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31A-069 (13) 206 ELM ST BP-2018-1106 GIS;:: COMMONWEALTH OF MASSACHUSETTS Mag.Block:31 A-069 CITY OF NORTHAMPTON Let: .001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Categorv: PlumbinG BUILDING PERMIT Permit BP-2018-1106 Pro 9 JS-2018-001705 Est.Cost: $5800.00 Fee:$100.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: UseGroun: MERITTRICHMOND 25639 Lot Size(so. ft.), 8058.60 Owner. SALLOOM SIMON Zo.mw URB(100y Applicant: MERITT RICHMOND AT: 206 ELM ST Applicant Address: Phone: Insurance: 14 RATTLESNAKE GUTTER RD (413) 548-9288 LEVERETTMA01054 ISSUED ON5/3/2018 0:00:00 TO PERFORM THE FOLLOWING WORK.FRAMING FOR BATHROOM RENO 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 5!3/20180:00:00 $100.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2018-1106 APPLICANT/CONTACT PERSON MERITT RICHMOND ADDRESS/PHONE 14 RATTLESNAKE GUTTER RD LEVERETT (413)548-9288 PROPERTY LOCATION 206 ELM ST MAP 3 I A PARCEL 069 001 ZONE URBT00)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST NCLOS REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Eaulditug Permit Filled out Fee Paid TypeofConstructionFRAMING FOR BATHROONTRENC, New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 25639 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON ApATION PRESENTED: proved 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 De olition Delay r 'e of Bui ding(� i gal Date Note: Issuance of a Z mm;permit does not rplcant'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. 4 . A Version l.7 Commercial Buildin Permit May 15,2000 Department use only APR L 6 _ „ City of Northampton Status of Permit: Building Department curb Cut(Driveway,Permit - cnons 212 Main Street Sewer/Septic AvaiIai DCFB 'Al r fir�,r_`c�.i+✓ ' Room 100 WaterNVell Availability Northampton, MA 01060 Two Sets of Structural Pte` phone 413-587-1240 Fax 413-587-1272 Plot/site Plans Other Specify APPLICATION TO CONSTRUCT,REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Properly Address. This section to be completed by office Map Lot Unit Zone Overlay District -- - - --- -- Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Signature .��- Telephone�/, ,j 2.2 Aut oneeduAt l i t f y 1.[rl k-liri Name(Print) Current Mailing Address o toSignature telephone rI l3-5 fF c9-R Z9 SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bpermit applicant 1. Building (a) Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee JJ[[ 4. Mechanical(HVAC) 5. Fire Protection --..... -- 6. Total=(1 t 2+ 3+4+5) Check Number This Section For Official Use Only Building Permit Number Date Issued Si lure: r 7� missioner/In or of Buildings Date�N /� s Versionl.7 CommerciaBuilding Permit May 15,2000 SECTION4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ,n Demolition Repairs Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofinpg❑ Change of Use❑ Other ❑ Brief Description .Enter brief description here. �eMt7/1 "'--15� fi�fl e/e C/-"Q Of Proposed Work: r�{�/ P�f A eQ'- S'011le '6-i0Mf"9.. �eq.-{Li t1A. l Il 't'i h _... _.._ SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ to ❑ A4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 [] 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1-1 ❑ I-2 [] 1-3 ❑ 3B ❑ M Mercantile ❑ _ 4 ❑ R Residential R-1 ❑ R-2 R-3 ❑ 5A ❑ S Storage ElS-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify: _.. _ _.... ...._. . M Mixed Use ❑ Specify: S Special Use ❑ Specify, _... _. __.. _.. COMPLETE THIS SECTION IF EXISTING BUILDING LIND'_RGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group. _ Proposed Use Group: _. Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA OFFICE USE ONLY BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION Floor Area per Floor(sf) /^ 151 /pa.0. .. .. 2n° 2°° 1yOa 3rd 3 rd 4th Total Area(sf) C� Total Proposed New('.onslrucron (sf) Total Height(ft) Total Height ft 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑ ( f i Verswul.7 Commercial Building Permit May 15,2000 S. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be fined in by Building Department Lot Size 77 .SFwe. Frontage 7-57 �i }__.. .S R..-r•.t' ..... Setbacks FrontT Side L:,21 R: 6 L: t2 R:t-6 l.__.. Rear fg( C) �o Building Height Zt/ ' Zr/ ' Bldg.Square Footage 7 % / Open Space Footage (Loc area minus bldg&paved , parking) 4 o Parking Sprees rvommo&tnearoN A. Has aSpecial Permit/Variance/Finding ever been issued for/on the site? NO Q DON'T KNOW O YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O 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 DONT KNOW ® YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained ® , Date Issued: C. Do any signs exist on the property? YES ® NO 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 0 IF YES, describe size, type and location: E, Will the construction activity disturb(clearing, grading, excavation,or filling)over t acre oris it partof a common plan that will disturb over 1 acre? YES O NO & IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Versionll Com inrcia Building Permit May 15.2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant), ---- --- Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Data Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Not Applicable ❑ Company Name: Responsible In Charge of Construction Address Signature Telephone Versioul.