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18-031 20 EMILY LN BP-2017-0359 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18-031 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:ROOF BUILDING PERMIT Permit# BP-2017-0359 Project# JS-2017-000598 Est. Cost:$7815.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: MICHAEL FLOQUET 74483 Lot Size(sq.ft.): 14766.84 Owner: BOYNTON ROBERT D JR&NANCY 1 zoning: Applicant: MICHAEL FLOQUET AT: 20 EMILY LN Applicant Address: Phone: Insurance: 16 MEMORIAL DR (413) 374-5314 O AMHERSTMA01002 ISSUED ON:9/19/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE 2 SKYLIGHTS, STRIP OFF 1/2 2ND FLOOR, NW SIDE & KITCHEN ROOF, ICENVATER, REPLACE WITH NEW ROOF 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 ft 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: FeeType: Date Paid: Amount: Building 9/19/2016 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Fite#BP-2017-0359 APPLICANT/CONTACT PERSON MICHAEL FLOQUET ADDRESS/PHONE 16 MEMORIAL DR AMHERST (413)374-5314 Q PROPERTY LOCATION 20 EMILY LN MAP JJ PARCEL 031 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FIL ED OUT Fee Pal. innaranif Building Permit Filled o t Fee Paid Typcof Construction: REPLACE 2 SKYLIGHTS 1/2 2ND FLOOW W SIDE&KITCHEN ROOF, STRIP OF• ICE/WATER,REPLACE WITH NEW ROOF New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 74483 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: t,/n"Cpproved 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 •• 'lion Delay r filileost 7-77/6( Signature of Building 0'idol 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. Department use only City of Northampton Status of Pemmi: Building Department Curb Cut/Driveway Permit �'-- 212 Main Street Sewer/septic Availability 1 -.! m Room 100 Water/Wen Availability Northampton, MA 01060 Two Sets at Structural Plans Zr i U) phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans �/.71 —�`~. Other Specify TION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING _ SECTION 1 -SI INFORMATION 1.7 property Address' This section to be completed by office 4 20 E 44 t L Y Z.-.q-Ili C Map Lot Unit Nott-tr ss Pro ail, MA Zone Overlay District 0 1060 Elm St.Diatrkt CB Dianlct SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT $,7 Owner of Record: 013FI�--t etatFa Zo of Zo ersn icy .Nbtfenomfidfir" N -nq Current Mallin$Address:-. Telephone ignature 22 Authorized Agent: Name(Print) Current Mailing Address: .�_ 40r 1k y/3 -3 J r3• . Signature Telephone ;xecTION 3-ESTIMATED CONSTRUCTION COSTS 7 Item Estimated Cost(Dollars)to De Official Use Only completed by permit applicant 1. Building �I,( __e r (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 f 6. Total=(i +2+3+4+5) �"a 15 Cfieck Number 01 Check t�J This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Co mmissiarertinspector 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❑llvb in by Building Department [AL Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg.Square Footage Open Space Footage `Pr (Lm area minus bldg&paved parking) it of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW ® YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW fg YES /"� SJ 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 0 Obtained () , Date Issued: C. Do any signs exist on the property? YES (,.J NO a 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,excavation, or filling)over 1 acre or is it part of a common plan K"+' that will disturb over 1 acre? YES O NO IF YES,then a Northampton Stone Water Management Permit from the DPW is required. SECTION S-DESCRIPTION OF PROPOSED WORK(check ell applicable) New House [J Addition Wewa AIFFMSfifirrai Roofing Accessory Bldg. ❑ Demolition © New Signs IDj asses -eider Other IQ Description of Proposed '` - tr!7lt r- ; �Yrt Work: AMY/ 'rDLtarp Ktt-pipNe4/�T/ 17 7-7 , Alteration of existing bedroom_,,, Yes S No Adding new bedroom Yes C No Attached Narrative Renovating unfinished basement _ Yes lC No Plans Attached Roll -Sheet Ga.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. t. Septic Tank_ City Sewer Private well City water Supply ,,,,_ SECTION 7s-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 170 0£4$fNiaii _ 3OYN7ad as Owner of the subject Property tr,,,�. hereby authorize •l - PLO " Qe T to ,d erl�ry1behalf,in all matters relative to work authorized by this building permit application. / Signature of Owner al.. )/ r Date Mt C-t'}'r` Et— Put? C. J E r , 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. Mtt.44t L FLPoZJET Print Name 1 V/y/r4 - Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES @,t Licensed Construction Supervisoryl_L't :t �^ Not Applicable /•t ❑ Name of License Holder: lf}'6-1- Lf-o Qt)f 02 Y( $ j License Number 16 Motto R.4 t t p t t se- 4 wFhzu7 1A, 0/aa 2- t (9 I t} Atldres's ,r _�E//", 122 Expiration Date /r►rtFt 3 —3 fit} -5-31 tf- Signature Telephone 9,Registered Nome ImproyemeM Contractor: Not Applicable U N 'ctf4 L PCOQfC7 t t 3 4-9 rCo Deny Name f Registration Number CL /G rear- �,471lry 1 le tapaj#Y6-- 4"I I o( t 8 Address r Expiration Date /4/re7alo/Z4't dsey lTelephone� 33f".Zt7 f 01002- „.. SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MAL.c.152,§25C{S)} 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 O 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-eccunied Dwellings of one(I) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,providati that the owner acts as supervisor.CMR 780. Sixth Edition Section 108.3$.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 he,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 budding 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 1 ncal Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature 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: Z o E s1 r Ly La W Nlo42-4+4, t Pro Nt The debris will be transported by: petW ck( LSS >"2vckA &IC- The debris will be received by: DAA#E LA) rceceT r2uc/u&J'C Building permit number: Name of Permit Applicant /14 cth Z- h-La Qtr 9/YA6P Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents I t Office of Investigations • ,__ 1 Congress Street,Suite 100 "2'i� Boston,MA 02114-2017 •��� www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �, � Please Print Legibly Name (Business/Organization/Individual): M/(.4-ht p t_. IC-CO6? ✓t'. 7 _ Address: IL ML9IIOA/4C 2/&vr City/State/Zip: f4'AItle st M4-. 0(00L Phone#: VVi3-39j S3! Y Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. 10 New construction employees(full and/or part-time).' have hired the sub-contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. e: Remodeling ship and have no employees These sub-contractors have g. l: Demolition workingfor me in anycapacity. employees and have workers' P ry 9. 0 Building addition [No workers' comp. insurance comp. a corporation 5. 0 We are a corporation and its 10.® Electrical repairs or additions 3.0 1 am a homeowner doing all work officers have exercised their I I. Plumbing repairs or additions myself. workers' right of exemption per MGL Y [No comp. 12.g Roof repairs insurance required.]* c. 152, 81(4),and we have no employees. [No workers' 13. Other comp. insurance required] 'Any applicant that checks box d I 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: 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 underthepainsina/ndpenalties of perjury that the information provided abovebois true and correct. Signature: (A/.0 i/ O x/pe Date: //I i/(.6 / Phone#: 7t3 — 3 �"' — 5,3/ 7(/ ' Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License II 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#: