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31A-142 (2) 36 FORBES AVE BP-2019-0061 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A- 142 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categorv:window replaced BUILDING PERMIT Permit# BP-2019-0061 Project# JS-2019-000091 Est. Cost:$6000.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO. Const.Class: Contractor: License: Use Group: RANDALL ROBERTS 042573 Lot Size(sa. R): 6926.04 Owner: CZOPLINSKI MATTHEW Zoning,URB(100L Applicant. RANDALL ROBERTS AT: 36 FORBES AVE ApplicantAddress: Phone: Insurance: 41 HEMENWAY RD (413) 530-2703 O Workers Compensation LEVERETTMA01054 ISSUED ON:711612018 0.00:00 TO PERFORM THE FOLLOWING WORK.'19 REPLACEMENT WINDOWS 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$0 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 7/16/20180:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner o9mOV1'N016wV111tlON /0//V 00C'0S DepaltntdpS> -tt��¢! iF'3 ff'"°� xP - ityofNorthampton sub+ddrFentaE .� ,� r bra, �" 9tOZ Z l lfif wilding Department Coll` 212 Main Street Sew9j$�ppcpyaN¢4pliry ` ^*,� n `< Room 100 alief/WeYtAYaB§8 '�:e`;+scr' ''iv+ N hampton, MA01060 T'xolooil`Oventfit a3AIDO a 1, 587-1240 Fax 413-587-1272 , [ltlJefiS}tgpy �... .,rs APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION bQ� (� 'l.0 1.1 Procerty Adtlress: This section to be completed by office 3� Fbrk�T1,o, Map 31A Lot IL/1) unit 4' Zone Overlay District Elm StDistdct ca District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: II II x1 11S1Cr ,A�b25 m a (PlCuSS44-M--/��/ailirpf��ress 1' Telephone Signature 2.rthorizedA �, ( �DbertS 3 ? ! ✓SSS r(�[`�GG Na a(Pont Current Meiling Address: i -- i Signat Telephone sECIRION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant t. Buildingmoo o a (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 1 4. Mechanical(HVAC) �� 5.Fire Protection 6. Total=11 +2+3+4+ 5) 60 f Check Number This Section For Official Use Only Date Building Permit Number: Issued: i� 1 Si ature: Bulking Com nerMsltenror of Builtlings Date SECTION 5-DESCRIPTION OF PROPOSED WORK/cheek all applicable) New House ❑ Addition ❑ Replacemnt eYyjntlows Alteration(s) O Roofing Or Doors G8- Accessory Bldg. ❑ gamogtlon ❑ New Signs [0) Decks [M Siding[01 Other[OJ Brief Descri tin Pro Work' pii p� eA2 14GvA, s � v� � • Alteration of existing bedroom_Yes pA Adding new bedroom Yes No Attached Narrative ,1 Renovating unfinished basement Yes No Pians Attached Roll -Sheet 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? J, Proposed Square footage of new construction. imen n e. Number of stories? f. Method of heating? Firepla es or Woodsloves Number of each g. Energy Conservation Compliance. Mas eck Energy Compliance form attached? h. Type of consbuotion L 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 gretle 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 PERMR /r I, G I SG G/L 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. Signawreof Owner I I Date Ke",— I� C3I,pS as Owne ih dzed .qgplAereby declare that the statements and information on the foregoing application are We and accurate,to the best of my knowTedge and belief. Signi d unde� �afd pen hies of p bry. Print Name fl 7 z /V Sign eo ner ge Date 'I a t4 P y� L x'Eym ,.vasa', .t' SECTION 8-CONSTRUCTION SERVICES Na Licensed ConsVVetion Su�� � � � � � Not Applicable Name of License Hol tlgr:—flV^ (� `r §'+-k' CS- DZ'ZS 7 License Number ke✓..l 4 , l�YlyT� 8 -z5 - zat8 Address p T Expiration Date Signat Telephone S.Ra ' nratl b ne' s ECotrhacfor. Not Applicable ❑ moo., 1873 Com an Name A p //'' Registration Number �/ �{'erttnlJAuP�tr � eyea�GT� , }� C? �- (5 - Zc�ZO Ad dress a(Qgy Expiration Date Telephone�ll3—_2X 35 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..... ❑ tt—, nemytlon The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A Person svito constructs more than one home In a two-year Period ailing not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion ofthe work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153(Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances.State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning