24D-306 54 HILLSIDE RD BP-2017-1206
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D-306 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2017-1206
Project# JS-2017-002034
Est.Cost: S800.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MICHAEL PHILLIPS 082683
Lot Size(sq. ft.): 15638.04 Owner: BUSCHER ROBERT C& ELIZABETH B MARCH
Zoning: URA(100)/ Applicant: MICHAEL PHILLIPS
AT: 54 HILLSIDE RD
Applicant Address: Phone: Insurance:
POBOX 514 (413) 250-79900
GOSH ENMA01032 ISSUED OM4/25/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR BACK DORMER 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 ft 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 4/25/2017 0:00:00 $40.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Departnent use only ,
•
/
City of Northampton Suras of Permit
_\ Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
100 Water/Well Availability
Northampton, MA 01060 Two Sets ofstuctiatplans _
phone 473-587-1240 Fax 413-587-1272 Plot!$le Plans
Other Specify
i
\APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 641 /a"
1/.�7�/,Property Address: � y/,,/f This section to be completed by office
Ng YR 1# n4 9 ) v�17� Map 4/2 LOverayDi r Unit
0)060
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Ovine!of Record:-
kClber / iS , r"
Name(Pri )._ Current Mailing Address:
A��� .Sade T-lephone
am-
2.2 Authorizedaent
M t��e ( ' :U q C . c( .c. -- x 91-( (so\cc,.OA0I6A-
Name(Print) 1 ' i t 1 Current Mailing Address.
cip1 A(
yii
Signature Telephone �' �� l
SECTION 1-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
/. completed by permit applicant
1. Building (a)Building Permit Fee
1 500 .00
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) Check Number 4470 6/1°
This Section For Official Use Only
Building Permit Number: > > Date
J��777
Signature: � ysad:
car:—��
Building Commiseiorer/Irspectorof Bindings Date
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied We To Incomplete Information
Existing Proposed Required by Zoning
This column to be tilled in b.
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Budd mg Height
Bldg Square Footage
Open Space Footage
}Lot arca minus bldg&paved
parkin I
#of Parking Spaces
Fill:
}volume 3 Location}
A. lies a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O Y6 O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commissiorf?
Needs to be obtained O Obtained 0 Date Issued:
C. Do any signs exist on the property? YES O NO O
F YES. describe size, type and location:
D. Are there any proposed charges to or additions of signs intended for the property? YES O NO O
F 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 C) 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 Alteration(s) ❑ Roofing X
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [Cl Decks [D Siding [C] Other[OJ
Brief Description of Proposed XV r pi t Ths ike n ,---40. "Work'Alteration of existing bedroom Yes k No Adding new bedroom Yes fix,V
No
Attached Narrative Renovating unfinished basement Yes )G No
Plans Attached Roll -Sheet
Ga.N 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 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
I, k, <) G -210-56 fi `'7 ,as Owner of the subject
property
hereby authorize / , tai \ i r -al j, •
to act an my ..r/%y attars .i a '• •rk authorized by ' Is bui ding permit application.
• /// i
S greture r• - ll11AA � pp 1 Date
I, r\(�'tt ON.Pf'C. I` , l¶>e) C : ,as Owner/Authorized
Agent hereby declare that the statemen&and infonnahon the regoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains an nett ury.
'k y,1�Y„\"•'.S ILA
Print Name
yr/�� / � �l/`{� C 'OOP" ` ;01k 1 1 1: 1 t:Pi Lt i IJO
Signature of Owner/Agent Dale
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Constructio'nSrupervis r: Not Applicable
Name of License Holder: '\IyA 1"(.(/ RCVS-
Op�$
1 - l//� (' MA License Number
Address `"r Xi
514 `x'60 ,x1633 Expiration Date t`aQ'3
'YY\,-rS� i 0 Qr�,. L (3 2S0?9�.
Signature Telephone
Not Applicable .
c ea e/4 -(025 enc . 1-2
)LC1
Company Name Registration-Number
0 . I[j (�/ Arn3
Add '
Exp� l
o(� ^ /• n 2.1'Q, .LQ9 ;,, Telephone c O
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 Ves.X ! No !
11. - Home ((Owner Exemption
The current exemption for-homeowners-was extended to include Owner-occupied Dwellings of one(I) or two(2 I families
and to allow such homeowner to engage an individual fix hire who does not possess a license.provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.51.
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 he.a one or two broil}dwelling.attached or detached structures accessxc to such use and/or term
structures.A person who constructs more than one home in a two-year periodshall not be considered a homeowner
Such-homeowneC shall submit to the Building OtfeiaL on a firm acceptable to the Building Official.that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor sour 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 he 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 pertbrm wort kw you under this permit.
The undersigned-homeowner' certifies and assumes responsibility for compliance with the State Building Cade_City of
Northampton Ordinances State and Local Zoning Laws and State of Massachusetts General Laws Amnbted.
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: pp
The debris will be transported by: n k Q t i L
The debris will be received by: Cue (( niL_
�o(c,1f
Building permit number: \ 'I m //
Name of Permit Applicant m.;( &UNC lc-Pk; R s Zitc_
c)(1) tr� 'i'L
`f�
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
e Department of Industrird Accidents
t 1
=_ .I_I Office of Investigations
�� . - 1 Congress Street, .Suite 100
a,, = Boston,MA 02114-2017
"4uz., www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information �('� ( / Please Print Legibly
Name(Business Organization Individual 1: t 1 1 . ,( � ,` t?4 c ,
Address: `� ,0 \ 3Q� �G 5) L( / I
City/State/Zip: , ll tI-S J Phone#: 4 (5 "%S b - 7q'1c,0
Are you an employer?Check the appropriate box:
I ant a eneral contractor and I Type of project(required).
d
L 0 I am a employer - ❑ 6. ❑New construction
employees (full and/or port-thnel.* have hired the sub-contractors
2.❑ I nm a sole proprietor or partner-
listed on the attached sheet. 7. 0 Remodeling
slip and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers'
comp. insurance.: 9 ❑Building addition
[No workers' comp.insuranceP _
required.] 5. We area corporation and its 10.❑Electrical repairs or additions
officers have exercised their
3.0 I am a homeowner doing all work 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MOL 1 ❑Roof repairs
insurance required.] 1 c. 152.§1(4).and we late no
employees. [No workers' 13.0 Other
comp.insurance required.]
*My applicant that checksbox VI must also fill out the section below showing their wakes'canpenselionpolicy 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 check this box must attached an additional sheet showing the name or the sub contractus and state whether or not those entities have
employees. tithe sub-contractors have employees,they must provide then workers.comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy andjob site
information.
Insurance Company Name: ---z--..LQ _S (o of e L '
Policy#or Self-ins. Lie. #: en()‘‘Ci --- 373 9 C)q Expiration Date: • 4 r
Job Site Address: City/State/Zip: C 4j. % ♦ ' A03
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
foe up to$1.5(1011 and/or one-year imprisoanent. as well as civil penalties in the form of a STOP WORK ORDER and a foe
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 under frr�,,�J�`,-,,-ns d ' a,' s of perjury that the information provided qr+e is lryr and correct.
Signature: � 6./� J"��(�4 Date: h4 I/ 3o��
Phone#: til-5 - ia150' / (ct6
Official use only. Do not write in this area,to be completed by cih.or town official