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36-264 (7) 199 MAPLE RIDGE RD BP-2019-1243 cls#: COMMONWEALTH OF MASSACHUSETTS Mao.Block:36-264 CITY OF NORTHAMPTON Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category ROOF BUILDING PERMIT Permit# BP-2019-1243 Project# JS-2019-002006 Est.Cost: $22500.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Groin ERIC DRIVER 97208 Lot Size(sa. ft.): 145926.00 Owner: DOURMASHKIN THOMAS&CYNTHIA A Zoning: Applicant: ERIC DRIVER AT: 199 MAPLE RIDGE RD Applicant Address: Phone: Insurance: 556 STAGE RD (413) 695-1947 WC CUMMINGTONMA01026 ISSUED ON.-5/6/2019 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF 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 DeoaHment Fireplace/Chimney: Rough: 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 sienamrc: FeeTviw Date Paid: Amount: Building 5/6/20190:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner fQpp CC F City of N rthariRE C E I V E w Department use only we t Department epa ment mC YDd�reway Pet 212 Ma n Sir et 6 i p06Aoallability MAY 2��9 Roo 10 ar ell Avallabiliy Northampto , M 01060 'S o 11 fStrulthind Plans phone 413-587-124 F - , ; Isi t/si Flaw voerHAMr'ON MAoms cis APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This secgon to be complete by office /QQ 144Q/L r, , T� Map Lot Unit //o�� Ilrl,�sr� /.IA /� Zone Overlay District /V •"`-'t' /„62©0 Elm SL District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner (Record: f] Curren Mailin Ad s'Y � �-1 �IIIOi11f Qt �'1 I �i13g o- 9y FJ Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address'. Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cast(Dollars)to be Official Use Only completed by permit applicant 1. Building �F S� (a)Building Penni(Fee 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) S.R�.S� Check Number This Section For Official Use Only Building Permit Numb Date Issued: G Signature: Building Com ussioneninspector of Buildings // Dale EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column in be Blicd in by Building Dnpmtmem Lot Size Frontage Setbacks Front Sidc L: R: . L: R: Rem' Building Height Bldg. Square Footage Open Space Footage (Lot arca minus bldS&Paved rkin ) 4 of Parking Spaces Fill (volume&Ioration) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW W YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW e/ YES O IF YES: enter Book Page and/or Document N B. Does the site contain a brook, body of water or wetlands? NO (D- DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained © , Date Issued: C. Do any signs exist on the property? YES O NO C 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/( y IF YES, describe size, type and location: C.� E. VVII the construction activity disturb(clearing,grading,excav tion,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? VES O NO 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 ❑ Atldition ❑ Replacement Windows Alteralipn(s) E:] Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks ip Siding Other(0] Brief Work escriPtion of Proposed P T/ AQt'r57'iiy `jly s�,b l3 C(� Alteration of existing bedroom_/--Vies vNo 7 Adding new bedroom Yea�4—No Attached Narrative Renovating unfinished basement Yes �No Plans Attached Roll -Sheet sa. If New house and or additlon to existing housing. complete the following: a. Use of building OneFamfli Two Family Other b. Number of roams 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? I. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attachetl? 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 I, fy,0.S r as Owner of the subject property f (yam\ hereby authorize Gyre `�-'z faee' to act o alf, in afters relative t rk authorizetl by this buildi7 perm t application. ng ani �f3�19 Signature of Owner Date D 6 If as Owner/Authorized Agent here 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 penalti rjury �'i�t� � �if'r'`--• L r I c� �l 1 vc� Print Name��` �g// Signature o wnerlAgent /\/ `^' / Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supee"iisor. `��/ Not a Applicable p❑ Name of License Holler: (/.�r� License N�be� / �.n' Mrl K 8 ZS ZO ZZJ Addr FxPlra�on D� q1.3 qy7 S,gkfues Telephone e is ered R me I n vem ht Con don Not Applicable ❑ Company Name Registrati Number ,�56 Sff/ , t S 2070 Address Expi ion Date Telephone %�/�/a 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....... C4� No _. ❑ City of Northampton Massachusetts t DEPARTMENT OF BUILDING INSPECTIONS Z ,� 212 Win Street a Municipal Building 06C Noxthamptan, M 01060 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, orconstruction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....cr 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. Type of Work: )rp,�l a Gl 'Est.Cost: 221te ✓r Address of Work: /IHB Date of Permit Application: /,� 2 ©lY I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): _Job under S1,000.00 _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 PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I herebyapply �i ff r a building permit as the agent of the owner: p 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: Date Owner Name and Signature City of Northampton Massachusetts W DEPARTMENT ..BUILDING INSPECTIONS 21z Main rtiemt oMunicipal sildiigNoi@�ampton, HP 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: 1qy A T(.1 FG,w (Please print house numbdit and street name) Is to be disposed of at: A I+f-na��C- 'Qe-��1� I � (Please print name and location of facilit Or will bedisposeddisposed of in a dumpster onsite rented or leased from: — (Coomm'pppanny�Name �and Address) Signature of Permit Applicant or Owner Dale 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 www.mass.gov/dia W\Yorkers'Compensation Insurance Affidavit:Builders/Contrastors/Electricians/Plumbera. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Orgaan(n'ii> tiowlnnddiv�idual): Address: - 6 City/State/Zip: v r}'!!h%A'e� Phone Myi3 : Are you an employer?Check the appropriate box: Type of project(required): i.❑1 am a employer with employees(full music prod-bone)` 7. ❑New construction 2.❑Imartode proprietor or paanership and have no emplaybas working for me in 8. Remodeling any capaciity.[No workerscompieaumbe, required] 3.❑1 am a homeowner doingII work myself No workers'won i mance re d 9. ❑Deilding n od ysc [ p 'n quire ]' 4.❑1 am a homeowner and will IN hiring contractors to conduct all work on my property. [still 10 E] Building addition ensure that au contractors either have workers°compensation insurance or are role 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5F I am a general contractor and I have hired the rub-commdors listed on the attached sheen 13. ,mf repairs I here sub contractors have employees and have workers comp.insurance 6_M—re a corporation and its officers haveexercised their right ofinernmion per MGL c. 14.❑Other M,and),and we have no employees INa workers comp.insurance required] Any applicant that checks box BI most also fill out the section below showing their workers'compensation policy informmion. t Hmneowners who submit this amdavit indicating they are doing all work and then hire ou6ide contractors rust submit anew affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entries have employees. If the sub contractors have employees,they must provide Iheir workers'comg pol Icy numi. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. J _ I 3 .-r ,62-6 _ A /r Insurance Company Name: G 1'f Policy#ar Self-ins.Lic.#: Ilk 70Ce Ir" p Expiration Date: , 6 7o Q u �t fi a /State zi Gf /K ,fir ,UAD(�6z Job Site Address: ty p: Attach a copy of the workers'compervislion policy declaration page(showing the policy number and expirati 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,0r one-year imprisonment,as well as civil penalties in the farm of 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. 1 do hereby certify under thermos and p //ties ofperluQry that the information provided ab vve/. if a and correct S' t �z 1/ Dates�Y/ � Phone#' Official use only. Do not write in this are,to be completed by city or town official City or Town: Permit/License Is 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#: