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38A-041 (6) 18 LAUREL ST BP-2017-1428 GIS#: COMMONWEALTH OF MASSACHUSETTS Mam:Block: 38A-041 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ADDITION BUILDING PERMIT Permit# BP-2017-1428 Project# JS-2017-002369 Est. Cost: $130000.00 Fee: $209.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RYAN REGAN-LADD 060508 Lot Size(sq.R): Owner: WEENE BARBARA Zoning: Applicant: RYAN REGAN-LADD AT: 18 LAUREL ST Applicant Address: Phone: Insurance: P O BOX 59 (413) 259-1149 SHUTESBU RYMA01072-0059ISSUED ON:6/21/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:REMOVE EXISTING ONE ROOM(ENCLOSED PORCH) CONSTRUCTING BEDROOM ADDITION 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: I Rough: OI: 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 6/21/2017 0:00:00 $209.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-1428 ttk APPLICANT/CONTACT PERSON RYAN REGAN-LADD ADDRESS/PHONE P O BOX 59 SHUTESBURY (413)259-1149 PROPERTY LOCATION 18 LAUREL ST tvfit MAP 38A PARCEL 041 000 ZONE �y THIS SECTION FOR OFFICIAL USE ONLY: PrI ' PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid DQ Building Permit Filled out ��/ J` J Fee Paid Typeof Construction: REMOVE EXISTING ONE ROOM(ENCLOSED PORCH)CONSTRUCTING BEDROOM ADDITION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owned Statement or License 060508 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: (/Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan b` Major Project: Site Nan AND/OR Special Permit With Site Plan ,ic y�(jSih I ZONING BOARD PERMIT REQUIRED UNDER: § 9 .3 JA 1" C�Rjrtarty 1 L Of l 4 C1-44aoe� d Finding Special Permit Variance* Oil J 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 Waterry�anagement em io laytelix / g 6/ Fig( Si nature of Building Official 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 ,y}+Af City of Northampton Status of Permit: tri a lli �t Building Department Curb Cut/Driveway Permit c 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 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO/ FAMILY// DWELLING SECTION 1 -SITE INFORMATION Y ' w 'Ll oL 1 1/r4 d 5 1.1 Property Address: Thi� I s fsection to be completed by office 46,-)4a1+70- 4.1 �/2 ���� e< - i Si, Map 3877 Lot v Unit /xoi7ryi,a1+70/J•t tit•„ Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2. ner of Record: v /-�C VA- 0- e67e- /7 /aureI Sf Name nt) - Current Mailing Address: -iX' /�/iJ/1 /Lem /Ke6(:Ct --Y/ Telephone �� 7 O $gnature 2.2 Authorized Age7M: Lai l �) �p 1 / ) d-N /'LYj i"1 JaJe /"G.6 .J / (Slut 's bu r7 /`7d. a(0-7 7 Nam ) /r✓ Current Mailing Address: Y /� rBs ' t ,6L tet. I/3 2c-9-7//2 Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only _ completed by permit applicant 1. Building /z5-w 0 (a)Building Permit Fee 2. Electrical (b) Estimated Total Cost of 7 6 Construction from(6) 3. Plumbing 2/13-1) Building Permit Fee 4. Mechanical(HVAC) d ection 2 0 4/ 6. Total=(1 +2+3+4+5) /30006 ' Check Number 3c/-/ 7prQ9 This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date Ihasbrouck @ northamptonma.gov EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING Al!Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to he filled in by Building Department Lot Size /7, l i o SG Frontage Setbacks Front r' ' • if Side L .3: R: / L: JJR: Rear =1-'d I' Building Height L:n CI:_ , r �' Bldg.Square Footage r. i % 11 z-i L. g' Open Space Footage r O t'1 d' '. (Lot area minae bldg&paved /(p34 x '�),J2 /��1 J • 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 © DONT KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW O YES 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 NO 0 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 O IF YES, describe size, type and location: E. Wil 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 g 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 [ET Replacement Windows Alteration(s) Roofing d may/ Or Doors 0 Accessory Bldg. El Demolition 1YJ New Signs [Dl Decks [® Siding Or Other[co Brief Description of Proposed ( Work: - y..: • l a.t. . , r\ - ..., aA. • r. . . Ia is tip. .E- • dcbebi41 D—‘. Alteration of existing bedroom Yes No Adding new bedroom 1/ Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet aa.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 Bathrooms '2- c. Is there a garage attached? /Up d. Proposed Square footage of new construction. Dimensions e. Number of stories? I �Z 1? I. Method of heating? 11.1A/11.4 Air- / 74A.l.Gdh Fireplaces or Woodstoves�-}trt� Number of each 1 g. Energy Conservation Compliance. 