12C-068 (5) 31 HAROLD ST BP-2017-0651
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block: 12C-068 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-2017-0651
Project# JS-2017-001062
Est.Cost: $12000.00
Fee:$78.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Grow): DEMYAN VOLKOV 104211
Lot Size(sq. e.): 12196.80 Owner: COX SARA F
Zoning: RI(100)/URA(I00)/WSP(100)/ Applicant: DEMYAN VOLKOV
AT: 31 HAROLD ST
Applicant Address: Phone: Insurance:
7 RISING CORNER RD WC
SOUTHW ICKMA01077 ISSUED ON:1I/8/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE EXISTING VINYL SIDING AND INSTALL
NEW
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:
FeeTene: Date Paid: Amount:
Building 11/8/2016 0:00:00 $78.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
s.
k - Department use o„n v _
City of Northampton Siafus-of Permit;-t
Building Department Curb Cuf/Driv way PermitNA — 8 ', 212 Main Street Sewer/SeptfcAvailability-
Room 100 WatermellAYailabiRt. '
orn Northampton, MA 01060Twp Sefs of SWctural Plans
`_- - phone 413-587-1240 Fax 413-587-1272 Plat/Site Plans u
Other Speedy
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address'. This section to be completed by office
- 1 nco) d s1 Map Lot Unit
T} 'v� r� ,/nJ /-� Zone Overlay District
l l(YZAnCe 1l 1 4 0! Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of RecIo�rd:
Slimea17 a'ph 3/ 1-1/m430 5-1 r/DRn nee 24
Name(Print) /^ ,, Current Mailing Address
EA
`-"' Telephone
Signature Gen(2.,./ .'
2.2 Authorized Agent: 1,60V
// RR
Name(Prin ''����G/ `
Current Mailing Addre9e/
Signature '/qN'✓//`rU\ Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building �j / \� (a) Building Permit Fee
2. Electrical J�V (b)Estimated Total Cast of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total = (1 +2+3+4+ 5) I?/Ott U Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: // // / #174V
ing Commissioner/Inspector of:uildings Date
Y Y
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 '__—_ L_____— I
r- I
Frontage — - - - ----
Setbacks Front - --;
Side LL- R:L__ L. R,—_..
Rear I L_. _. _ -_-
Building Height "_� I`_i _.—_—
Bldg. Square Footage �I • i
Open Space Footage
(Lot area minus bldg&paved ...._
parking)
#of Parking Spaces - -- ---
Fill:
(volume&Location) k )
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:'._
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW 0 YES 0
IF YES: enter Book Paged—_ I,, and/or Document g
B. Does the site contain a brook, body of water or wetlands? NO O DONT 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: li
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 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
that will disturb over 1 acre? YES O NO O
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 In Addition ❑ Replacement Windows Alterations) II Roofing n
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [CI] Decks [❑ SidingtT Other[21f
Brief Description of Proposed de
Work: ✓�L al DV /f( e'/`/,S)`/ri V (
Crank �' Wn•z�Qor.J Rav- V t(>O it 7. 10SI,eh _ 7 iota)
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 Ba • ooms
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. • etlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or ce :r floor below finished grade
k. Will building confor o 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
I, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
111111111.111.1
, 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.
Print Name
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Superviisor: 1Not Applicable Ill
Name of License Holder': J.� inpn ��n I ),)(6)/7
License Number
Address ke Si r� e COR n e(? RD. So".lAwfc ./c ito 1 &l 2-8
V Expiration Date 4/2 6/10:,
4 /323-7. LL-- -1
Telephone
9.Registered Home Imp/�j/pqvement Contractor: Not Applicable 0
03'74 2,C (on-TR9 4o s sn e 16?499
Company Name /� Registration Number
6RV �e Q SF �. Ri e�y /if
Address • 0/De4, Expiration Date
WCS/COn/rtiicaznKSu7gin/of/e`eJrhTelephone 0? 6 SbciYr
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 0
11. Home Owner Exemption
The current exemption for"homeavners"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 108.3.5.1.
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 be/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 dr 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,Jas defined by MGL c 111 , S 150A.
Address of the work: 3i r14 /I S/ n-{Z nipAn
The debris will be transported by: US/1 142 co /1 --zq
The debris will be received by: I) Sa l4a/0-1
Building permit number:
Name of Permit Applicant ✓ /¢v V�= /1641)2
11/4/j e "
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
NM, Office of Investigations
Gw 1T�
� 1 Congress Street, Suite 100
�� Boston, MA 02114-2 01 7
•• www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A. €leant Information Please Print Le.ibly
Name (Business/Organization/Individual):/ - /77 fe C' Lj _,7L�"
Address: b`� -3e$J�e/D// S) .
City/State/Zip: . /! NtPhone#: 4 /3 ' 6 qs
Are it an employer?Check e appropriate box: Type of project(required):
I. I am a employer with S 4. ❑ I inn a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in anycapacity. employees and have workers'
P tY. i 9. ❑ Building addition
[No workers' comp. insurance comp.insurance.
required.] 5. U We are a corporation and its 10-0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 L Plumbing repairs or additions
myself [No workers' .coinp right of exemption per MGL
12.❑Roofrepairs /1
insurance required.]t c. 152, §7(4),and we have no
employees. [No workers' 13.❑ Other 5/41'/
/
comp.insurance required.)
"Any applicant that checks box 41 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 subcontractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comppolicy number,
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. tin
#:
Insurance Company Name: p ✓/*�C
Policy k or Self-ins. Lic. !'^ A e ��/S3/C / Expiration Date: y/z Z// 7
Job Site Address: 3 ��ntr�/ 1 / /V�a{L A n+,,/n1 City/State/Zip: y 1.i/'
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 arid 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 certift un he in d penalties of perjury that the information provided ahoy is true and correct
Signature: .�' Date: l ahoy
Phone9: fit/7• 2 7 663-7 .
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 r: