /yi3) sgli - ] 7 L/9
,t 2 ' �' ,k,______ Telephone l
Signature
2.2 Authorized Agent:
Mar
/- t
/�ar k AI bf i ki q.g, Kcnn Rd . 1,4)5 p"I \
Name(Print) Current Mailing Address:
A4
L, f i (H)3) 251- So's
Signature Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Oniy
completed by permit applicant
1. Building _. c Gy (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) 3.5C° Check Number 7 5 l 6-
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissionerilnspector of Buildings Date
File#BP-2016-1479 lr '
r�le.v4-et)
APPLICANT/CONTACT PERSON MARK ALBRIGHT
ADDRESS/PHONE 481 KENNEDY RD LEEDS (413)259-5015 0 ”L't/
PROPERTY LOCATION 221 HAYDENVILLE RD-Route 9
MAP 06 PARCEL 047 001 ZONE SR(I00)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT ``
Fee Paid l ` ?CIS 7
Gc- Ci& _
Building Permit Filled out
Fee Paid
Typeof Construction:_CONSTRUCT 12X 18 DECK AT REAR OF HOUSE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 079655
3 sets of Plans/Plot Plan
THE FOL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
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
,1. . .•• ,elay
11,
:"..411W- B ild ng ffi al 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.
221 HAYDENVILLE RD-Route 9 BP-2016-1479
GIS i#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:06-047 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Deck BUILDING PERMIT
Permit# BP-2016-1479
Project# JS-2016-002533
Est. Cost: $3500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK ALBRIGHT 079655
Lot Size(sq. ft.): 14984.64 Owner: KANUS LOUISE A
Zoning:SR(100)/ Applicant: MARK ALBRIGHT
AT: 221 HAYDENVILLE RD - Route 9
Applicant Address: Phone: Insurance:
481 KENNEDY RD (413) 259-5015 0
LEEDSMA01053 ISSUED ON:6/16/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 12X18 DECK AT REAR OF HOUSE
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 6/16/2016 0:00:00 $65.00
212 Main Street. Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner