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38B-172 (3)
ap Cr 6l�G l'u//Or11 � Department use only ., City of Northampton Status of Permit: Building Department Curb Cut/Duveway Permit 212 Main Street Sewer/Septic Availability 6 Room 100 Water/Well AvaibNlity Northampton, MA 01060 Two Sets of Structural Plans _ phone 413-587-1240 Fax 413-587-1272 Plott ite Plans -- Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Pro rl Address. This /section to be completed by office N1/5 M,d-'Oh ��e,I Map es Lot I -Jl- Unit /V_I7 NG At'l9m / q 0�� 6U Zone Overlay District lJ Elm St.District Be District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Credit of Record; f-6 p✓r ZS /Y�a drSonLL Name (Print) Current Mating Address' � _ � H13 Z)9 fZv � Telephone 51 ature 2.2 Authorized Aaent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com leted b emit applicant 1. Bull lding .v,� e° (a)Building Permit Fee 2. Electrical L� (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total=(i +2+ 3+4 +5) ZLI 17'7 This Section For Official Use Only Date Building Permit Number: Issued Signatur Building C missioner/Inspector of Buildings Date 61 4 1 t CC A @ ko� C0� EMAI ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [tom Siding[0] Other[a Brief Description of Proposed Work: Reolac cPon]n reals-! , it ` IFfJel . (JiK pr7�"s� Alteration of existing bedroom_Yes '� No Adding in new bedroom Yes I/ No Attached Narrative Renovating unfinished basement Yes Li" No Plans Attached Roll -Sheet sa. 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? it 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? In Type of construction I. Is construction within 100 R.of wetlands? Yes No. Is construction within 100 yr. floodplain_Yes No I. 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, as Owner of the subject property hereby authorize to act on my behalf.. in all matters relative to work authorized by this building permit application. Signature of Owner T Date I, � IS�''/IG !�n as Owner/Authorized Agent hereby eclare that the state ents 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. Print Name Y zy�( Sign of ler/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9. Realstereo Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone 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....... ❑ No._... ❑ City of Northampton { X Massachusetts U 'A.lD212 m&&— Sl OF BBZLDZNG INSPECTIONS'�3:•5 212 Mein Stx'eet Municipal BuiltlingMorthampton, !W 01060 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 emity must be registered Type of Work'_ Est. Cost: Address of Work: Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): Job under$1.000.00 —1/6wner 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: 1 hereby apply for a building permit as the agent of the owner: 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 wner Name and Signature City of Northampton C Massachusetts �� ' �4fl �� DEPA INSNT OF BUILDING INSPECTIONS m 212 Main S[ eet aMu cipal Buil g �T Northampton, t 01060 s.y� .1��"� 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 constructionny work being performed at: 95 !'�4�r5 on / I✓ e. (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: J B� (Company Name and Address) 'gnatu a tVermit 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. 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 br Building Department Lor Size Frontage Setbacks Front SA L R: L: R Rear \ Building Height Bldg,Square Footage %o Open Space Footage (La,nma mumu bide&,"ad arAinel A of Parking Spaces Fill: (volume&IncalioN A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW O \is YES O IF YES, date issued: � IF YES: Was the permit recorded at the Registry of D3 CS? NO Q DONT KNOW O ES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO \Q\ DONT KNOW O YES IF YES, has a permit been or need to be obtained from the ConsetSvation Commission? Needs to be obtained 0 Obtained 0 , D�e Issued: S\ C. Do any signs exist on the property? YES Q NO O `v 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 O IF YES, describe size, type and location: E Will the construction activity disturb(clearing,grading excavation, or filling)over t acre or is it part of a common plan that will disturb over 1 acre? YES © NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. I npiaoc i i a- 25 MADISON AVE BP-2018-1084 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B- 172 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cateeorv:Porch Repair BUILDING PERMIT Permit# BP-2018-1084 Proiect# JS-2018-001952 Est Cost' $2000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor_ Lot Size(so.ft.): 8973.36 Owner. GILLIGAN CHRIS Zonin¢:URB(100)/ Applicant: GILLIGAN CHRIS AT: 25 MADISON AVE ApplicantAddress: Phone: Insurance: 25 MADISON AVE NORTHAMPTONMA01060 ISSUED ON:5/112018 0:00.00 TO PERFORM THE FOLLOWING WORK:PORCH REPAIR 