1 Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes -bf. No. Is construction within 100 yr. floodplain Yes_ _V No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Y Yes No. I. Septic Tank_ City Sewer 1( Private well City water Supply y SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APP IES FOR BUILDING PERMIT I, 1 G"i'� _ '; _ / , as Owner of the subject proparty ��y-f / [! to add f Drize / ' i'1 �/"1 -L.ze „-1 to my beh/ if in all m hers relatesauthorized by is building permit application. 'Si we of Owner Date I. /-(ua*, / . 4,,,L/t-Lail .asavwar/Ayhorized Agent hereby declare that tile 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.ry Print Na,n(,e�/�p/L1ov ✓ kw� /�/ Signa re Own:Agent Date e SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: 1 Not Applicable 0 Name of License Holder: (1. t;a.,.. Fcja - LIek c , O(o DSO g (t Lt./la/lumber Humber `flog r1/44 e 2d QD6 S t SL.ti-Iesbvr`- t-�4_ otc1Z li-c2z -48- - Addre - J Expiration Date F . z )fns Telephone 9.Realetered Home Improvement Contractor: Not Applicable 0 ray I)v,ea - 1 a /2/ 60b Company Name t 1 Registration Number LILA L,, �u ea Qd6 51 st\A-Ves )0T -r - L s Z�— , Addr) ,j� /' I`/ Expiration Date �•yff r,29/o,.a r/[ Telephone'y/3 2$�//U III 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 S. No 0 City of Northampton a7 .s +r .� Massachusetts g ( A 1, 1 t •, DEPARTMENT OF BUILDING INSPECTIONS e* 212 Main street • Municipal Building Northampton, MA 01060 srr' ane' AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes.Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units_..or to structures which are adjacent to such residence or building"be done by reentered contractors. Note:lithe homeowner has contracted with a/corporation or LLC,that entity must be registered Type of Work: Tona�a- e.,h - .del iI e / / Est.Cost: /30(0 if- Address of Work: /if- 7a rt/ J5-4, rt4a...., ' Date of Permit Application: (. /7 // ¶ I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): _Job under$1,000.00 _Owner obtaining own permit(explain): _Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter I42A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR `MORE INFORMATION. Signed under the penalties of perjury: `. . e �/ co-.- V/j` I hereby apply for a building permit as the agent of the owner: O� sC fieg/i7 ?y.>-.i Wegrafi—tad /z /604 Date • Contractor4J'ame HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton Q� Massachusetts A 4W) ; r DEPARTMENT OF BUILDING INSPECTIONS _ 212 Nein Street •Muna 01060 Building Ms1Y ��✓ Northampton, Debris 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. The debris from construction work being performed at: L tt re / 5�, (Please print house number and street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: n' i ert r u.t.tirat 5 (Company Name and Address) l ,! V.-/-9/ 417/sr nage of Perm! Ap++!cant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. The Commonwealth of Massachusetts --— Department of Industrial Accidents -? I= Office of Investigations '35!1:—= 600 Washington Street v Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information -�) Please Print Legibly Name(Business/OrganizatioMndiividual): !Guar` VcJv‘— Laic! �edAddress: )4/04Q6 City/State/Zip: SLrLsl r r' M i (.407 hone#: ¢ 4 13 Zs-9 - to`k/ Are you an employer?Check the appropriate box: Type of project(required): .❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors Lje.g,I am a sole proprietor or partner- listed on the attached sheet.< 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 94 Demolition working for me in any capacity. workers' comp. insurance. 9.Elguilding addition [No workers'comp. insurance 5. ❑ We area corporation and its required.] officers have exercised their I0.0 Electrical repairs or additions •.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]r employees. [No workers' 13.El Other comp. insurance required.] my applicant that checks box NI must also fill out the section below showing their workers'compensation policy information. :iomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. !ono-actors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. Isurance Company Name: [icy#or Self-ins.Lic.#: Expiration Date: ib Site Address: City/State/Zip: Hach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). inure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the Information provided above it true and correct. ignature: Date: lone#: 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other