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23C-027
503 RIVERSIDE DR BP-2017-0565 lal$4: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23C-027 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categor+.: ROOF BUILDING PERMIT Permit# BP-2017-0565 Proiectp JS-2017-000913 Est.Cost: $7100.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Grouo: JAMES FLANNERY 103061 Lot Size(so, PT: 9234.72 Owner: SAKREJDA KRYSZTOF Zottins: URBt.I9a Applicant: JAMES FLANNERY AT: 503 RIVERSIDE DR Applicant Address: Phone: Insurance: 56 CHESTNUT PLAIN RD (508) 294-4052 WC WHATELYMA01093 ISSUED ON:10I2412016 0:00:00 TO PERFORM THE FOLLOWING WORK:ST RI P & SHINGLE 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# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplaee/Chinmey: 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 Occuoancy signature: FeeType: Date Paid: Amount: Building 1 0124/20 16 0:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton Mktg of Permit - Building Department CMDCuVDdbewey Fein t 212 Main Street 9reerfSepticAnSati3ity lJ ZO`6Room 100 Wider/WellAveIabf*y orthamptonMA 01060 TwoSOtifSIrInW l Plans e4 3-587-1240 Fax 413-587-1272 Mausa ySpecify yu ATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION I -SITE INFORMATION 6P- tri -- 60 S 1.1 Property Address: This section to be completed by office (^�- Map Lot Unit /j 030eiversi1)1. Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Krny s7tt f ,S.-4_/C. ref'ck 503 PI Ice-CSt c�n Sir- Name(Pin I Curenl t Ad01e! I}b — 5��— (OS SS "�/(,'r .Ot Telephone Signature 1 2.2 Authorized Agent: .TMnF s 7. FLiW41CA/ 2 Loveheiel Si- L"-Ann/ MR- olozb- Name(Print) Current Mailing Address: ;PIpr3—,203- �- "�Soir;214— ion z SignaturIH Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Iter Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1 Building (a)Building Permit Fee , /00, co 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee l 4. Mechanical(HVAC) 5. Fire Protection 1y'`�/1 6. Total=(1 +2+3+4+5) �-, (OO. 00 Cheek Number t „L6 3 / TV This Section For Official Use Only Building Permit Number // Ssmretl: �r/l /][/ Signature:( ``� _;/V7' • �R Building Commasbn&Inspedor of Buildings D 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. Rt _._ i..._. '. Rear Building''eight -" ' Bldg.Square Footage % - - Open Space Footage , phot area minus bldg&paved parking) #of Parking Spaces - -- Fill: (volume&Location) A. Has a Special Permit/Variance/Findingever been issued for/on the site? NO 0 DONT KNOW a YES o IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES O IF YES: enter BookPage. .. and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW 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 V IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO 05 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading a vation,or filling)over 1 acre or is it pad of a common plan that will disturb over 1 acre? YES O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing SI Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs (D] Decks [I] Siding [D] Other[D] Brief Descr' tion of Pro ose Work faalkeiq .girls h ate( Jhu9'Ias lnst4.11 3Ff ice aa,acr rti a(c .Cove_, Alteration of existing bedroom Yes _No Addingnew bedroom Yes am No Attached t a 17C U / � y Attached Narrative Renovating unfinished basement Yes ✓ No y ' f ' /If I?Lit Plans Attached Roll -Sheet 1ch74-j C�i4f✓c�6 6a.if New house and or addition to existing housing, complete the following: I&{ 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 OR CO// . CONTRACTOR APPLIES FOR BUILDING PERMIT zlo2krzys "�k-/e d , as Owner of the subject property v hereby authorize (MS.S T. FLAUA16-iy to act on my behalf, in :II tatters relat eta ork author' ed by thisbailding permit application. ' �- e, Ti/ I61 /lv Signet re . Owner / Date I, f 1/FngS J- PACau ,as Owner/Aumorized teMe Agent hereby declare that the stants andinformation on the foregoing application are true an accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. T4 iE-5S. 1!muv6,€ Print Name ` n / /0/t/ / G