23A-147 (5) 122 PINE ST BP-2019-1403
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23A- 147 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: ALTERATION BUILDING PERMIT
Permit# BP-2019-1403
Project# JS-2019-002266
Est.Cost:$2000 00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License.
Use croup: Homeowner as Contractor_
Lot Size(w. R.): 49222.80 Owner: LAIDLAWWILLIAM
Zoning, URB(IOOVSI(Ol/ Applicant: LAIDLAW WILLIAM
AT: 122 PINE ST
Applicant Address: Phone: Insurance:
122 PINE ST (413) 834-1972 0
FLORENCEMA01062 ISSUED ON:6/17/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.REPLACE PORCH POSTS"MUST BE TO MASS
STATE BUILDING CODE"
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspectorof Plumbing Inspector or 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 Occuoancv signature:
FeeTvoe: Date Paid: Amount:
Building 6/1720190:00:00 565.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
(�p Po�c�c.Poa71s
ddlmllkh City of n
8 In rtmentb 209 rocuvOnveway Perms
12 in SU@9l ' , pHs er/Septic Availability
R00 10Q apSQo , WaterNyell Availability
Northa ton, 01 Tiro Sets of Structural Plans
phone 413587-1 40 72 PloVSite Plans
0EP HOP Other Specify
APPLICATION TO CONSTRUCT,ALT ,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Prooerh Addreas. This secdun to be completed by office
Map _ Lot X5'7 Link
122 Pine St Florence MA 01062 zone OwrlayDlstari
Elm SL Disenct CS Distinct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZEDRGENT
2.1 Owner of Record:
William Laidlaw,Caroline Cuthbert Same
Name(Print) Current Mailing Address: 413-834-1972
Telephone
Signature
2.2 Authorized Anent:
Name(Print) Current Mailing Address:
Sig.w. Telephone
SECTION 3-ESTIMATED CON8TRUC710N COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by pennit applicant
1. Building $2000 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Penult Fee
4. Mechanical(HVAC)
5.Fire Protection
8. Total=(1 +2+ 3+4 +5) $2000 Check Number
This Section For OMelel Use Only
Building PermDate
Issued:Num r: Issued: /
Signature: (,' )Z' ZD)q
Budding Commisslonernnspwbr of Buildings pate
scott.laidlaw.wma@gmail.com
EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Must Be Computed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column m be filled m by
Bunding Department
Lot size O D
FrontageO O
Setbacks Front O O
Side L:0 R:0 L:Q R=
Rear
Building Height O 0
Bldg.Square Footage
Open . bw,&S. e O O %
ltaO
r w minor bWg a paved
#of Parkin Spaces 0
Fill:
vdume&lacerim
A. Has a SpeciiYESO
mit/Variance/Finding eve been issued for/on the site?
NO ODONT KNOW O YES O
IF YES, date issu
IF YES: Was tmit recorded at the egistry of Deeds?
NO ODONT KNOW O YES O
IF YES: entBook ] Page—.� and/or Document#F__ _ _7
B. Does the site ca brook, bo of water or wetlands? NO O DONT KNOW O YES O
IF YES, has it been or tied to be obtained from the Conservation Commission?
Needs to beined Obtained O , Date Issued: L
C. Do any signs en the operty? YES O NO O
IF YES, descize, pe and location:
D. Are there any changes to or additions of signs intended for the property? YES O NO O
IF YES, descze, type and location: '�.`_ _E. WiIItheconsnuctivity disturb(Gearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
thatwilldisturb acre? YES O NO O
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 ❑ Addition ❑ Replacementwindows AkomH n(s) ❑ Roofing ❑
or Doors 0
Accessory Bldg. ElDemolifion ❑ New Signs [0] Decks IE) Siding 10] Other(En]
Brief Description of Proposed RapNm(4)porch pow
Work:
Alteration of existing bedroom_Yes=No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _ryes W No
Plans Attached Roll -Sheet
sa. If New house and or addition to existing housing, complete the following.
a. Use of buildmg: 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?
