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24D-294 (2)
140 CRESCENT ST BP-2017-0572 GIS#: COMMONWEALTH OF MASSACHUSETTS Man:Block:24D-294 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: demolition BUILDING PERMIT Permit# BP-2017-0572 Projects JS-2017-000930 Est.Cost: $2000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROGER CLARK 021310 Lot Size(sq. ft.): 13460.04 Owner: VEATCH ROBERT L&CAROLYN K Zoning: URB(67)/URA(33)/ Applicant: ROGER CLARK AT: 140 CRESCENT ST Applicant Address: Phone: Insurance: P O Box 34 (413) 586-1491 n LEEDSMA01053 ISSUED ON:10/24/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:REMOVE 2 CHIMNEYS & DRYWALL FROM 1ST FLOOR CEILING & WALLS 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 10/24/2016 0:00:00 $65.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use--only , i. '�mn,,..1.v D City of Northampton Ste(tls gfPerrrliS,.�,� _ �? Building Department Garb CutNnveway'Pelmlt 212 Main Street Sewer/$eptiCAvailabIllry r? 4 rill Room 100 orthampton, MA 01060 Two,Sets Cf Suauturst Ptans - pfiotfe 4 3-587-1240 Fax 413-587-1272 PlaVSite'Plana Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.i Property Address: This section to be completed by office I g d ( ecso -t 6t Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: p 1041 akvt O e_ I arK S ' C > Et? 1.4&_,04Ott,,,D 2'2Authoriz t: ;slsphJer f<.\jit CC'M'At80 .G'd Name Print k\ ( ur - rnlc& net- , P, Glt( f' 0. Boa 3 Y Geeees/4/1 A.IOs-? Name(Pant Current Mailing Address: �'C' Y/3 -` 344 -4 ,1a- Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee S5-5- 4. Mechanical(HVAC) 5. Fire Protection f a a 6. Total=(i +2+3+4+ 5) r S re Check Number 0 'yor - - �_ This Section For Official Use Only Building Permit Number: Dale Issued: Signatureer- � AP" U2 /O L Building Commissionerflnspector 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 I .._. . . . II I ( Frontage I_._ I 1 _._. _.__._.I Setbacks Front I 1 1I1 1 l Side Lk IRI I LI _ R 1 I Rear 1 _.I I Building Height _I - 1 Bldg.Square Footage I1 I I /o ! Open Space Footage (Let area ni,n,bldg&Ainea FI FI - _ r _-I 1 I Balking) #of Parking Spaces L ---1 H -1 I Fill: 1I I_.. _. II (volutne&Location) _ _.. A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW 0 YES O IF YES, date issued: I IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW O YES O IF YES: enter Book r Page I and/or Document k B. Does the site contain a brook, body of water or wetlands? NO Q 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 I _.. C. Do any signs exist on the property? YES O NO QJ 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 ef IF YES, describe size, type and location: E. MI 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 © NO el IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House n Addition ❑ Replacement Windows Alteration(s) n Roofingng IjI Or Or Doors El Accessory Bldg. ❑ Demolition [✓r New Signs [D] Decks [0 Siding[D] Other[C Brief Description of Proposed 1 /� /1 - Work: risme ✓e 0ZC-�rmn r y5 i- dry wit �� T(`OM 511--/OEr <-eI!/Y� t(N4115 Alteration of existing bedroom Yes No Adding/ new bedroom Yes No Attached Narrative Renovating unfinished basement Yes _No Plans Attached Roll -Sheet ea.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 I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT 1ptO�R,,C/ONTRACTOR APPLIES FOR BUILDING PERMIT C \iA 1 (fV4.'1 �a , as Owner of the subject proned9-' /� 1 hereby authorize R 0 rr Clark to act on m bevixeha�l)l in all'mat s relative to work authorized by this building it application. gyp" S natuo r• (/ Date `` o 91;11 I, 60 ,ef II CI' larler` , as Owner/Authorized Agent herebtj 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. ie, o9tr )° Ljarlt" Print Name rel-d-• /oh y//6 Signature of 0 ner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: y/�' t1� Not Applicable ❑ :t Name of License Holder: t� O/l1.0 1 , C /atk � 5 —Q ?)3/0 J License Number Pi0, 86x 3y e-eots AA o /os3 VJa3ji ? Address Expiration Date e? / 3— 3e, f—�aia Signatu t, Telephone J L e_ C J o t c &j o CO i+1 C c.s t , net 9. Registered Home Improvement Contractor: Not Applicable El R044e.r- P. Clark 6,c , /faa69 Company N me Registration Number a 3 B , 4i ' 14k s t, 6/9/P) Address ( Expiration D to F/0rencr, MA O/ 66:A. �(Telephone 7/3 (911a 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 No ❑ 11. - Home"Owner Exemption The current exemption for"homeavners"was extended to include Owner-occupied 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,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 lie/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,duringand 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 perfonn work for you under this pennit. 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: '90 C;e-s C'nA- St The debris will be transported by: Armen 5f Tt`vc-J r j The debris will be received by: 110,1197 Trans { (- Building permit number: Name of Permit Applicant Raiff- C C lark Date Signature of Permit Applicant The Commonwealth of Massachusetts � Department oflndustrialAccidents _ . Office of Investigations ' = 1 Congress Street, Suite 100 ,_ r'.!E=umrBoston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ I ain a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.7 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. B 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 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGI. 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.❑ Other -- comp. comp.insurance required.] *Any applicant that checks box#I 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 street 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'coup_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 It 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 dale). 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. !do hereby certify under the pains saand penalties of perjury that the information provided above Ls true and correct Signature: /4JC "/ts ,cavi.., Dale: /dal/ /b Phone#: 7 1 OO = 3 -3 ("y - (pa)4 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): I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: