35-138 (3) 40 WESTWOODTER BP-2017-0285
GIs#: COMMONWEALTH OF MASSACHUSETTS
Man:Block: 35- 138 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# BP-2017-0285
Project# JS-2017-000480
Est.Cost: $2800.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: EDWARD RICKEY 96159
Lot Size(sa. 0.): 10454.40 Owner: FORRETT DONALD.'&AGNES M
Zoning: Applicant: EDWARD RICKEY
AT: 40 WESTWOOD TER
Applicant Address: Phone: Insurance:
P 0 BOX 62 (413) 695-7059
W ILLIAMSBURGMA01096 ISSUED ON:9/1/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE CORNICE TRIM WITH VYNIL SOFFIT
& ALUMINUM FASCIA
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:
FeeType: Date Paid: Amount:
Building 9/1/2016 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
p It r ity of Northampton Status of Penult
r - ------ -^I wilding Department curb Cuwnveway Perms
I I 212 Main Street Sewer/Septic Availability
- ') 11' I Room 100 watermeil Avaia�hy —.... _—
IL N rthampton, MA 01060 Two Sets of Structural Plans
cr phone 41 587-1240 Fax 413-587-1272 Plot/Site Plans
—._- Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPARL RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
n 1,1 Property Address: -...... This section W be completed by officeW Ye 2di0 eZ at , Map Lot Unit
t I yr 2224 0/0 6 2-
Zone oveday District
vietnata
fi 7" ' EM'St strict Ce O6htC
rtl
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 1
2.1 Owner of Record: ,c
L2nn�� ?i.. 2L ......... t' 7//t ,4 .4 t_ieca. ois a—
Name(Print) ,( .,y.p J,l,.{e" Current Mailing Address:
)C �^'a 1LS' v `�E ' _. Tetephor:e ..
Signature
2.2 Authorized Agent:
G . 2. /G' 0/4172
J.
Name{Print �� Current Mailing Address: u u.-.t�.. I
��.g..✓ 7-'may VAI-696-96--705,
Signature -/ Telephone
SECTION -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
_ completed by permit applicant
1. Building as (a)Building Permit Fee
z 900.
2. Electrical (5)Estimated Total Cost of
Construction from(6),
3. Plumbing Building Permit Fee 6rp'
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) 2,800,or Check Number
L
.. ^. This Section For Official Use Ony . I;j
` 1 J
Building Permit NumberDate :�
��+ Issued:
aille .I//.wig 64, n:(. T 1 i
I
Signature:
Mirvir�� � 4"
/ uni
Building Commissioner/Inspectord
Buildings ,aApicc_
Section 4. ZONING AB 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 Dep,unxn
Lot Size
Frontage
Setbacks Front
Side IL Rr. L: R:
Rear
Building Height
Bldg.SquareFootage °e .....
Open Space Footage 0,a
dot arra minus bldg&paved
#of Parking Spaces
Fill:
technics&imxti,mf _,
A. Has a S ial Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW Q YES 0
IF YES,date issued:
IF YES: Was permit recorded at the Registry of Deeds?
NO DONT KNOW 0 YES Q
IF YES: enter Book Page a /or Document ft
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES Q
IF YES,has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q Date Issued:
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and tocation:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO 0/
If YES, describe size, type and location:
E. Will the cohstructionSzc1ivay disturb(clearing,grading,ex atkan,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
3F YES,Men 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) Q Roofing D
Or Doors O /
Accessory Bldg. D Demolition ❑ New Signs [O] Decks [p Siding(2 Other(O]
Brief Des iof Proposed
Work:Dec,
atiosen, .luso., 7 .IMG«4 err- 4!/taview.a.v Itcccv
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Rol! -Sheet
sa,If New house and or addition t4 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIESA - FOR BUILDING PERMIT
1)Q kter—p ede +T ,as Owner of the subject
property f
hereby authorize. e L/ "Pit
�.....
to act on my behalf all ers relative to wo k thorized by this building permit application.
X G — -t /44 UP
Signature of Owns Date
4, 11; ,as Owner/Authorized
Agent hereby declare that the -.tements 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 p��
.f V/ ..._ LSI_9/6
Signature of`;:.' sent e
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License fielder e 09ti/59
License/Number
lei 9o-vt7 47 x M4 O/o96 >//s/ir
Address C Expiration Cate
W3
Signature
Telephone
p:Reaissttered Home Immbbrov�veement Contractor - Not Applicable ❑
Registration
/Sot`
Company Name n Number
Bosr La i y .��.y 'I17/ti o/op6 Si�yr
Address U ' Ex re' 11Date
Telephone 9/3-67S-Ms9
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I.. 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 buildipg permit.
Signed Affidavit Attached yes....... Ld" No 0
11. -Home Owner Exem r tion
The current ex- • for"homeowners"was extended to include Owner-occupied Dwellings of one(I) or two(2)f: •' -s
and to allow such homeo - r to engage an individual for hire who does not possess a license, ,rovided that the I •r .ets
as su,ervisor.CMR 780 Six dition Section 108.3.5.1.
Definition of Homeowner:Person(s o own a parcel of land on which he/she resides or intends . -side,on which there
is,or is intended to be,a one or two family• elting,attached or detached structures accesso. • such use and/or farm
structures. A ,arson who constructs more than . e home in a two- ear ,eriod shat rt be considered a homeowner.
Such"homeowner"shall submit to the Building Office. , •n a form acceptable to • :uilding Official that he/she shall be
res,onsible for all such work ,erformed under the builds ermit.
As acting Construction Supervisor your presence on the job site v,' • equired 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(Worke - ompensation) an. apter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the •'ssachusetts General Laws Anne : ed,you maybe liable for person(s)
you hire to perform work for you under this pe •. .
The undersigned"homeowner"certifies a • .ssumes responsibility for compliance with the State : 'ding Code,City of
Northampton Ordinances,State and • al Zoning Laws and State of Massachusetts General Laws Ann•.• ed.
Homeowner Signatur
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: yo &Sec,.L dew... .,fir 7121
The debris will be transported by: ""b
The debris will be received by: 7n
Building permit number:
Name of Permit Applicant
23" /6
Date Signature of Permit Applicant
2� The Commonwealth of Massachusetts
Department of Industrial Accidents
,71 '
L —s II,., Office of Investigations
1 { I Congress Street, Suite 100
Boston,MA 02114-2017
y-``� www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information �� Please Print Legibly
Name (Business/Organization. ndividual): lam.!.-�./,./) „+
Address: IS, A,.,14'Z t,//
City/State/Zip: 0/04 Phone #: 5/3 -69g-7O59
Are you an employer? Check the propriate box: Type of project(required):
1.❑ I 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.X 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
workingfor me in anycapacity. employees and have workers'
P ty 9. ❑ Building addition
{No workers' comp. insurance comp. insurance.,
required.] 5. ❑ We arc a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 I.❑Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §I(4),and we have no
employees. [No workers' lig) Other
comp. insurance required.]
*Any applicant that checks box 141 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.
tContractors 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 theirworkers'comp-policy number.
/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 under the pains and penalties of perjury that the information provided above is true and correct.
Sienattut i ✓ , Date: 8/V1
Phone#: 59.1-0* .Ytcy ✓✓✓✓✓✓
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#: