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24D-173 (3)
202 STATE ST BP-2016-1532 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24D- 173 CITY OF NORTHAMPTON Lot: -000 Permit: Building Category: ROOF BUILDING PERMIT Permit BP-2016-1532 Project JS-2016-002604 Est. Cost: $9750.00 Fee: 5100.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: MICHAEL STOSZ Lot Size(su. ft.): Owner: peter whalen Zoning: URC(100)/ Applicant: MICHAEL STOSZ AT: 202 STATE ST Applicant Address: Phone: Insurance: 115 MARKET HILL RD (413)374-4715 AM H E RST MA01002 ISSUED ON:6/24/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:Strip garage roof and install asphalt roofing 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 6/24/2016 0:00:00 $100.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck-Building Commissioner RLI E: ! Department use only - City of Northampton Status of Permit: 'JUNBuilding Department Curb Cut/Driveway Permit VIV 2 - - - I • 212 Main Street Sewer/Septic Availability Room 100 WaterfWell Availability °err r au IN -- H i orthampton, MA 01060 Two Sets of Structural Plans pnone a 3-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify wdd APPLICATION TO CONSTRUCT,ALTER REPAIR,RENOVATE OR DEMOLISH WtIVOITTWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 PropeM Address: G�� This section to be completed by office f^� �� 1y,� /SIC cJI'cj ` Map Lot Unit IV r0o-thpiM, 72"1- M4 0IN,'ll 1 Zone Overlay District V �e� "`--" _ Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT I2.1 Owner of Record: �ry�,y{� lit /� 11.,If^V1KRg lit ( Kt. i 1'! AIal.,Jrli. 4 1 Name(Print)�j� Current Mailing Address:,� ham cim if�GL �� A �rV/J' Telephone 'Jl. J Signal 2.2 Auth ed Agent: � A ,, Aon Ih maQCc� li Liz f �f, m CI Name(P nQ 'rc l I / Current Mailing Address: �d' (L 3 SID 57H 'y9S Signature i e Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building T 71) ' (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) / O Q 5. Fire Protection 6. Total= (1 +2+3+4+5) Check Number / 94-/ This Section For Official Use Only Building Permit Number _Pate Issuetl: .;#, Signature: ' y� 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 % (Lot area minus bldg&paved parking) #of Parking Spaces Fill. (volume&(malon) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW O 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 0 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 0 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 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,ex vation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES © NO IF YES,then a Northampton Storm Water Management Permit nom the DPW is required. SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicable) New House n Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doom 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [q Siding[0] Other[0] Brief Dew/�yppnrygp� of Proposed y s* Work: piput � -ki�, if (4-'414�� 1� ' `—eiQGE� U%l 4kAI'l-51111/*, C/ Alteration of existingbedroom ' es Noddo dingnew bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa.If New house and or addition to existing housing.complete the followina: 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 la-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT r I, AL ea—�• f I .. D ll k, , till. °._ Lges Owner of the subject property f / -, i hereby authorize I'LL' t. ` = '� to act on my behalf, in : ...tters r- authorized by this building permit apdica6•n. i .. _ .t...� — 6 .v Signature of Own, Date I. \ �h �[ ! y1�'7 as Owner/Authorized Agent he t) d lai that e s merits aid information on the foregoing application are true and accurate,tc the best of my knowledge and bell. Signedi(Ager the pains and penalties of perjury. Print Na e NH]IT \ I( \Aa Signed ,- CZ 1� "tet) i, [u Signature of yA crit ate SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor. Not Applicable ❑ NameotLicenceHo or. 111L L 1_ pp:YU (57 License Number 1:11.1. 1t4 I to 4^. i 5 a WZ 01 Expiration Date rrI / ssK ki(gf < Sipn.tu Telephone 9.Registered Home Imoroygnent Contractor Not Applicable 0 (110.1 Company Name Registration Number /� b57/ Cpnpklu�trn ' , eaQei J '6 C i v i S /i� b3 l� Address Th r 7,?{ Ex irati n Date 1r/ddaldo4Q4- ei• It ?,03 L + / Telephone 31123 alio 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 a No ❑ 11. — Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one 0) 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 City of Northampton 212 Math 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: c) ciTh7 The debris will be transported by: ' 1" /'c>3�� The debris will be received by: Z ors kit-1./ Building permit number: Name of Permit Applicant , ',,:7,21r ( 1 -If C‘ij"Ir,-,� " / � ; l '7 ✓ Date Signature of Permit Applicant The Commonwealth of Massachusetts e, Department of Industrial Accidents L' Q,Qlge oss Str est Suite s1 a ] Congress Sheet, Suite I00 � Boston, MA 0211 4-2 01 7 www.mastgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): lar ' ,� 5 \' ', � JA > d s. -�1 Address: IK 1 dp.i..P I �i IL �0 City/State/Zip: 14a- if.a 'CA 681 _ Phone#: ei133 ] tiI< Are you an employer?Check the appropriate box: 1. Type of project(required): CI (full and/or pa _r have hired the sub-contractors 6. ❑New construction listed on the attached sheet. 7. ❑Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have g, ❑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.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.171 Roof repairs insurance required.] 1 c. 152,§I(4),and we have no employees. [No workers' t3.0 Other comp. insurance required.] 'Any applicant that checks box el must also fill our the section below showing their workers'compensation policy infmmation. t Ilomcowrers 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 attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have=players,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:------A (53 t-••F LS Policy#or Self-ins. Lic. #: Expiration Date: (}L h~ l i 1 lob Site Address:�t.(' �— e 5It,,n'- ll) >!t-k P'' SNAP}b^ N11 City/SWe/Zip: 6160 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required wider 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 fie 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 cel jd.I Is ahs d ties of perjury that the information provided is true and correct Signature: JJJIIIIII/l yl l 14h u/XI �3 Date: ,� I @ Phone#: /1)3 Tn 1 1 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#: