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32C-210 (8)The Contntomwealth of Massachusetts Departntent of1nAzs&ia1AccWna OffiCC Of In VeSfigatiOnS 600 Washington Street Boston, MA 02.111 wi -oww.mas�gotl&a _...Wo rkers' Compe satim Appliegnt Information Please Print T&Wbly NaMC (Busiaoss/Organization/hidividual), Five Star Building Corp. Address: 17 East St Cfty/State/Zip. Easthampton, MA. 01027 Phone #: 413-587-4060 Are you an employer? Check the appropriate box: Type of project (required): 1. 211 am a employer with 9 4. Q 1 am a general contractor and 1 6, E] New construction employees (foil and/or pari -time).'` have hired the sub -contractors 7, E] Remodeling 2.El I am a sole proprietor or partner- listed on the attached sheet t ship and have no employees These sub -contractors nave 9. E] Demolition working form in any capacity. workers' comp. insurance- 9. ] Building addition [No workers' comp. iusumace 5. Q We are a corporation and its l0.F1 Electrical repairs or additions required-] officers have exercised their 3. 0 1 am a homeowner doing all work right of exemption, per MGL I LE] Plumbing repairs or additions myself. (No workers' comp. c. 152, §1(4), and we have no 12.EJ Roof repairs Kitchen/Bath insurAnce, required.] t employees. [No workers' 13.0 Other Accessories comp. insurance mwlireci_] 'A-Qy epplic-t that cheeks box #1 must also fill out the sediou below showing their workm' compensation policy infonmation. t Homeowuem who submit this affiWav4 indicating they am doing alt work and then kite oetsidt conwaam must mbmit a new affidavit indicating suctL tCoatra m that cbock this box mwL anadwd an ad6fienat sheet showing the name afthe xdaoorthattors and their work=' comp. policy information. lam an employer that lsprovOng workeWcooWensafian btszoviarfor my mrloyeex Bdow is dire policy and job site Insurance Company Name: Associated Employers Insurance Company Policy #OrSelf nom. LiC.#. WCC500626401200 Expiration Date: 5/9109 Job Site Addmss: 47 A Holyoke Street CjW&faterZip:—Northarnpton, MA 01060 Attach a copy of the wortwn' compensad-ou policy declaration page (showing the policy number and expiratioa date). Failure to secure Coverage as requited under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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 ' later. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for Coverage Vcdftatiom I & Hereby and pmahles ofperjoy th a t the informaden pro vided above is &we and wrrea 8/29/08 41 Off loW use only. Do Not write in this area, to he compkiwi hy city or tmw official 1*1, =7 Issuing Authority (circle one): 1. Board of Health Z Building Department 3. CityfTowu Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person- Phone SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Kevin Perrier 85319 License Number 17 Eas S reet Easthampton, MA 01027 1/13/09 Expiration Date Address 413.587.4060 Signature Telephone 9. Reaistered Home Improvement Contractor: Not Applicable ❑ Five Star Building Corp. 134511 Company Name Registration Number 12/3/09 Address Expiration Date 17 East Street Easthampton, MA Telephone413.587.4060 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 buildinq permit. Signed Affidavit Attached Yes....... © No...... ❑ 11. - Home Owner Exemption 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 who constructs more than one home in a two-year period shall 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 of the 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 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 17-1 Accessory Bldg. ❑ Demolition ❑ New Signs [E-3] Decks [C] Siding [O] Other [Ct7] Brief Description of Proposed New kitchen cabinets, bath fixtures Work: Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes x No Plans Attached Roll - Sheet Ba. 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? d. 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? h. Type of construction i. 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 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 Amy Milo as Owner of the subject property hereby authorize Five Star Building Corp. to act on my behalf, in I matte relativ to work authorized by this building permit application. 10.10.08 Signature of Owner Date Kevin Perrier, President- Five Star Building Corp. ,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 pees of perjury. Kevin Pe er Print Name 10.10.08 Signature of Owner/Ag Date I/ 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 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 bldg & paved parking) # of Parking Spaces r Fill: volume & Location _..._.., .. ..... ,. __. ,,. ... . A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW 0 YES 0 f IF YES: enter Book Page and/or Document #, B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO IF YES, describe size, type and location: E. Will the construction 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 0 NO G IF YES, then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton Building Department 212 Main Street y,Room 100 Northampton, MA 01060 phone 413,087-140 Fax 413-587-1272 APPLICATION TO -CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be completed by office 1.1 Pronertv Address: 47 A Holyoke Street Map Lot =Unit Northampton, MA 01060 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Amy Milo 4 Birchwood Dr. Huntington, MA 01050 Name (Print) Current Mailing Address: Telephone 413.537.4929 Signature 2.2 Authorized A ent: Kevin Per ie 17 East Street Easthampton, MA 01027 Name (Print) „ Current Mailing Address: t 413.587.4060 Signature Telephone SECTION E (MATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only com leted by permit applicant 1. Building 20,000 (a) Building Permit Fee 6.00/1000.00 2. Electrical (b) Estimated Total Cost of 20000 Construction from 6 3. Plumbing Building Permit Fee 120.00 4. Mechanical (HVAC) 5. Fire Protection 6. Total = 0 + 2 + 3 + 4 + 5) 20,000 Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissionerlinspector of Buildings Date File # BP -2009-0414 APPLICANT/CONTACT PERSON FIVE STAR REMODELING ADDRESS/PHONE 17 EAST ST EASTHAMPTON (413) 587-4060 Q PROPERTY LOCATION 47 A HOLYOKE ST MAP 32C PARCEL 210 001 ZONE URC000V THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid TyTeof Construction: INSTALL NEW KITCHEN CABINETS & BATH FIXTURES New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/ Statement or License 085319 3 sets of Plans / Plot Plan i FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON ATION PRESENTED: pproved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Major Project: Site Plan AND/OR ZONING BOARD PERMIT REQUIRED UNDER: § Special Permit With Site Plan Special Permit With Site Plan 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 Demolition Delay Signature of Building Official Date 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. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information. BP -2009-0414 GIs #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category Permit # BP -2009-0414 Project # JS -2009-000558 Est. Cost: $20000.00 Fee: $120.00 Const. Class: Use Group: BUILDING PERMIT PERMISSION IS HEREB Y GRANTED TO: Contractor: License: FIVE STAR REMODELING 085319 Lot Size(sq. ft.): 3179.88 Owner: MILO SANDRA J Zoning: URC(100)/ Applicant: FIVE STAR REMODELING AT. 47 A HOLYOKE ST Applicant Address: Phone: Insurance: 17 EAST ST (413) 587-4060 () WC EASTHAMPTONMA01027 ISSUED ON:10/17/2008 0:00:00 TO PERFORM THE FOLLOWING WORK. -INSTALL NEW KITCHEN CABINETS & BATH FIXTURES POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Underground: Service: Rough: Rough: Final: Final: Gas: Fire Department Rough: Oil: Final: Smoke: Meter: House # Driveway Final: Building Inspector Footings: Foundation: Rough Frame: Fireplace/Chimney: Insulation: 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 10/17/2008 0:00:00 $120.00532 212 Main Street, Phone (413) 587-1240, Fax: (413) 587-1272 Building Commissioner - Anthony Patillo