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18C-025 754 BRIDGE RD BP-2019-0224 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: I BC-025 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOFING/REPLACE WINDOWS BUILDING PERMIT Permit# BP-2019-0224 Proiect# JS-2019-000362 Est.Cost: $12000.00 Fee: $75.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JDR BUILDERS 074105 Lot Slze(sp.ft.): 97574.40 Owner: JAESCKE RICHARD E&SANDRA H Zoning: SRn00yWP(20)/ Applicant. JDR BUILDERS AD 754 BRIDGE RD ApplicantAddress: Phone: Insurance: P O BOX 4 (413) 665-7587 NORTH HATFIELDMA01066 ISSUED OM8122/2018 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & REROOF, 10 REPLACEMENT WINDOWS, 2 DOORS & MINOR NON-STRUCTURAL INTERIOR REPAIRS 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: FeeTvpe: Date Paid: Amount: Building 8/22/2018 0:00:00 $75.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2019-0224 APPLICANT/CONTACT PERSON JDR BUILDERS ADDRESSTHONE P O BOX 4 NORTH HATFIELD (413)665-7587 PROPERTY LOCATION 754 BRIDGE RD MAP I8C PARCEL 025 001 ZONE SR(I001(20V THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid U Building Permit Filled out Fee Paid TvoeofConstruction: STRIP&REROOF 10 REPLACEMENT WINDOWS 2 DOORS&MINOR NON- STRUCTURAL INTERIOR REPAIRS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 074105 3 sets of Plans/Plot Plan T FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON ORMATION 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 s olition Delay Sign r uilcfinT O cial Dat Note: Issuance of a Zo ' rmit does not relieve a applicant's burden to comply with an zoning requirements and obtain all required permits from Board of Health,Conservation Commission, Department of public works and other applicable permit granting authorities. *Variances we granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning&Development fm more information. sects tlW'NO1dWVH1eON Department use only City of Northamp n Stews of Permit: .w d0q D6Wrn nt Curb Cut/Dnvevai Permit 212 Main Str Sayer/Septic Availability `(. Water/Well Availability �O�1060 Two Sets of Structural Plans �- phone 4 - - - 7-1272 Plot/Sfte Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 ProoertV Address: This section to be completed by office qc� / ^P n bw n I Map Lot.. _ Unit �n//..'�f/J1 �WVkLT% y(�1 Zone Overlay District No ' ' RW Elm St Distinct CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: Saflonik �fc Sc —77L-/ ,U`7a�✓ Nam (Print) a Current Mailing Address'. 0 Telephone Sgnature 2.2 AuthorizedA a t: 5<; �d �, A)O_ Name(Print) Current Mailing Address. 37W- 7? K3 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bpermit plicant 1. Building (a)Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) �'U 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number ( Q This Section For Official Use Only Building Permit Number Date Issued: Sign re: Buil ng Co ioner/lnspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicablel New House ❑ Addition ❑ Replacement Wyt' Uows Alteration(s) Q Roofing Or DooSZ rs Z r� Accessory Bldg. ❑ Demolition ❑ New Signs [LI] Decks [O Siding[=l Other[m] Brief Descnption of Proppset Work: 5T'721� A;.J�LEI�O� In K/PKCf✓n Gw� la)tn c'r.J fy �QOeS /hii✓o2- l A/TE/L+ Alteration of existing bedroom Yes No Adding new bedroom_Ves No Attached Narrative Renovating unfinished ishetl bbasement Yes No Plans Attached Roll -Sheet ea. If New house and or addition to existlna housing, complete the following: a. Use of building. One Family Two Family Other It. 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? ireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masschec rgy Compliance form attached? h. Type of construction i. Is construction within 100 of wetlands? Yes No. Is construction within 1110 food Iain Yes No I. Depth of basement or Ilar floor below finished grade k. Will building confor 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 NT AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, , JMY1 C3'PAY �1 aes-rYc as Omer of the subject property / hereby authorize to act n my behalf, in all me m relative to work authorized by this building permit application. S' ature of Owner Date I, J 'b SS / as Owner/Authorized Agent hereby declare that the statements andinfor ation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under Ill an l pe - s of perjury. Pr t Name Signature of Owner/Agent Date ^ b M }2 ,,ingl F^?J 7C r� SC"�4v: (� 55'3Jsp-;LA-A)VIj- 1 1 ScrO� � , r1 aS ys101� C SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervis o r: Not Applicable D Name of License Holder: V / t t-r D VZ/ "" License Number Ly No. Y`7 4��f C)106C )-/- Address Expiration Date 612- EgN- 79B Signature Telephone 9,Registered Home Improvement Contractor: Not Applicable D `T1�2 &IWD�i2s iniG �l �( ' Company Name Regishation Number �x Gb 1*7- 9-26 Address / Expiration Date Telephone 97Y- 77:3 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C.152,§25C(S)) Workers Compensation Insurance affidavit must be completed and submitted vdth this application. Failure to provide this affidavit vall result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes...... �1411 No...... ❑ City of Northampton -v^ Massachusetts �' IL`"-� ® `s DEPARIRffiiT OF BUILLIIBG IB3PECTIOBB y f� 212 Hein Sheet •Municipal Building uS. C Q�"\. NoiNampton, . 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40, 554, 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: q5y '3lzib6C- -A?A . (Please print house number and street name) Is to be disposed of at: VtIdGn Please"m name and to on of facilit Or will bedisposedof in a dumpster onsite rented or leased from: v12`CS� ���i •✓<< (Company Name and Address) Signa f 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. City of Northampton .�( Massachusetts 1212 damn is OF 13* uuni`i l Bui dlO 232 Main rtha o Nun 010 Builtlin9 NorNavq+ton, MA elO6o 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 wntmetor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"mconstruclion, 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:Lf the homeowner has contracted with a corporation or LLC,that entity must he 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 _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 PACE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for aa.building permit as the agent of the owner: -,Z ,p - IO � -i iuU .emRA 16L" I U "l -7 Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice, 1 hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature The Commonwealth ofMassaehusetts V11,drivers' Department of IndustrialAccidents I Congress Street, 2Boston,rYl9 02114-4-200177www.mass.gov/dia Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbem. TO BE FILED WITH THE PERMITTING AUTHORITV. Applicant Informations " �.�,., Please Print Legibly Name (Busimss/O�anikwioMndividual): '1/P�jl("( E�45 Address:�777rL000l A ' 6 6 / City/State/Zip: W i4Ask 14),4. Phone#: (0 6S' -75( Arc you on employer?Check the appropriate boa: Type of project(required): LE�l am a employer with �remployees(full and/or pantand).a 7. ❑New construction z.❑Iamaaom proprietor ar partnersM1ipand haveno employees working torment 8. ®Remodeling any capacity.INo workers'camp.insurance required./ IF-11—ahoeownerdoingall warkmmm yself[Noworkers'cop.norencruxuard.It 9' ❑Demolition m 4.❑1 am a homeowner and will he hiring contractors to conduct all work on my property. I will I U❑ Building addition crescre,hat all contractors either have worked compensation insurance or are sole IL❑Electrical repairs or additions proprietors with no employdes. 12.❑Plumbing repairs or additions 5 r 1 am a general contractor and I have hired the subcontractors listed on the`trached sheet, 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance 6 F We are a commando and its onieers have exercised their right ofercemplion per MGh c. 14.❑Other 152,§I(4),and we have no employees.[No workers comp.insurance haunted.] `Any applicant that checks box kl must also fill out the sedlon below showing their workers'compensation policy information. t No coram rs who submit this idudavit indicating they are doing al I work and then hire outside emir acmrs must submit a new affidavit indicating such. tConthentors that check this box must attached an additional sheet showing the name of the sub-cunoactors and state whether or not those entities have employers. Ifthe subcnnmtom have employees,they must provide their workers'aut,policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information J( Insurance Company Name: S.Q IGb"P✓,�I l d f�; 00 .Ui '7 q Policy#or Self-ins.'—Lite.#: �/�77���p"�"� y�� q Expiration Date:.. II G Job Site Address: / Wrc— Z - City/State/Zip: N '/�- A . 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 ofa STOP WORK ORDER and a fine ofup to$250.00 a day against the violator A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify r tke fhai s nd ena6ies of perjury that the information provided aasbovve�is true and¢correct. Si nature: Date: U "<D" ILI Phone#: Oficial use only. 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#: Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning 'this wiumn lobe fill in by Building nepanment Lot Size Frontage Setbacks Front Side L: R: R: Rear Building Height Bldg.Square Footage % Open Space Footage % (Wt area minus bldg&paved arkm #of Parkin Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES,date issued: IF YES: Was the permit recorded at the Registry of s? NO O DONT KNOW © ES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or lands? NO 0 DONT KNOW O YES O IF YES, has a permit been or need to be tained from the Con Nation Commission? Needs to be obtained 0 btalned O ate Issued: C. Do any signs exist on the prope . YES O NO IF YES, describe size, type d location: D. Are there any proposed ch nges to or additions of signs intended for the p perty? YES O NO O IF YES, describe size, ype and location: E. Will the construction a ity disturb(Gearing,grading, excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 cre? YES O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required.