32C-022-005 29 PLEASANT ST- UNIT I BP-2017-0909
GLS 4: COMMONWEALTH OF MASSACHUSETTS
May:Block: 32C-022 CITY OF NORTHAMPTON
Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:Bath reno BUILDING PERMIT
Permit# BP-2017-0909
Project# JS-2017-001553
Est,Cost: $3600(.00
Fee:5234,00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group_ MARK BONDE 67758
Lot Size(se.ft.): Owner: LONG ANDREW
Zoning:CB(100)1 Applicant: MARK SONDE
AT: 29 PLEASANT ST - UNIT 1
Applicant Address: Phone: Insurance:
205 PARK ST (4131535-9529 (� WC
EASTHAMPTON MA01027 ISSUED ON:2/1/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:BATHROOM REMODEL, REPLACE FIXTURES,
TILE LIGHTING
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 4 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:
FeeType: Date Paid: Amount:
Building 2/1/2017 0:00:00 $234.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Departm em use only
�'` City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
\-\ 212 Main Street Sewer/Septic AvailaLlity
\1` Room 100 Water/Wel Avalabdity
• l t3 Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413.587-1272 PIot/Site Plans
Other Spedry
PPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
ei
SECTION 1 -SITE INFORMATION 3a Qa(d"
This section to be completed by office
11 property Address:
"101 1- \. untr1 Map Lot Unit
ryok�i ANMt TON( H(\ 01060 Zone Overlay District
Elm St DIatdetCB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
21 Owner of Record:
Ac 0,. -+ w :C ♦ e. 1,-,-2C k a'p I ,s-r:
Name(print) — Current Mailing Address'
4 ..•,,,,-...e" ..-e,----- 1* R,5-LILIO$
Telephone
Stature
2.2 Authorized Agent:
, }
Name(Print) �; �, Current Mailing Address:
`PrA r1-A-� l?Y'TR47�o t-k0) 5:3 c-c Iciz1
Signature t Telephone
SECTION 3-ESTIMATED CONSTRUQTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Permit Fee
2. Electrics( (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection o
6. Total=(1 +2+3+4 +5) j(4p/®� Check Number got rip 43V
This Section For Official Use Only
/
Building Permit Number Date
-ued:
Signature: _VPfr __ I _
/I►F / Ir V //
Bui•ung Corn issioner/Inspector 0 Buildings Date
Section 4. ZONING AU Information Must Be Completed.Permit Can Be Dented Due To Ircornpkete Information
_ Required by Zoning
This column to be hued in by
Building Department
®---
MLIMIMIIIIIIIIIIIIIIIIMIIIIIIIIIMII
From
Side 111111.11111
kg
®---
_®_--
Open Space Footage -®--_
(tut area minas bldg R paved
IPBIMMIIIIIIIIIIIIIIIMIIIIIIIIIIIIIIIIIMIIIIIIIIIII
MiNiENIMitimmanimi
iiaieMMN MINIM
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW CY YES 0
IF YES,date issued:
IF YES: Was the permit recorded at the Registry.of Deeds?
NO 0 DONT KNOW 07 YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO ar---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:
C. Do any signs exist on the property? YES O NO C:3--
IF
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 9
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excav • ,or filling)over I acre or is it pan of a common plan
that wd disturb overt acre? YEE 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S-DESCRIPTION OF PROPOSED WORK(check all apolicabie)
New House 0 Addition 0 Replacement Windows Alterations) [J Roofing D
Or Doors ❑
Accessory Bldg. ❑ Demolition 0 New Signs ® Decks [0 Siding®1 Other gip,
Brief Descriptionbf Proposed
--r-
Work: rata—Ft'PM?P-1 ?F MispE L.; ZETtisa ' i',LiveV\ Lrtsl=r 1 ir'±f1-IAili--
Alteration of existing bedroom Yes I----No Adding new bedroom Yes I.---No
Attached Narrative Renovating unfinished basement Yes t„----to
Plans Attached Roll -Sheet
sa.If New house and or addition to existing housino, 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. Massoheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 fl.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
I. W 1--DN ,as Owner of the subject
Property
hereby authorize & 1C -)E
to act on my beh all maters relative o work authorized by this building permit app Cation.
Si nature of Owner Date
I. I")faDk t-tc ,as Owner/Authorized
Agent hereBY declare thaT77the 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 vm Agent Date
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: a6 71.-EA ahLT
The debris will be transported by: -y S)MV7F roNci 2 fnk1
The debris will be received by: Ow c'T Un
Building permit number:
Name of Permit Applicant { h¢k tdT
I -21— /i_L Ste
Date Signature of Permit Applicant
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name al Licence Raider: Ofxrek 1-'cFCW CSO(aT15$
� L� License Number
-
S 1kk GT. CA-S- 1{P -tno I- 2-143
Address5?�1 Expiration Date
- --r,.de �t13 — 2`t— 217b
Signature Telephone
9.Rgpiatn(ed Home Imorovemem Contractor. Not Applicable 0
&)PJVF 6)xJ•h"az`c noIJ Itag
Company Name Registration Number
gdsR/ Sr FAITHANt k) eqA
Address Expiration Date
Telephone Y/3 529—Zl7A
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted vnth this application. Failure to provide this affidavit veil 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"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 108.33.1.
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
The Commonwealth of Massachusetts
P.
Department r
Department of IndustrialAccidents
t� .5 Office of Investigations
E ;= . 1 Congress Street,Suite 100
="'_. 4 Boston,MA 02114-2017
kb„-.- www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (BusinesstOrganization/individual): T rNr?F (h.Jy'ff7t XSi, mj.f
Address: 20 .Rot e.iir
City/State/Zip: t h 3-%AM -Otic i }-41t.# Phone H: 013 6 z' - RI 7 L
Are yokyan employer? Check the appropriate box:
Type of project (required):
1. I am a employer with L 4. ® I am a general contractor and I 6. ®New construction
employees(full andror part-time).* have hired the sub-contractors
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. olremodeling
ship and have no employees These subcontractors have 8. ❑Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp.insurance.t 9. ® Bulding addition
required:) 5. a We are a corporation and its 10.0 Electrical repairs or additions
3.a I am a homeowner doing all work officers have exercised their I In Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]f c. 152, §1(4),and we have no
employees. (No workers' 13.0 Other
comp. insurance required.)
*Any applicant that checks box#1 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.
tContmctots that check this box must attached an additional sheet showing the name of the sub-contractors and state whethet or not those entities have
employees. If the subcontrxxors 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, {yip..EtL Eft
Policy#or Self-ins. Li : der„' `D e) Expiration Date: -4zf2 Lie # . —J,, i`7
Job Site Address: ; .y:. .s v - i . 1x7io o1ionk✓ City/State/Zip: tjbf�7'y)}t�'�CyJ i "-A
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 MOL 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 certify u r ,r the pains and penalties of perjury that the information provided above is true and correct,
iaature: 4 ,�J
> 0-7..0.Q Pate: i-27 17......._
Phone#: i' 2 2-a)
_ _
• Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License It •
Issuing Authority(circle one):
1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other 1
I
Contact Person: Phone#:
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