I. Method of heating? Fireplaces or Woodstowls Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
I. Is construction within 100 fl.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 confom to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION Tat-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ,as Owner of the subject
property
hereby authonze
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, ,as Owner/Authorized
Agent here d re 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 penalties of perjury.
Print Name
Signature or Owner/Ageo Data
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable
Name of Llama Holder
Ucense Number
Address Expiration Dale
Signature Telephone
9.Realstered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Fxpiraton Date
Telephone
SECTION 18-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.182,428C(9q
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide Nis afildavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
The Commonweaith of Massachusetts
Department oflndustrialAecidents
I Congress Street,Smite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contraciors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Bnsiness/Oigani atioMndividuap:
Address:
City/state/Zip: Phone#:
Areyoa u nmple"s?Crack traappmpriak ban: Type of project(required):
1.❑1 atn a employer with employees(full and/orpart-time)• 7. ❑New construction
2.❑lamamleproprieororpa mhipudhavenoemployersworking barman S. Remodeling
any capacity.[No workers'comp insurance requirM.l
3❑lama homes clating all wutk myself pJo wtrkeri comp.insumocetequired l t 9. ❑Demolition
aam a M1ommwmraM will be hiring cmmannrs to mndun ell work on my WOPerY. 1 will 10❑Building addition
emure east all cunmacrots either have wortchs'empaertormairaaeof are sole I1.❑Electrical repairs or additions
propridors with no enrployas.
12.[3 Plumbing repairs or additions
5 0 I am e,geteml connector oras I lone, M ahaveM1i n Ne subs»m (rated on de auacM1Mat
Theme,msh .
Thebconucrors ehave employees have workess,r coem mp.msmances 13.[:]Roof repairs
6.❑We use a corporation and in olficcrs have memimd their right ofexerrown per MGL c. 14.❑Other
152,110),end we have no employees.Mo worker'comp.mausana requiredl
Airy contend that checks box at must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work end then hire outside contractors mum submit a new,affidavit indicating such.
rConaacmr that check Nis box mum athached an additional sheet showing the name of thu mhconrraaors and share whether or not those entities have
employers. Ifthe sub-contractors have employees,they mut provide their workers'comp.policy number.
I am an employer that o providing workers'compensation insurance for my employees. Bet"a!helm andjob site
Lnformadon.
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 in 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 cerdfy under d/re pains and penaider ofperjury thatthe information prodded above is we andcorrect.
Simatu �
re: � hAn — Date: G '/• R
Phone#: a{IS • t412
Official use only. Do not write in this area,to be completed by city or town i fficiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityfrown Clerk 6.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 MGL c 111, S 150A.
Address of the work: ,u P-.A- 4.41
The debris will be transported by: Lmj ,, ,i,r
The debris will be received by: \�a>ath a•.Lr 1�
Building permit number:
Name of Permit Applicant W.<coFA- �aA'W
Date Signature of Permit Applicant
Your Confirmation number is 2019060610047883
Date of Confirmation:6/6/2019
NOTE:When paying by ACH(Checking)it will take two business days for the payment to be debited from your bank account.Your
account number is not verified until this payment is presented to your bank.They have the right to return this payment if unable to
process this transaction against your account.
Your request for payment(s)of$68.95 has been received and is subject to approval by your financial institution. A confirmation of this
order to pay will be sent to your e-mail.
Account Information Payment Information
Name: WILLIAM S.LAIDLAW Payment Type: Credit Card
Nate: QUICK PAY TRANSACTION Payer Name: WILLIAM S.LAIDLAW
Card Number: """""""6412
Transaction Information
Transaction Quantity Amount Fee Payment Type
City of Northampton-Building 1 $65.00 $3.95 Credit Card
Department
Misc.QP
Permit Option:Building-Zoning-Sheet
Metal Permits
Full Name:William s Laidlaw
Phone:413-8341972
Email Address:
scott.taidlaw.wma@gmaii.com
Notes:122 pine st-building permit
Total:$68.98