mi,,mlunm to be filled m by Building Department Lot Size Frontage Setbacks Front Side L_. _ R:- L. R:. Rear Building Height Bldg.Square Footage Open Space Footage (lot area minus Wig&paved ,kin ) 4 ofParking Spaces Fill: (volume&Location) - - A. Has a Special Permit Variance/Fin ng ever been ssued for/on the site? NO © NT KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry f Deeds? NO © DONT KNOW O YES O IFYES: enter Book . Page and/or Document# B. Does the site contain a brook, body of water wetlands? NO O DONT KNOW O YES O IF YES, has a permit been or need to be ob ined from the Conservation Commission? Needs to be obtained © Obtai ed Q , Date Issued: C. Do any signs exist on the property? YES O NO O 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 O IF YES, describe size, type and location: E. Will the construction activity disturb(Gearing,grading,excavation,or filing)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. . I i J i1�i01177TI0)IMI + +�Wbn4 uoQru3suo� M�MIi M iN1ii0Y M P�aY � .. AliRi�d Ie iw•WndiO�V>�iN '_ i. uWudP7rg1 u II MLOVW' AWW III 4ug0U ANuutl . 1i1N0¢. Sfi,}JiiOU 3 TtlONW 9ITLB YIQ'WMH - `"� ilii AP6'mldVud Ol. vm sOr" MAL lusm— oNW�EHPN N�YJP�O igYfrWN0.'!L®BACMdN 31pN xoam�+Po�A'4uP�ln+lis"Po+eM9 _ �\ The Commonwealth ofMassaehusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 0211 4-2 01 7 www.mass.gov/dia WNYorkers'Compensation Insurance Affidavit:Builders/Contractors/E]mtricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant I f motion Please Print Leeibly Name (Business/Organicationflndvidua):Randall E Roberts DBA Window Works Address:321 Russell ST City/State/Zip:Hadley, MA 01035 Phone#:413-530-2703 Are you an employer?Check the approprtele boa: Type of project(required): I.O lam a employer with 5 employ.,(fall and/or part-time)• 7, Q New construction 2.❑l am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insarence coquina.] 3.❑I am a homeowner doing all work myself[No workers'wrapinsurance required.]' 9. El Demolition 4.❑1 am a homeowner and will be hiring contmotors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole II.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5 r I am a general contractor and I have hired the sub-contnctom lined on the attached shed. 13.21toofrepairs .. These subcontractors hove employees and have workers'comp.insurance. 6.❑Weave acmlonatax,audits officers have exercised their night of exemption per MGL c. 14.❑Other 152,.§1(4),and we have no employees.[No workers'wont, insurance required.] 'Any applicant that checks box ql most also fill out the section below showing their workns'wmpauamon policy information. a Homeowners who submit this affidavit indicating they are doing all work and than hire outside contrecmrs most submit a new affidavit indicating such. Contractors that check this box most attached an additional sheet showing the name ofthe sub-contractors and state whether or not Nose entities have employees. If the subcontractors have employees,they must provide their workers'eump.policy 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:Wesco Insurance Company Policy#or Self-ins.Lic.#:W WC3231176 Expiration Date:10/192016 Job Site Address: All Locations 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 w$250.00 a day against the violator.A copy of this statement may be forwarded M the Office of Investigations of the DIA for insurance coverage verification. I do hereby cemfy de e m and peealfies of perjury that the information provided above /u7true andcorrect Signature* Date- Phone#: 413 0-2703 Ojficial use only. Do not write in this area,to be completed by city or town officidet City or Town: Permit/License# SII Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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 by MGGL c 111 , S 150A. Address of the work: .3c=' The debris will be transported by: TP—IJ C The debris will be received by: t=/7 C, t r✓ S /�pS Building permit number: Name of Permit Applicant �Cc N O) 4 ` � �0 K1C Yxw� � s Za Date Sign re of Permit Applicant