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: FeeType: Date Paid: Amount: Building 5/1/20180:00:00 $65.00 212 Main Street, Phone(413';587-1240,Fax: (413)587-1272 Louis Hasbrouck-Building Commissioner File#BP-2018-1084 APPLICANT/CONTACT PERSON GILLIGAN CHRIS ADDRESSIPHONE 25 MADISON AVE NORTHAMPTON PROPERTY LOCATION 25 MADISON AVE MAP 38B PARCEL 172 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Tyeof Construction PORCH REPAIR New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 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 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 emolition Delay <l7 rre of ildm ffiend Dat 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. i Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning&Development for more information. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service ofanother under any contract ofhhe, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in ajoint enterprise,and including the legal representatives ofa deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152.§25 Coil 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 compliance with the insurance coverage required." Additionally,MOL chapter 152,§25 (7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill oot the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-eontractoils)morels),address(es)and phone numbers)along with their cenifieate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. Ifan LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage, Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law,or ifyou arc required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Too Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the 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 which will be used as a reference number. In addition,an applicant that must submit multiple pcook/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under lob Site Address"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 future permits or licenses- A new affidavit most be filled out each year Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture rx. 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 Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia The Commonwealth of Massachusetts as _'= Department oflndustrialAccidents Ig is I Congress Street, Suite 100 a Boston, MA 02114-2017 www,mass.go ildia 11 orkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibly r � Name (Business/Organization/Individuap: f I Ol 16n N Address: ZS //lv`�g df'Vol AJt City/State/Zip: bh'GO Phone #: Z Are you an employer?Check the appropriate box: Type of project(required): L❑I am a anises ra with employees(full orator pan-timec' 7. E]New construction '_.❑lam asole propnemr orpanncrship end have no employees wmekmg 6rmeio S. [J Remodeling � n achy.[No workers comp.insurance required.] 3 E�I am a It doingall work myself No worlr+s'nom - d 1 ❑Demolition ee [ p.mrurevcc rcgmrc ]� 4_�1 am a homeowner and will be hinng-mall.,.m conduct all work or my properry. I will 10 E] Building addition ensure that all centmcmrs color have workers compensation instance orare sale I I.❑Electrical repairs or additions proprietors will,on employees. 12.n Plumbing repairs or additions 5. lam a general conmeter and I have hired the subcontractors listed on he attached sheer - �Thesesubsonvaaorshaveemployeesandhaveworkns'comp.itsum ae_ 13.E]Roof[epaus fi_❑we as a eoryomnon and its offices have exercised civil inch,of wemution per MGL c. l4.❑Other lop,illy,and we have no employees.[No workercompinwnmc rcquipad] 'Any ap,licar th e checks box#1 must also fill our the section below showing their workers compensation policy lnforprolion. t Homeowners who submit this affidavit indicating they are doing all woes and then hire outside convectors must submit anew affidavit indicative such tCovtmetors Net eM1eck this box must anecM1ed vv additioml sheet ffiowina-tire:ionic ofthe subcontractors and spar whether or not those entities have employees. If the sob-contractors have onployees they must provide the workers'camppolicy number_ I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self--ins.The.#: Expiration Date: Job Site Address: City/Stri e slip: 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. i25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisornnent,as well as civil penalties in the form oft STOP WORK ORDER and a fine of up to 5250.00 a day against the violator.A copy of this statement may be finwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify unndeerr'tthhe airs and a tattles ofpeeury,that the information provided La(b ve s true and correct. Si® t /// � Date: / �s ;� Phone#' "ll� 2�� ow 5 Official use only. Do not write in this area,to be completed by city or town offieiat City or Town: _Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/]own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: