17A-158 (13) 53 FOX FARMS RD BP-2017-1009
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Map:Block: I7A- 158 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Skylight BUILDING PERMIT
Permit# BP-2017-1009
Project# JS-2017-001742
Est.Cost: $2500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq.ft.): 28793.16 Owner: RONDEAU PATRICK D& KRISTA S
Zoning: URA(I00)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 53 FOX FARMS RD
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:3/8/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL SKYLIGHT IN KITCHEN
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 3/8/2017 0:00:00 S65.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-1009
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 53 FOX FARMS RD
MAP 17A PARCEL 158 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
FNCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tvoeof Construction: INSTALL SKYLIGHT I ten CHEN
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 077279
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received& Recorded at Registry of Deeds Proof Enclosed_
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
D- •.
Sign."f Building b'mit Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission, Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning& Development for more information.
Department use only
2U�1 City of Northampton Status of Permit:
Building Department Curb CUVDdveway Permit
I 212 Main Street Sewer/Septic Availability
` Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plat/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION /7,4_ ICI
1.1 Properly Address,: �J This section to be completed by office
53 Enc lL vn7 dad Map Lot Unit
Potence. Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
le _ _ r 53 roc rr&vr,-, 2A Pi&&ice Ma: or O( 2
Nam - Current Mailing Address:
ci 'Ct) Tele
t 7)7— S39�
phone
Signature
2.2 Authorized Agent;
Pawn S frnur) PO .&oc (dyad? P7ocnce / oro-z_
Nam (Print) Current Mailing Address: (((( �/ q
�� Telephone 11/23— 5g/-
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 2./ 5o 0 (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 �/�q
6. Total=(1 +2+3+4+5) 21 Soy Check Number Zj 00/ 4(G' tc
This Section For Official Use Only
Date
Building Permit Number Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING AU Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Hwlding Department
Lot-Slag
Frontage
Setbacks Front
Side R: L: R:
Rear
Building Height
Bldg.Square Footage
Open Ss nu Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces •
•
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO. 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES Q
IF YES: enter Book Page and/or Document ft
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO Q
IF YES, describe size, type and location:
`•• - - E.... ..�( \ ve 'I rr It inert of a mammon oleo
that will disturb aver t acre? YES Q NO Q
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 ❑ Addition ❑ Replacement Windows Alteration(s)Nr.54 Roofing C
Or Doors 0
Accessory Bldg. 0 Demolition ❑ New Signs (03 Decks CI Siding 3C] Other la
lL,
Brief Descdption of Proposed '
Work: TNSTAI-L- SKY LafariC )1‘1 ktitHe — 2x0 cath& fie s- - PA ti3 ,>„ilifa,
Alteration of existing bedroom Yes 4T4 No Adding new bedroom Yes 'a4 o kACC4t VIA?
Attached Narrative Renovatingunfinished basement Yes No
Plans Attached Roll -Sheet — + $ t ly ?
sa.if New house and or addition to existing housing, complete the following: S au,*
a. Use of building:One Family_ Two Family Other
b. Number of rooms in each family unit Number of Bathrooms
z
c. Is there a garage attached? /
d. Proposed Square footage of new construction, Dimension/
e. Number of stores? /
f. Method of heating? Fireplaces or toodstoves Number of each
g. Energy Conservation Compliance. Massch- Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetlands? . Yes Yes No. Is construction within 100 yr. floodplain Yes`No
i. Depth of basement or cellar floor below finished grad-
k. Will building conform to the Building and Zoningregulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I._____ iC.L q i{.`')U.QQ�(•`_ ,as Owner of the subject
property ,,,�,, _ �i-
hereb . . �ll k _.ar_ is _t / Ir eL��..
to_.s on m •• i elf ' ma =. - to work authorized by is building permit application.
Signature of Owner Date
I. ('' Si _ _ ,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 u er the pains an¢4�.p,e,enr��a ties of perjury.
Teti U/ j 7 f ...
