31B-013 (4) 5 CRESCENT ST BP-2017-0636
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:31B -013 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit ft BP-2017-0636
Project# JS-2017-001030
Est.Cost: $4000.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
use Group: AARON PUNSKA 105542
Lot Size(sq.ft.): 8668.44 Owner: MARTYN TIMOTHY 0&JANET L
Zoning: URC(1001 Applicant: AARON PUNSKA
AT: 5 CRESCENT ST
Applicant Address: Phone: Insurance:
111 KINGS HIGHWAY (413) 626-6033 0
WESTHAMPTONMA01027 ISSUED ON:11/7/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE 4 WINDOWS & ROTTED TRIM
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: moke: 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 11/7/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
- De artn,e --Ont _
�. City of Northampton S smYP'erm' "`
Building Department Curb Cut/Dnveway Permit
\\ 212 Main Street Sewed- SepticAvallabilRy
l--""C� - Room 100 VyaterABell A ailahility -.
\„0\ / Northampton, MA O1O6O Two Sets of StrugturatPlans
phone 413-587-1240 Fax 413-587-1272 Plot/S-ite Plans
�i Other Specify
c- r
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION I I '� ��
This section to be completed by office
1.1 Property Address
c CY( 5c efrt F- 5-1 • Map Lot Unit
Zone Overlay District
Elm St.District CB District
MSECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
0
2.1 Owner of Record
Mt Tim (� IYh" 5 C+e%tet 8�-. OWWI Li
Name(Print) yer/��� Current Mailing Address
ft I%& - yr 7 Telephone
Signature 'Cmgr7 : y MLW h& t/hs .c Wtin(} , act
2.2 Authorized Agent:
Ayozo Qa bwN UUI kr. ) thy
Name(Print) Current Mailing Atltlre�:
la1C 60?3
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building y0ao Ga (a) Building Permit Fee
2 Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection ,
6. Total= (1 +2+3+4+5) C{NVJ , W Check Number aao fr,
This Section For Official Use Only _
te
Building Permit Number. Issu
Issued:
Signature: � �� �/ 7—'��
(/�/Building om issioner/Inspector 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_ ___ _ __� 1 _
Frontage Li- - - -�
Setbacks Front -- —'
SideR L.I _'I I •
L
R L.. `_.
Rear --.. ___ h I
Building Height ______
—__
Bldg. Square Footage --- r---; %
Open Space Footage % ---
(Lorareaminusbldg&paved � I__ _ -_-_ ..
parking)
._--1 :i___,
I _._.._..
n of Parking Spaces _ `--
Fill: ,
_(volume&Location) I— IL_ — _
A. Has a Spe ial Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW O YES O
I
IF YES, date issued:',
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW O YES O _ _.
IF YES: enter Book Paged '', and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO 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:
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location: L
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO e
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? YES O NO Cy-
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 Wi ws Alteration(s) n Roofing n
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [q Siding [0] Other[O]
Brief Description of Proposed I 1
Work: ✓r9if.LLz M utlobv3 I '/Y.rItAt, h TYr'1'1
Alteration of existing bedroom Yes Adding new bedroom Yes '/No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ga. If New house and or addition to existing housing, complete the foil-owing:
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 CONTRACTOR APPLIES FOR BUILDING PERMIT
tAN1 / a I , as Owner of the subject
property /� V
hereby authorize /r�'}T^` 1010 s.
to act on my behalf, in a rs relati c tfork au ' d by this building permit application.
S.. � /l/u/. ? . Z D ftp
Signature of
/g/ oer Date
111111.
/TtL VO✓t R'AS L ,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.
lTGfon hs/Nt
Print Name
Ai, 7 21fi,
Signature of 0 r/Agent Date
SECTION B-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: tt�r__ Not Applicable El
Vane of License Holder: /QVIN QM6'✓'l c5– ld ST/ a_
License Number
lu kt,r !d 5 � Wes�.(u l s�n /0/L,,17 5
4ddress 1 Expiration Date
6LE -cagy
Signature p Telephone / �
rY;ir rlp✓h5 & '4sttil as7
9.Registered Home Improvement Contractor Not Applicable 0
&✓eN PvY.dt4 Cox Sf�cbr- . l//
Company Name ) Registration Number
pa kikcs fbhy Ve• tri— 7,01..." w.' y F! "t-'
Address //]� Expiration Date ti Re Fier_
Telephone 6 ,03) f-4 $
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 t3-" 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 108.3.5.1.
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-sear 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 tin State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws andState 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: r (vis - s t—
The debris will be transported by: _ Ar, 114% ICA
The debris will be received by: VI,Sy (Zc afry-
Building permit number:
Name of Permit Applicant X v-T . P.�� u b^+
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
^-- Department of Industrial Accidents
'yhc Office of Investigations
1 Congress Street, Suite 100
'e Boston, MA 0211 4-2 01 7
--37.
www.mass.gov/dia
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information dd� Q Please Print Legibly
Name (Business/Organization/Individual): sy,,i evn 6
Address: /0 kgk/5 14-7,-
City/State/Zip: We,tG.., /14, aro Phone#: G 2 6 Z d 3
Are you an employer? Check e appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ 1 am a general contractor and 1
eoyees(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 g, ❑ 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 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.D Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.]
*Any applicant that checks box 41 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.
tContrauors 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.
l 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.
1 do hereby certify under the pains and penalties of perjury that the information provided abovellcorrect
�� is true and
Signature: Date: ,/vd%-' 7,
Phone g: Z6 — 6o 33
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):
L Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: