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38b-222 (6) 31 FAIRVIEW AVE BP-2016-1516 GIS n: _ COMM IC NWEALTH OF MASSACHUSETTS Map:Block:388-222 CITY OF NORTHAMPTON Lon-901 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: KITCHEN RENO _BUILDING PERMIT Permit x BP-2016-1516 Project JS-2016-002582 Est.Cost: $30000.00 tee:$0.00 PER&t1SSIG.'! Is HEREBY GRANTED TO: Cnnst Class' Contractor: License: Use Group Andy Cole Lot Size(sa.ft.): 5532.12 Owner: FOUNDS ti VP .e SANDRA C/O ADELINE HOOPER Zoning:URB(I00)/ Applicant Andy Li.:.a AT: 31 FAIRVIEW AVE Applicant Address: Phone: Insurance: 469 Main Road :413) 325-1333 GILLMA01354 ISSUED ON:6 2011.'16 0:00:00 TO PERFORM THE FOLLOWING WOK. : Kitchen POST THIS CARD SO IT IS VISIBLE FROM T: .i ,STREET Inspector of Plumbing Inspector of Wiring ai'.1C. Building Inspector Underground: Service: ... Foolings: Rough: Rough: i:.... Foundation: na cPbxi: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: moke: Final: THIS PERMIT MAY BE REVOKED BY THE UV! -.' OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy _I (,l.n are: FeeType: Date Paid: Ani,.:_.p Building 6P20/20l 6 0:00:00 tin/fitr. O 212 Main Street,Phone(41. 4S7-1240,Fax:(413)587-1272 Louis Hashrou.S.— aiding Commissioner OK-a Sr- .r Department use only -- - - City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability JUN 2 0 Room 100 WaterNVell Availability Northampton, MA 01060 Two Sets of Structural Plans Y,phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans HOa'1 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 2y /St 'Air (6 .1 �vCM(,JE Map Lot Unit N or.T4 A r-w°70 ti,, yhq CI 06C Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: O.) LiL iNNa iitoCPC2 l 'FA. RU IF_1,,1 <WEN/ Ve Name(Print) V Current Mailing Atltlress'. Telephone it( 3 - S pE -2 l 7,/ Signature 1 '/ 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building . 25 oe o, c.-0 (a)Building Permit Fee 2. Electrical (b) Estimated Total Cost of 11 sco' C Construction from (6) 3. Plumbing a 2, g c^0 Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection ����// Jam�J[[(( 6. Total=(1 +2+3+4+5) 53d eCD Check Number1/77/2 7 / 7 49 q5.- This 5/This Section For Official Use Only Building Permit NumberDate Issued: / Signature: ��i��' - [7 /r /K Building Commissioner/Inspector of Buildings Date Section 4. ZONING AU 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 , o X 5�- 6o 0 2- Frontage Frontage 6 o G o Setbacks Front ZS 2y Side L: Is IL L: I - R: 7.5 Rear y"1- 4 2- Building Height 21 'z'z Bldg.Square Footage I yno % jdi in Open Space Footage (Lot area minus bldg&paved parking) P of Parking Spaces 2 2 Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW ® YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW © YES O IF YES: enter Book Page and/or Document X B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained I Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO 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 IF YES, describe size, type and location: E. WII 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 3. IF YES,then a Northampton Storm Water Management Permit from the DPW is required. The Commonwealth of Massachusetts Ns=.� Department of Industrial Accidents . l _:1- .—• Office of Investigations =.:1- 1 Congress Street,Suite 100 . ill Boston,MA 02114-2 01 7 %I— I www.mass.govldia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Indilviduual): 4,4 t c ./.j7 t/f��/yx Address: /6f r'4 /4 / �^ City/State/Zip: :/ Phone #: 9/? 3 LJ 2 373 Are you an employer? Check the appropriate box: Type of project(required): 1.,21 I am a employer with / 4. ® I am a general contractor and I employees (full and/or part-timg.*. have hired the sub-contractors 6. ®New construction listedon the attached sheet. 7. 511 Remodeling 2.® I am a sole proprietor or partner- ship and have no employees These sub-contractors have S. 0 Demolition working for me in any capacity. employees and have workers' 9. ® Building 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 11.0 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' 13.0 Other • '� cornp.'insurancerequired.] *Any applicant hat checks box e I must also fill out section below showing their workers'compensation policy information. 'I lomeowncrs who submit his 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'comppolicy number. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 2 ere/frj Policy#or Self-ins. Lic. #: p1130 7 p y / 6 Expiration Date: ��/r� -7 -/ / _. lob Site Address: Z 7'l ! Afrin e✓ AUb City/State/Zip: wd%s/^9/O4 rJf 01060 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 u r the pains and penalti sof perjury that the information provided above is true and correct. Signature: Date: h-/o -/4 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 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. 2 et-31 f v R.v 1 @ t„I Ave Address of the work: ��11 The debris will be transported by: &SD't CO Li The debris will be received by: Building permit number: Name of Permit Applicant ADesk w. k"'P`a. Date Signature of Permit Applicant SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) I Roofing ❑ Or Doors 0 _ Accessory Bldg. ❑ Demolition ❑ New Signs Cl] Decks 1(—i Siding m1 Other[Z Brief Description of Proposed Work: REMcV 4-sr t<I ftItN may€ (Nit 21 et{ Or a2 H)ky 4 FnET, Rf Mee!; DEccia,1114 Tel IA Pi.'-Yu;r*N 6w v,� + Lt4INL Alteration of existing bedroom Yes X No Adding new bedroom Yes "C No Lexrq 5 Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet ea. If New house and or addition to existing housing, complete the following: • t a. Use of building : One.Family Two Family Other b. Number of rooms in each family unit: Ca Number of Bathrooms c. Is there a garage attached? N ° .- d. Proposed Square footage of new construction. d Dimensions e. Number of stories? 2. /' f. Method of heating? & 5 Ct5c Fuwa0 OIL ('1d D inept c� O -- Fireplaces or Woodstoves N Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction cv A LY.on) i. Is construction within 100 ft. of wetlands? Yes Na Is construction within 100 yr. floodplain Yes X No is j. Depth of basement or cellar floor below finished gradefits, k. Will building conform to the Building and Zoning regulations? X Yes No . ` I. Septic Tank City Sewer X' Private well City water Supply X SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ADE LIME Mao Pf tz ,as Owner of the subject property nn hereby authorize r1 Ni Ott Coit to act on my behalf, in - atters relative to work authorized by this building permit application. /i ✓ ! i 6 Signature of Owner Date I, ,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. Print Name Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor:��tso /fir^ w Not Applicableicab ❑/ Name of License Holder': AA/y eo/e (5.-v/ ` 61- / License Number Nlvo /2/ G// /flA 0/3S`/ b-z.?-/7 Address Expiration Date y/3 32-C /3- 6 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable 0 „49,0•944 /14.,//r/� /5727 Sy CompanyameRegistration Number Sof m. n/ 9-245-=2-o/6 Address �} Expiration Date 6:// 414 6/3� Telephoney/fl 1-139; - 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_.._.yli 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 1083.5.1. 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 a • .ssumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,Stat-�#! ening Laws and St.-- of Massachusetts General Laws Annotated. _� Homeowner Signature /r--� =+iii•-