Signa a of nerlAgengen Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: �I,,1 Not Applicable 0 / '7 Name of License Holder: JAMS J 5 , f�J `J JO3 pill 1 License Number / We 6e. ld Sf Etvrtk 1,7Jleq,, /14 Gic,e1 -ilziq- Add _ Expiration Date ¢ �5 413-Lc3-S&-BB Signa re Telephone 9.Registered Home Improvement Contractor Not Applicable ❑ Pea PEEFOR fA E (wwfzuF 41-0 /8364 Company Name Registration Number 1 znvePeid s* li/41f7- Address Expiration Dale Telephone.413-20S-.5t 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 f3 No 0 11. - Home Owner Exemotion The current exemption for"homeowners"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 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: Lt(3I de ,fir The debris will be transported by: J4 q2_s FuNw4/F / The debris will be received by: VAL-LEV Zee ve t.j,tl ft Building permit number: Name of Permit Applicant JOIE S cs. F2_thuee-te/ Date Signature of Permit Applicant The Commonwealth of Macsaclmsens Deportment of Industrial Accidents t Congress Street,Suite 100 Boston, MA 02114-2017 wwtv.mass.gov/dia Waken'Compensafioc Insurance Affidavit BaitdersicoatractorslEhctiicinnslPiumbers. TO BE FILED WITH THE PEItMrn1NG AtvIHORTIY, Avolicaat Information imp t P lvastYrint treihly Name (l3u'neic'Organbationrindividual): aV /e/ tY .a4Ge r9cl6re GLC Address: 1 Layn7h✓ S/ City/State/Zip_ t7 rottattN , ,4711- 01 02.7 phone#:_ 4/3-2_03 -588 Are pm so employer?Check the appropriate box: Type of project(required): am a employer with J.___employees With edam thin-tinier' 7, D New construction 2.01;WI atom proprietor or partnershipaid have no enployees working for the in 8. ❑Remodeling nor a paeity.{No workers romp nlwnr_mee rcgdrod9.h =E l alma boinuumw'doing all work nyveLLlNnwmtyn� nary lmnr,lnuu rat iredi �DClnalidUlll 4.DIMn a ar d 'tib tet + t .t< ten r ll srNa v wigwag Iwin 10 Building addition nere dot all wtmaors Cilber ham Wrkn.- mmpcnbn -tinsurance or ere utile IL Q Electrical repairs Or additions - pnmpdctarswith nn ampiny.a. 12.EI Plumbing repairs or additions S. Inmayuncrul commrm have el ham ployecned the wboonhummxlioted nn lha attached sleet 13.'�/, Roof repairs t Ivorsubwmmehvn have employee and have wndvrP comp.innnemcal 50j We arc a c.,rpmr;nlrm ami it nitioer&have cxucised am co right of cwenp»ton per MGL C. 14.ijQthei'_ 5141.11,awl we have an employees.[No workers comp.insMele manmatl *Any applicant Mut check;bon I mom alto rill oto ate senior bdowMowing their worker.'oono en:nlmm rydicy iaancone. Ilenwnwnms who submit this mmideviI indicating they are doing all wvrk and cam hilt tamida cool curium must aubniI a new affidavit indicating moot, sL'mnrocmnrs that chock dosbo' thug aaeetaed an rldl6nmat sheet Mowing the ounce ofthe,wt''+ntracwrs wW stele whuher or not these entities lists: aegdoyets. It the atb.awtramn lswc sitailtrY,rrg hey awxt lusund lbeir woekns'ming.pulley number_ I am an employer that is providing workers'compensation insurance for cry employees. Below is the policy and job site information. Insurance Company Nance: J coat ff-2eE #79-7/ thein �-f/ 0.7'0/0-P--1\ Policy ti Or Self-ins.Lie.#: £2 TEC +4/0 ilk " 1 / Expiration Dale: lob Site Address: [,„JU, g'r.+S city/stale/zip: {191' 010(02 _._ _._ Attach a copy of(he workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c 132,X25A is a criminal violation punishable by a tine up to$1.50001 and/or one-year imprisonment.as well as civil penalties in the foam ofa STOP WORK ORDER and a fine of up to$250.00 a day against the violator, A copy of this statensent nary be lulwardel to the OIYcc or investigations or the DIA for insariik.e coverage vend leaf ion t do hereby cert 4 under a pains and penalties of perjury that the information provided above is true and correct. .. /(Yk Signya}erre: _,. T.... Date: 1r 111� L0 -.56)e-8- Official use only. Do not write in this area,to be completed try do or town official City or Town; Perrnit/License# Issuing Authotil'y(circle one): I.Board of Health 2.Building Department 3.CitytTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: