24A-124 (2) 5 CALVIN TER BP-2018-1238
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24A- 124 CITY OF NORTHAMPTON
Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateaorv: KITCHEN RENO BUILDING PERMIT
Permit BP-2018-1238
Proiect# JS-2018-001755
Est.Cost: $30000.00
Fee $195.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: TIM STOKES 083602
Lot Size(sa. IT): 6621.12 Owner., POLLIN MILLER SIGRID&ROBERT
Zoning—URA(100)/ Applicant. TIM STOKES
AT: 5 CALVIN TER
ApplicantAddress: Phone: Insurance:
20 TURKEY HILL RD (413) 203-3046 ()
WESTHAMPTONMA01027 ISSUED ON:5/23/2018 0.00:00
TO PERFORM THE FOLLOWING WORK REMOVAL & REPLACEMENT OF EXISTING
KITCHEN CABINETS, WEATHERIZE AND INSULATE BREEZEWAY
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:
FeeTvve: Date Paid: Amount:
Building 5/23/20180:00:00 $195.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
RECEIVED G
yM� Department use only
YAY 1 6 6RtyrOf Orth melon Status of Permit
Building Dep rtment Curb Cut/Drivaway pamM
'I� 6 oc BuadNGlNS In feet Sewer/Septic Availability
nnaMVTON.MA of m1 0 WalerNvell Availability
Northampton, MA 01060 TWO Sets of Structural Plans
'� .= phone 413-587-1240 Fax 413587-1272 Plot/Sae Plana
- __ Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE ORQQDEMOLISH
A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address: This section to be completed by office
Cwr¢
5 r^V1r Sjj-j'Mk
_ Map -)y/rhi )L(4—
CLot I 1 Unit
wn�v l"Tn" Zone Overlay District
1660 Elm SL District CO District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 OwOwnsr of Record: �.l
fH> rc/ Robert Po flea (- �' `/ 6 E9ff ✓f
Namt IL—gL�-- Cwrent Mailirg Addre�ds:
��e�rsaf /
G/ oo2
Telephone
S,gnat.ml
/ '
O /
2.2 Authorized AOenh
Na— CurteM Mailing Addres
X1B Cis zz&+
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Oficial Use Only
completed by Imo applicant
1. Building (a)Building Permit Fee
Sinn aU rJ
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) OrJO Check Number 5:37 2
This Section For Official Use Only
Date
Building Permit Num Issued'
Bui,i, mmissionerlimpectorof Buikings Data
S`Tc6K.6SBVILO617S� CAV-A O&AL. COw
EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING AU Information Must Be Completed.Permit Can Be Denied Due To Womplete intoanation
Existing Proposed Required by Zoning
This codmn mb MW io by
Budding Depmrienx
Lot Size
Fronts
Setbacks Frond
Rear
Building tieight
Bldg.Square F« j k'
Open Space Fmtage %
(�I wes miwaWdgS paxcd
aim
4 of Parlun S es
Fill:
(v041ne&LIIC'n000)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW Q YES Q
IF YES: enter Book Page and/or Document At
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtabced O Obtained O . Date Issued:
C. Do any signs exist on the property? YES O NO Q
IF YES,describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO O
IF YES, describe size, type and location:
E. Will the ConsWction 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 O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ I Addition ❑ Replacement Windows I Alteration(s) 971 Flooring ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [171 Decks [p Siding[o] Omer[o]
Brief Des.�nption of Proposed WAJ-kw II.za/ IA
Work: ILiT"CN�I , p�'+ 1771f1R11�fCMnl'S#'� oF' �GGPq'�fn L�.ft�41�_Cf�1T t!v�lloZSN
Alteration of existing bedroom_Yes No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes )_No
Plans Attached Rall -Sheat
On. If New house and or addition to exleting hOU51119, COMPlete the follOWing:
a. Use of building:One Family Two Family Other
b. Number of roams in each family unit: Number of Bathrooms
c. Is there a garage attached?
at Proposed Square footage of du construction. Dimensions
e. Number of stories?
I. Method of heating? Fireplaces or Woodslown; Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 k.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.
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, S l tw(Le l� \ 1\lt.IM �wl•\G� as Owner of the subject
property
hereby authodu I. KIS!
to act on my°�half`n all matters relative to work authorized by this building permit application.
rno ) ii 2o19
Signatureof0irnifir
/ Date
1, lw S�KtrJ as OwneOAuthorized
Agent hereby declare that the statements and information on the foregoing application are ime and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
PrirM1 _ /1 �F�G /16,/IJ
SignsitureldrilivnedAgent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:: Not Applicable ❑S
NameofUcense He
older: �j� —,kg 83647,
Ucense Number
p z/6 ala
q� iratio Date
113 G IS 77-4!t
SignatureV Telephone
9 Reolalered H Nn oyelnenl Contractor, Not Applicable ❑
IgS7Zs
Co Registration Number
6Iq
Address Ezpuatio Dale
—
V \ti(i Telephon
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 pennil.
