31A-096 (2) 57 VERNON ST BP-2017-0340
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A-096 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit# BP-2017-0340
Project# JS-2017-000557
Est.Cost: $3000.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: NICHOLAS JONES 066878
Lot Size(sn. ft.): 29620.80 Owner: Pamela Lawrence
zoning: URBn00)/WP(481/ Applicant: NICHOLAS JONES
AT: 57 VERNON ST
Applicant Address: Phone: Insurance:
P O BOX 515 (413) 665-7927
WHATELYMA01093 ISSUED ON:9/13/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALLING NEW 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 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:
FeeTvpe: Date Paid: Amount:
Building 9/13/2016 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
( City of Northampton Status of PermitDepartment use only
Building Department Curb Cut/Driveway Perms
m 212 Main Street Sewer/Septic Availability
�I ', N sy;, Room 100 Water/Well Availability
Ii : cv Northampton, MA 01060 Two sets a Structural Plans
! — - phoria 413-587-1240 Fax 413-587-1272Piottsite Plans
AI y other Specify
x� `
APP TION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
i-
SECTION 1 - INFORMATION
LI?roped,/Addrrerss: f This section to be completed by office
5-7VerneA h Map Lot Unit
Ar,x- 0,04elrei nu a l oho Zone Overlay District
Elm St DWrfct CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
yv‘e I Fl1-0,,k,,,, � }c e 0 ( e CI- J e r nn✓A ca.-I,,, I.A. t ( At---r .., '?{Tu-
Nam (Print) Current Mailing Address:
Telephone
Signre
2.2 Audio - A ant: �"` e0 goy. C/5'`.1 D . W� mo,,, o t 013
Name(Pont) Current Mailing rens:
/t1 �, W 3 — (65- 712-7
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Defiers)to be Official Use Only
completed by permit applicant
1. BuildingOOv (a) Building Permit Fee
.
2. Electrical (b)Estimated Total Cost of
Conshuction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection .
S. Total=(1 +2 +3+4+ 5) Check Number gyp e7
This Section For Official Use Only
::::r:mmirprp
......_
SM / // f�
Building Commissioner/Inspector of Buildings pate.
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Ihis 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 7c
(tot area minus bldg&paved
parking)
N of Parking Spaces
Fill:
(volume&location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW YES 0
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#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW 0 YES 0
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
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 oris it part of a common plan
that will disturb over 1 acre? YEE O NO GD
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
TION 5-DESCRIPTION OF PROPOSED WORK{check all applicable)
New House ❑ Addition ❑ Replacemenf_Wlndows Alteration(s) ® Roofing 9
Or Doors OO
Accessory Bldg. 0 Demolition 0 New Signs too Decks ED Siding fl Other[CI
Brief Description of Proposed ) f} net ft C�rx `�
`� r - A2w d8171. 2x4 }Ieg4 t
Wart s tt�r .6aria, r� v b « ;n one s eI
Atteration of existing bedroom Yes pt No Adding new bedroom Yes a No
Attached Narrative Renovating unfinished basement Yes r No
Plans Attached Roll -Sheet
sa.If New house and or addition to existing housing, complete the foltowina.
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 stones?
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 TYes _No
j. Depth of basement or cellar floor below finished grade
k. WiII 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
'Sat"— c �� �nh/•'(Cr C.(4 ,as Owner of the subject
property rjt {
hereby authorize liChd las
to act on my behalf, in all matters relative to work authorized by this building permit application.
ti/ f 4 (o
Signature of Owner Date
i, /Gttc?(ftJ ; raj ,as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and emirate,to the best of my knowledge
and belief
Signed under h. pars and penalties of perjury.
IC 4 cn t) `/��
Print Name if�7/Ni'+^"i� i��
Signature of•' ertggent nate
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Suoe�rv/lso : �('' Not Applicable ❑
Name of License Nobler: AliLiota5 Cler1R-)
License Number
'e Cott
5 175 (L',wt Plan nal cs - o66278
Address 7 Cy �-j "1 °fry('j Expiration Date)
l 12°17
Signature elephone
IP; 76f- 1177
9.Reoistered Hom,jmorovrent Contractor Not Applicable 0
A4 (101w) D. 3,ns 12I14 ?I
Comoanv Name Registration N tuber
t 75 ck A pick,, AA 511e dot$
Address I Expiration Da e
iti t f Yt et cl3 Telephone tin 6KS 7122
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152,6 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 f 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 108.35.1.
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 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: S-7 'J2rrts- . 54
The debris will be transported by: XII to 4 s trvi
The debris will be received by: \4 ley QitJcy( lir
Building permit number: J
Name of Permit Applicant , 4, >✓)'/
/IA
Date Signature of 'Permit Applicant
The Commonwealth of Massachusetts
_ Department of Industrial Accidents
)t 't Office of Investigations
.: 1_ c
1 Congress Street,Suite 100
+(NW; Boston,MA 02114-2017
°0.a.. ` www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
/Q �� Please Print Legibly
Name(Business/Organization/Individual): q �///6//L (. n I �J p inti
Address: ti-75j C1 ,J eit$irs Ylcl.,
City/State/Zi.: Wet t Ala. o(O1 hone#: `-JI '-/CS- 7927
Are you an employer?Check the : .propriate box: Type of project(required)'.
I.0 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. 0 New construction
2.R I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers' 9. Buildingaddition
[No workers' comp. insurance comp.insurance.: 0
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 11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MOL
12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
13.0 Other
employees. [No workers'
comp.insurance required.]
*Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they am 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. it 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 coils .• pains a ,enalties of perjury that the information provided a• .ve % true and correct.
is , r:: //I Al Date: d
Ph.m #: S Z
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#: