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06-022 (17) 1 r Departrr e t us4 only a„-_mr,o 4City of Northampton Sta ..4 fPe mit--TT' ' 4S 1 f✓.-� '`.- Building Department Curb moray-Permit--' 212 Main Street Sewer/Septic Availability 1 I • t Room 100 Water/Well Availability t , _ , f Northampton, MA 01060 Two Sets of Structural Plans i phone 413-587-1240 Fax 413-587-127 - - ans Other Specify APPLICATION TO CONSTRUCT,ALTER, ' -'Al , ENOVATE OR DEMOLISH A 0 OR k 0 FAMILY DWELLING (./t SECTION 1 -SITE INFORMATION bni nAPrC %` 1.1 Property Address: tl}Is sectio completed by office r 8 L u e r of.e.4 0 Map 0-0 Lot 0 aa)— Unit L.tCJ 5 ftq Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of arrRec ow, b` / I C (' y � C� Name(PIA) Current Mailing Address: Telephone Signature 2.2 Authorized Aaent: " 1 PO Bac- 1r f,,-Stt, �( -hnm� O I���^'.tl rnp}on, - M. Na e(Print) Current Mailing Address: 14.1?)-62.5n "(4010 Sig Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building ii / coo (a)Building Permit Fee 2. Electrical 7 (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 /Se N /: (),2 This Section For Official Use Only J Date Building Permit Number: Issued: Signature: 8011 LH Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 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 Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg.Square Footage % Open Space Footage %o (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Fin ing ever been issued for/on the site? NO 0 DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW f 4 YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO e DONT KNOW © 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 ID NO IF YES, describe size, type and location: ri of E -y (i)4 Yg1U i Hit-v S'EU D. Are there any proposed changes to or additions of signs intended for the property? YES © NO a, IF YES, describe size, type and location: E. Will 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 NI 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 ❑ ReplacementY�(Indows Alteration(s) [J Roofing Or Doors T®� Accessory Bldg. ❑ Demolition 0 New Signs [D] Decks [El Siding[0] Other[0] Brief Description of Proposed / Work: gk,r.�x:a,. I / q J rds / /it/5 Litt (Jew OcO21 Alteration of existing bedroom Yes No Adding new bedroom Yes } No kr 30 Attached Narrative Renovating unfinished basement Yes P No / n f4f__s Plans Attached Roll -Sheet 6a.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 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 APPUES FOR BUILDING PERMIT I, atbOtAasZaH1.'e1 1 , ,as Owner of the subject property hereby authorize .-B f1/416- + SE(W 1 C S on my behalf,in all matters relative to work authorized by this building permit application. '25• 1 • ao9- Sig of Owner Date I, n rdht I Ppb(� ,as Owner/Authorized Agent hereby declare that the statements and informal torYon the bregoing kation are rue nd accurate,to the best of my knowledge and belief. S' • under the pains an. -•-(ties of perjury. ft-10(1&211.1th-t-Vill : • �• / • da re• Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Suoervisor: Not Applicable 0 Name of License Holder: 50611X etti4CE ( S 1 69 c 26 License Number 4/7 ( ATC3 C-04.1) Ne It) Atel bi S3(Ad .-)16119 Exp on Elate 013))1 Z 1°1 Sig a ure elephone 9.Reoistered Home Improvement Contractor: Not Applicable 0 -1)/ B 1\-) CL-) ( PG-LAW6 sciwicei f 5 51- Comoanv Name Kegistration Number 7 6,fitu_s g,,,,$) Lc./ Deli eitA. 0 3° (51/ II PPK5 Address Expiration Cite Telephone(Y1))71Z- 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 ‘1( No 0 , City of Northampton __ oa%^M-To 5�5 Sir,' 1 ' ', , S,\ Massachusetts .44' --- � 4,...'‘! ‘ DEPARTMENT OF BUILDING INSPECTIONS y j .'W �r� ,' 212 Main Street • Municipal Building Jtir ,c, !I .:* " Northampton, M8 01060 :1'n 3;-3<^ 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 registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered t Type of Work: `,J i,,t JJ`a--% DA4,5 Est.Cost:10 6 O 0 Address of Work: le) C".U5RA c1 ctJf t f1c . Date of Permit Application: a 1 II+ 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 142A.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: I hereby apply for a building permit as the agent of the owner: (I 19 131 R kiEw eloanti D SetvicC5 lb; `l Cy Date Contractor Name 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 optH��rPro ti a � , St Massachusetts �4.t *- `''<<; ii i { �+ DEPARTMENT OF BUILDING INSPECTIONS '.. r 212 Main Street •Municipal Building xJti a' +' Northampton, MA 01060 ' r si<P a00' 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 o at: '16 Cvtf ik' Lcw LTJ; / , (Please print house amber and street name) Is to be disposed of at: 10/4_ pr.' t narhe and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: • (71.41 k.k 1-).15r (Company Name and Addsss) 8_Xg"------ Signature of Permit Applicant 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 —= lioi=`/ Office of Investigations 600 Washington Street -_if�-- -r Boston,MA 02111 '''',<�,o,. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):13 7, 0 c v j c JJ LA CP-' J Address: Cr? �r� ©rt\e S (L City/State/Zip: L•tVCJ M 1 .44c.‘, O 13CA Phone#t`(13) i7,� -7 l0 Are you an employer?Check the appropriate box: Type of project(required): 1.IR I am a employer with 3 4. 0 1 am a general contractor and I 6. 0 New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers' comp.insurance. 9. 0 Building addition [No workers' comp.insurance 5. 0 We area corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their 3.❑ 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.]t employees.[No workers' 13 Other (.)l.(/LX''/0006 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 check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. r Insurance Company Name: •k- f 1Ci `f 4 S. (a Policy#or Self-ins.Lic.#: (a SG "r Q - 71 l 10 5—/ 3 3 —//Expiration Date: 3,////16) Job Site Address: 'lb G Up(99'24 1-44t City/State/Zip: JJ A44, Attach a copy of the workers'codfpensation 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do here /,r tI,'ins an,penalties of perjury that the information provided above is true and correct Si'na •: Agi � Date: Phone#• � -_ _ `C3). .77Z ? � ., r . _ ._ ._ _ u . _ ,. . _ . .� Official use onty. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector " 6.Other , Contact Person: Phone#: 'EMI 1111 .111111.111 u 8 Cal COC J 001 MO ,Z- ® *0` N O a N allNENE it 1111 �_ I!il$n o y0,r OsPf = QFtlit w t.A AOCJ1pPtatA wt&) WCA _ 01 g ON P 00 p Q 00 ‘"11t,� 1. o , 41.�+OtoCo wNJW0�N+1N tri t ew+ tip 41. wWi .;. v .4 0> N IN 1DN: q 1111>4 msN li ,I. rusa` '� W W Crl 01 +1 Os u' t A0 lr. ` J it rN A 00 W __I, ,00 W i, A E W11 N 00 O U\ OC c. r 111 — y 0 n> . '13 cal *0 N-'W t DJ � C 6,' to - tit -+ ^ 1c...) v. -• p 41. F,�w t„ W w 1. 0 01 Lt� % W v N i -- L, ,, 00 , OJ 00 0o Oo 00 00 ; OD 00 "� tD `+. l0 `*.. 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