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36-002 (2) 1135 BURTS PIT RD BP-2016-1438 GIS ft: COMMONWEALTH OF MASSACHUSETTS Mao:Block: 36-002 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Siding BUILDING PERMIT Permit 0 BP-2016-1438 Project 4 JS-2016-002479 Est.Cost:$15179.00 Fee:$60.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: MAURICE KIROUAC 097695 Lot Size(sct. ft.): 9191.16 Owner: RIVERA DELBUSTO HECTOR Zoning: Applicant: MAURICE KIROUAC AT.• 1135 RI JRTS PIT RD Applicant Address: Phone: Insurance: 45 WOLCOTT ST APT 1L (603) 674-0877 SOLE PROPRIETOR HOLYOKEMA01040 ISSUED ON:6/7/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:SIDING AND NEW BAY WINDOW 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: ittfV Final: Smoke: Final: v, c Q G THIS PERMIT MAY BE REVOKED THE I NORTHAMPTON UPON VIOLATIION OF ANY OF ITS RULES AND RE I I ad-"4"0 /Atm Certificate of Occupancy ft Signature: FeeTvpe: D to Paid: Amount: Building 6/7/2016 0:00:00 $60.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner ilrilir& .- .- RECEIVED Department use only City of Northampton Status of Permit: JUN — 6 Building Department Curb CuUDriveway Permit 212 Main Street Sewer/Septic Availability DEPT.OF BUILDING INSPECTIONS Room 100 Water/Well Availability NOR-14.P.!;PiON,MA01C60 Northampton, MA 01060 Two Sets of Structural Plans phone 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 Property Address: This section to be completed by office //35 BU1t45 TIC jd Map Lot Unit x r/02EN� f fl 0106d- Zone Overlay District 7" Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 11E42 L. Z vE/oi - 1 (&,.t 4 18-5- Ai s d 7% 1Z4'(e Mf) 0/0b2 Namfnt) k. Current Mailing Address: /AA f t /t/it. �f�' ,u7 Telephone gnature q� z,q 2.2 Authorized Agent: �PT i la * , : "1- 01-)761 / 14A, r')/ 0 '16 ame(Print) Current Mailing Address: 237(0a�k �` _ �7 Sig . .e / Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building /2-1- `n 6° (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of — 7 ? p0 Construction from(6) /J , 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection l� 6. Total=(1 +2+3+4+5) Check Number / S'5 This Section For Official Use Only Building Permit Number: I sssuu ed: Signature: Building Commissioner/Inspector of Buildings Date �. • �J 1. SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: / Not Applicable ❑ Name of License Holder: �/Q�(1 C� License Number ',s' LA)e. z4p-. l L. fia►-yovii ( a 719_5 Address Expiration Date Si ature Telephon= G1-� � 7 9.Registered Home Improvement Contractor: Not plicable 0 Company Name Registration Number 4)141* 4-5 14 / `q 3e) Address Expiration Date — Telephone 15 / 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 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 I j Side L: R: L:!___ ! R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg&paved Ping) #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 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O 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 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 O 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 O 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 ❑ .Of-Deers (7] Accessory Bldg. El Demolition ❑ New Signs [0] Decks [D Siding Other ICI] Brief Description of Proposes. Wo s1L. 1 4 _ . S t sem. r: . V. _...` : StvI.JG Alteration of existing bedroom Yes I No Adding new bedroom Yes No / Attached Narrative Renovating unfinished basement Yes V No Plans Attached Roll -Sheet 6a.if New house and or addition to existing housing, complete the following: a. Use of building:One Family V 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 1/ 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, 4,643 1 . A - `Lu-S h ,as Owner of the subject property hereby authorize , (L1? /d.-f- 7 1l�� ,(�rv, ( , Z to a o�ehal in all matters relative to work authorized by this building permit application. ignature of Owner Date o2 I, `/ i gi. z• , 1 It ,a ner/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. itilAtt re.)c_ -_- -KtRi, w„ei-c, --ir-----i- Print Name i%--�. 1'L,71.Zer,{-1 . ./12.//A'( Sign.. re ofawner/ t Date 71. . i' :'1 '1I 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. j Address of the work: The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant / liettPR(2f 1<(iZo V016 )0440-1.1:403te,_94,___ Date Signature of Permit Applicant • . i • • • • ' I. The Commonwealth of Massachusetts M =t-TZ Department of Industrial Accidents PA — = Office of Investigations „ ' _ , 1 Congress Street, Suite 100 =414=it = Boston, MA 02114-2017 wt' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ;VI jA t p ! r _ Address: S AID J�`T City/State/Zip:ar a n(: # • Q Phone#: Are you an employer? heck the appropriate box: Type of project(required): 1.❑ 1 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' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5• 0 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.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 13`�Other,c1 % 7 A..)( comp. insurance required.] yy *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. Iam 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. /40 / ....1--//e > Signature: i9. i Date: fp Phone#:( I / 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#: • . -- - r _ 41 r .� .rri • 1. . lj