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23C-104 (3) 103 BLISS ST BP-2019-1086 GIS a: COMMONWEALTH OF MASSACHUSETTS MAp:Block:23C- 104 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:BASEMENT RENOVATION BUILDING PERMIT Emit p BP-2019-1086 Proiect N JS-2019-001769 Est.Cost:$8700.00 e :ce $65,Qg PERMISSION IS HEREBY GRANTED TO: Const,Clens: Contractor: License: Use croup: Homeowner as Contractor_ Lot Siu(so.ft.): 80019.72 Owner: WILBY BRIAN&LINDSEY zoning:URA(l00)1WSP(100y Applicant. WILBY BRIAN & LINDSEY AT. 103 BLISS ST AoplicantAddress: Phone: Insurance: 103 BLISS ST (413)218-0430() FLORENCEMA01062 ISSUED ON:412/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.RENO PORTION OF BASEMENT, ADD HALF BATH 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 Find: 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 Occuoancv Signature: FeeTYpe: Date Paid: Amount: Building 4/2/2019 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Faz:(413)587.1272 Louis Hasbrouck—Building Commissioner File#BP-2019-1086 APPLICANT/CONTACT PERSON WILBY BRIAN&LINDSEY ADDRESS/PHONE 103 BLISS ST FLORENCE (413)218-0430 O PROPERTY LOCATION 103 BLISS ST MAP 23C PARCEL 104 001 ZONE URA(100)/WSP(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCJDSkD REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: RENO PORTION OF BASEMENT F BATH New Construction Non Structural interior renovations Addition to Existing Accessory Structure Buildine 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 Demolition Delay y-Z-2014 SigKture of Building Official Dam 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. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans IQ phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION I -SITE INFORMATION ECEIVED a,& /,?, i J/LIF-- to Property Address: This section to be completed by office !03 Bfss APO 1 2019 M p -$3C— Lot a'/ Unit S+. �lorencei M-4 DEPT OF BUILDING INSPECT, a Overlay District NONTIUMPrON."'"I Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 90011 Glad J;aJszy lnl,tby /03 BfIrlSa.y 'Fl0erce, NIA C, V2 Name(Prim) Current Mailing Address: &t~., w� Telephone ( 13 - Z I$- o I/'3 Signature 2.2 Authorized Agent: Name(Prim) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bpermit applicant 1. Building 0Duo (a)Building Permit Fee 2. Electrical 000 (b)Estimated Total Cost of Construction from 6 3. Plumbing 7.r �V Div Building Permit Fee ^ r $.T 4. Mechanical(HVAC) OO 5. Fire Protection ; 200 fi. Total=(1 +2+3+4+5) 0. --;-0 Check Number This Section For Official Use Only Date Building Permit Numb Issued: /� �n 1 42 Signature: I-Z'UIIQ Building Commissioneoinspector of Buildings Dale bgw;lbs @ gwa,l . <OK' EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Ad i i /Uol rwild - b4kM4it.1- h IVfihM Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed X Required by Zoning / This column I.be filled,n by Building Department Lot Size Frontage Setbacks Front Side Lj R:L. L:i R: .-] Rear Building Height Bldg. Square Footage Open Space Footage % � (Int area minus bldg&paves _ parking) 4 of Parking Spaces Fill: volume&Loc on A. as a Special Permit/Variance/Finding ever been issued for/on the site? 0 © DONT KNOW Q YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO © DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained O , 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(clearing, grading,excavation,or filling)over 1 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. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Iteration(s) Q Roofing E] Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [q Siding[O] Other IAK Brief Descrip0on of Proposed Work: P ovaiC p 1e o u Uiu l GNeMU aJd IiM4 6it4k 64acwl qVAC J.dvo k- &JAS apf .x.35-o {'y Alteration of existing bedroom—yes No Adding new bedroom Yes No 0 kWiij Aren N rradve Renovating unfinished basement _Yes No a Plns AHache oll -Sheet Sa.if New house and or addition to existina housing complete the followirlm 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 afiached? 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 H.