Print Name ibl, 4Sr q
—VgA7
Signature of Own- t Date .�
SECTION 6•CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: f Not Applicable 0
Name of License Noble(: 5'Cc' cC\ Jt`sikirnOLos C -1 )IJ5f
License Number
_7k-1 V r 0.1 Y, l-ka. CA(513 to 1241 z .
Address J, ` Expiration Date
A_ i1 . �—`Icon.
Signet Telephone
9.Registered Nome lm•rovement Contractor: Not Applicable 0
CS _ 105593 -_
Comnafy Name - Registration Number
�. 3oxc /no 6 .a- '7 - 711 ? jz
Address Expiration Date
icwe4`l a Orb✓ri Telephone 581),--1€
_ I
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.._... Cj. 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 10835,1.
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. ,er on who eons rue { t e than ae home in a o-:ear ,triad shall not tett nsid:red a h,meowne
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official that he/she shall be
responsible for an such work performed under the buntline 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: 53 FOX F2rin
The debris will be transported by: / flu cl/91fratin,(/ 1-
The debris vvill be received by: / wfr
Building permit number: •
UU J
Name of Permit Applicant
,/
3/7/7& f
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
_ Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 0211.1
www.mass.gav/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lenibly
Name (Business/Organization/Individual): VQ 41.0, \? Tryic){6,....'men-- ,
Address: 331-10 (2\t .v"�tC,�e 6(kc C-, ..._.
City/State/Zip: Q/env _ l t `& Qtl'
1 lhone II: 5 �� �S22-
Are you an employer?Check the appropriate box: Type of project(required):
1.DI I am a employer with ]S 4. ❑ I am a general contractor and I
6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
flirted on the attached sheet. 7. 0 Remodeling
2.❑ I am a sole proprietor or partner-
ship
artner
ship and have no employees These sub-contractors have g. ❑ Demolition
workingfor me in anycapacity. employees and have workers'
9. ❑ Building addition
[No workers' comp. insurance comp. insurance..
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.01 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 ❑ 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#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.
'Contractors that cheek this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the subcontractors have employees,they must pmvide their workers'comp.policy number.
T am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. (� ,.,
Insurance Company Name_ 1vbe\jt e tKx' ua ' f p.-e G f J
Policy#or Self-ins. Lie.#: l gd.) 0302 1 S Expiration Date:_ a \ 1 118
lob Site Address: �i far' ea _ City/State/Zip: Ki 'e' f 7o 002-
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 'fication.
I do hereby certify the pains aaod penal r perjury that the information provided above is true and correct
� 9 • AA
Signature: t22� p tl /�//i-r' Dater ��i 7
Phone 4: A-J—S L "'��Jc
Official use only. Do not write in this area,to be completed by city or town official
City or'Town: PermitiLicense#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
arc ot3 arg Rcy a a ... ...ams
L c^ CS-077279
•
..
STEVEN A SILVERMAN {# �
268 FOMER ROAD
SOUTHAMPTON MA 01073 x'
_ lf...,_ Expiratcn
Commissioner 06/2112018
ir i
%rF , ,Iiurr-,rru.-ri/ttr r�r j/u.; arflrrilrir,
•triF lI f 1 it a sin c on
f �fi� o. Consumer Affairs < n6 t3rls' F >ul;1t'_
O Park PLIza - Suite 5170
Foston. Massachusetts 0= 116
Home Improvement Contractor Registration
Reg:st etten: 105.543
Type, Private Corccration
Expiration: 71171201: T* at92 1
VALLEY HOME IMPROVEMENT INC.
STEVEN SILVERMAN
P.0. Box 60627
FLORENCE, MA 01062 - . -_.. .. . . . -.
. •..... 1L er n.22
(Office offone A fctIrs R S R idonoa Li.:case ur regiNtration valid for indiNdual use only
HOME IMPROVEMENT CONTRACTOR tcrOi &tic. If loan,/
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