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes © No O SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT //' I �/^+0 1 _S loy---s 2,006 /" J e eLZC Z )4 /�14ja_ , as Owner of the subject property hereby authorize �� � � �� /"C' 1 C//_. -to act on my behalf, in all ers relative to work authorized by this building permit application. �. yAr Signature of Owner Date I, �/ rl v—. J Ga[, (/' _, 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 under the pains and penalties of pemny. Print NamLe Signature of Owner/Agent ` Data SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Constructio Suervi�sor: Not Applicable ❑ Name of License Hold,r. YiT- 'I ICI�h C5-0z563 / License Number i4 2��+IP,n�i Cwt 2C lrc Nr- 01051 �fI6 /z 'zD Address Expiratio Date � 4/3—Sy9—q7.A� nature Telephone SECTION 13-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 fp( No C) PIC �zl ss8 (?CP' 5/zo�La � 1 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 byM GL c /111, S 150A. Address of the work: �L1, S� , //L/,) ,y/,) f A,,p � , /V O/o60 The debris will be transported by: _ The debris will be received by: Building permit number: Name of Permit Applicant I�'IT'rl ILIC (lftll Apl azol Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Aceidents 1 Congress Street,Suite 100 Boston,MA 02116-2017 wrromass.gov/dia UVWorkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organleadon/lndividuap: Address: / 7 ICrIFSI�yG��I(' C7ts>'�•f City/State/Zip: lif 6 . Q I Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.E]I am a®ployer with employee'(thll and/or parttime)` 7. ❑New construction 2,XIamasole proprietor orparmeoup and have no employees working for em,un S.I&Remodeling any rapsaty.[No workms'comp.moreanw mquired.] 3.❑Iaahomeownerdoem gallworkyself[Noworkers'comp.Nsuramemqubed.] 9. Demolition m 4.❑1 am a homeowmm and will be haus contractors to conduct all work on my progeny. 1 will 10❑Building addition we Net all comtracmrs either have workers compensation unmaoce or me sole 11.0 Electrical repairs or additions cv,ur,cA,v itb no employees. 12.tgPlumbing repairs or additions 5 r7 I am a genael coommuncand l bavelmodthe sab-ocatractors hmedon the stacked sheet 13.�ROOf repairs These sub-co ixecors have employe.and have workers insuran comp. ce. 6 r We ore a corporation and As officer,have exercised then dghtof exemption pur MGL c. 14.❑Other 152,41(4).and we have no employees-[No workers'comp insurance required-] 'Any applicant Nat checks box#1 mum also fill out the section below show as them workers'cou sonsame.policy ecreaseon. 'Homeowners who submit this affidavit indicating they me doing all work and Wen more outside connectors must submit a new affidavit indicate,such. tc..ca,ra Nat check this box most attached an additional sheet showing the name of the sub-commuctors and state whether or not those entities have employees. 1[We sub-covvucrors bane unployee,Wey mart pfovidetheh war wn comp.poficy mmbtr. I am an employer that is providing workers'compensation insurance foritny employees. Below is rhe policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DLA for insurance coverage verification. I do hereby cern under the pa' penalties perjury that the information provided above is true and correct $ t Datil�Xl 1 Z-7ZO i@ Phone# 3- 546'97.9A � � Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/Licevse# 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all empl tyers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...emery person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,assn nation,corporation or other legal entity, or any two or more of the foregoing engaged in ajoint enterprise,and irwlucl r;the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,associatiot or other legal entity,employing employees. However the owner of a dwelling house having not more than three aparments and who resides therein,or the occupant of the dwelling house of another who employs persons to do.nairtenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thendo shall not wcause of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of.:ompliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither th,commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public wurk inti)acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the cor tracting authority" Applicants Please fill out the workers'compensation affidavit couple ely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)camels),address(es)and phone numbers)along with their certificates)of insurance. Limited Liability Companies(LLC)or Lim ted -lability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this atfida-it may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also bt sure to sign and date the affidavit, The affidavit should be returned to the city or town that the application for tie p,amn or license is being requested,not the Department of Industrial Accidents. Should you have any questions o garcing the law or if you are required to obtain a workers' compensation policy,please call the Department at the nun her listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed lclybly. The Department has provided a space at the bottom ofthe affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number whici wi I be used as a reference number. In addition,an applicant that must submit multiple permithcense applications it an) given year,need only submit one affidavit indicating current policy information(if necessary)and under`Job Site A ddrrss"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for f rtme1 ermits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license rr permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc)said person Is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonweath of Massachusetts Department of Industrial Accidents 1 Congress S treet, Suite 100 Boston, rVU.02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 61"r-727-7749 Revised 02-23-15 wwtt'.messgov/dia Cabinetmaker-Carpenter 14 Rattlesnake Gutter Rd, Leverett, Massachusetts 01054 AP11) ) 27 W 18 r413i 548-9288 Meritt Richmond YnI CO(r r p j tit 300 go-at a rjice ldR ')o uwe4c re�rre m Fcr r�{ c(*51 rud/cn r(V "W'k ) a rtuPcr allt"e,al, )t r61 a-Fc,rt he4 ch-css,brl (r{(' 'yo a- Jtwlr '�') M,?Ol wyV—' '�ra s +rhproc7f'e'l W-thed 4, cosi n-f- eeJrrfrd j ecnsfroo IM is (te, ;6forOf UACY) n vnp d - o-4ii ccDH cf-Ae prpPa3-� un-k. ans;det # " Mrss.�rrndmenl; suet tQ7. ! otic�cr,s -J I- ate, r_ CIVV GO -6rrn crrrt nO) a4lOhOra7 -- PCs 1-ft ,�Ichrncrd cs-OZ 5639 i4 04k-,n4o 64r V- � , i�s4-