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 Date t I. rr an W! 1: ' ,as Owner/Authorized Agent hereby declare that tie statements 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. Pjrta', W. I by Print Name �� 3 Signature AOwner/Agent Date Date SECTION S-CONSTRUCTION SERVICES $.7 Licensed Construction Supervisor: Not Applicable IkAeosuhQr /S �Pr�e.n'la1 Wr�l( Name of License HOIMr: JJ License Number Address Expiration Data Signature Telephone 9.Registered Home Imorowmenl Contractor: Not Applicable X Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS'COMP,PdATION INSURANCE AFFIDAVIT(M.G.L.c.152,$25C(B)) Workers Compensation Inswrince 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 A shad Yes....... ❑ No...... ❑ Does opo Yr , - hD DLy1t, P1`4N �� wa,�— City of Northampton s Massachusetts LEPRRT W OF BUILDING INSPECTIONS 212 Main Street a Municipal Building JL b Northeet,ton, MA 01060 s y`W11ti. lh 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 entity must be registered Typeof Work: i6�mt17 "f/� bwV '.'�(0.''^''/t Est.Cost: Address of Work:_ _ /03 61,w `J -, Y l olw e 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 C1`*c n' , Owner obtaining own permit(explain):�04*ot*et/ 's ,Aj vi- ,k--Building not owneroccupied 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: 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: 3 �9 jig Date Owner Name and Signature City of Northampton u--",o Massachusetts 212 lKain S OF BUILDING INS uilT nNS212 Nain Street •Nunicipel BuildingNorthampton, MA 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 property licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from construction work being performed at: 43 81, ss A,�t1- (Please print house number and street name) Is to be disposed of at: vat �KJ<<n -�3y Eas+ltaw f,N,( d.) drd u11 Alt (Please print narAe And location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) A-- �/ 3 )7g/M Signature of 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. The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Ir Boston, MA 02114-2017 www.mass.gov/dia Witrkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITV. Applicant Information / ' Please Print Le i blv Name (Business/OrganizatioWIndividua0: iQ r!an Iz72dbl Address: /D3 ?t;ss St, City/State/Zip: r/D/'e/7Cp A 01012 Phone 0 Are you an employer?Check the appropriate box: Type of project(required): I.[]I am a cmploycr with employecs(full and/or part-time). 7, [ Cw C0 truetion 2.E]l am a sole proprietor or partnership and have no employees working for me in g, m110d01ing y capacity.[No workers'comp.insurance required.) 3. am a homeowner doing all work myself.[No workers comp.insurance required.]t 9. Demolition 4.I I am a hmrnmemor and will be hiring contractors to conduct all work on my properly. 1 will 10 O Building addition casum[list all contractors either have workers'compensation insurance or arc sale II.E]Electrical repairs or additions pmpnemrs with no mnployeve. 12.E]Plumbing repairs or additions 5{:]l am a general contractor and l have hired the sub-contmerors listed on the attached sheet. l3 Roof repairs These subcontractors have employees and have worker comp.insurance. 6.E]We arc a corporation and in officers have exercised their right of exemption per MGL a 14.00ther 152,II(4),and we have no employees.fNo workers comp insurance required.] *Any applicant that checks box#I most also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this atidevit indicating they arc doing all work and then hire outside co rrommrs mus[submit a new affidavit indicating such. :Conamemas that check this box must anached an additional sheet showing the name of the sub-contractors and state whether or not those cntitics have employees. If the sub-contractom have employees,they must provide their workers'comp.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: Policy#or Self-ins.Lic.#: __ _ Expiration Date: Job Site Address: 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 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. I do hereby certify under the p ins and penalaes of perjury that the information provided/above is true and correct. Sienature: ? Date: 3/Zall9 Phone#: y13 -71�-0�3� Official use only. Do not write in this area,to be completed by city or town ofcial 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#: No ::::::: ;• ..■.. . .. �.NEI so ...;■p■::;; ■■■■ [9■. :: ■ ■■■M ON ■■■:■ ' :::am :::: • H :: :: :::•::' IMMUNE::■■ . ■. .: ..: Chi: ■.� :: ME ME a No ��� C.... ...�...;.��..�; MEN so No ...■� :::� �■■ . ■ ■■ ■■ ■■.■� H ■■■■■■ ■ ■■ ■■■■■ ■■■ ■■■■ ■ ONEENEV 0 , mill m ■■■ ■■■■■■ --------- ■