Signed Affidavit Attached Yes....... No...... ❑
City of Northampton
Massachusetts
l1ENT
OF BUILDING INSaPoEiClTtlIiOnNg S
212 Wn Stat a acipal
Northwi—, vA 01060
U�'
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 preexisting owneroccupied 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:/f the homeowner has contracted with a corporation or LLC,that entity must be registered.
Type of Work:&,(TQM-sit 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 order$1,000.00
Owner obtaining own permit(explain):
owner-occupied
not owneoccupied
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:
'
as5 Ic iiv� �aY.�
1 '1 S`1Z�
e 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
r
�._ Massachusetts �
DEPARTMENT OF BUILDING INSPECTIONS
212 He>n 5[reec •Nwicipa1 B iitl ng
NoxNsmpWn, M 01060
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:
S )LI
(Please print house number and stree ame
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:
rlgNS'7wrly, h
/(C(Company Name and Address)
Sighaturilf4 PerniWApplicant 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
'- 1 Congress Street,Suite 100
Boston,MA 02114-2017
µ„ www.massgov/dia
- Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Aanlicam Information -7+ Please Print Legibly
Nature(Business/GrganiwionAndlvidaul): A1M� )�'��
Address: ZO'k u M
City/State/Zip: Phone 0: 3 001 Z Z.44-
Are you an employer?Cheek the appropriate box: Type of project(required):
A1 I am a employer with employti
ees(full and/orpat- me)• 7. ❑New construction
sole laminator or pamership and have an employees working forme in &. FRemodeling
At
solved, [No workers'comp-aso m ue reyuirW 1
3F I oma lard e,doing all work myself lNn workers'rump.insumnM1
cewelo .I' Demolition
4mwn
.El I am a haeoe,aryl will he hiring warmanm ms conductall work oa my pmpeny. twill IB Building addition
ure Nat au conmacmrs either have workerscompeneatan ner arre ar are sale 1 LQ Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
SC]I am a general contractor and l have hired thesub-connaztors listed on Ne anached sheet IL�ROOf repairs
These sub-contrawas have employees mW have workers'camp.iasura gee I
fi.[_1Weare aempomtmen and its officer,have exemisealNeirright oredemption pa,MGL, 14.E]Other
152,§I(4),and we have nil employees.[No workers comp.memadve required.l
•Any applicant and chwks box A must also fill am Ne seelion below showing their workers compensation polity information.
I Homwwmers who submit this adidwit indicating they an,doing all work and Nen hire outside wnbacmrs must submit a new affidavit anshea ing such.
[Cored ms Nat chunk Nis box must aaeched an additional sheet showing the name of the sub-rontmctors and state whether or not Nose entities have
employers. If the sub wntmcmrs have employes,Ihry must p,ovide their wodps'comp.polity number.
I am an enWloyeT that is providing workers'conrpematian insurance for my employees. Relow is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: _ Expiration Date:_
Job Site Address: City/Sme/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 ofthe DIA for insurance
coverage verlficat'
I do hereby urtde penal0es ofperjury thin the information provided above is true and correct
Siglu Date S/l/+ //�
Phadd#- AL', o5 ZZG- I
Of tial use only. Do not wrae in this area,to becompleted by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/fawn Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
512312018 City of Northampton Mail-5 Calvin Terrace
C.ibi of Kim Carson <kcarson@northamptonma.gov>
8afltmnpitat
5 Calvin Terrace
1 message
Sigrid Miller Pollin <smillerp@gmail.com> Wed, May 23, 2018 at 9:44 AM
To: kcarson@northamptonma.gov, Tim Stokes <stokesbuilders@gmail.com>
Dear Kim,
Please remove Larry Rideout's name as contractor for 5 Calvin Terrace renovation and
replace with Tim Stokes.
Thanks
Sigrid Miller Pollin (Owner) -
RECEIVED
YAY 22 2018
DEPT RW "P oN"0NSPF 60 NS
https'7/mail.googl e.coMmaillce/?ui=2&ik=28605c862]&jsverF Pvd]uxXULs.en.&cbl=gmail_fe_180508.13_p10&view=pt&search=in box&th=1638d3e3dcc3057d!