29-101 (5) I
15 BRIERWOOD DR ! BP-2020-0247
GIS#: COMMONWEALTH OF MASSACHUSETTS
Man:Block:29- 101 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Siding BUILDING PERMIT
Permit# BP-2020-0247
Proiect# JS-2020-000424 i
Est.Cost: $8000.00_ {
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License: I
Use Group: MATT MAYNARD 112584
Lot Size(sq. ft.): 12066.12 Owner: ROVITHIS ADAM !
Zoning: Applicant: MATT MAYNARD
AT: 15 BRIERWOOD DR
Applicant Address: Phone: Insurance:
1209 SPRINGFIELD ST ' (413) 262-7676 WC
FEEDING HILLSMA01030 ISSUED ON:8/28/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.VI NYL SIDING
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POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Servicer Meter:
Footings: .
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final: !
Rough Frame:
Gas: Fire Department r Fireplace/Chimney:
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Rough: Oil: Insulation:
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Final: Smoke Final:
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THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy i Signature:
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FeeTvpe: I Date Paid: Amount:
Building 8/28/2019 0:00:00 $60.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
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Department use only ;
City of Noll amp �=/Vslusof ermit.
t ti, Budding De artm nt Cur .Cut/ riveway Permit
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L 212 Main
St
t AUG 2 7 2019 se er/S tic Availability.
ROOM 00 W ter/W II Availability
Northampton MA T Set of Structural Plans
phone 413-587-1240 Fax° �,T4��p R��2rsPECT 'Site Plans
TON.MA 0106 ther S ecify
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APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR-DEMOLISH A ONE OR TWO FAMILY DWELLING
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SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
/te t M q I Map . Lot CJ Unit
✓V V7 Zone Overlay District
j Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
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2.1 Owner of Record:
=hn ,�oV�th�s (91�L( / - ;/� .1-�5�Lcr t� _/t'I (09
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
rcl Ho vn r _ 711Ave— G.% a., ota?f
Name(Print) Current Mailing Address:
Zia-
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Buildingi� 00,a^ (a)Building Permit Fee, -
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) I
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only i
Building Permit Number: DateIssued:
pf
Signature: f 2 g-201
Building Comm issio ner/Inspector of Buildings Date
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EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
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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:0 L:0 R:0 0 0
Rear 0
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Building Height
Bldg.Square Footage j0110
Open Space Footage % j
(Lot area minus bldg&paved
parking)
#of Parking Spaces 0
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO ® DON'T KNOWjj�, YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW ® YES
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IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NOse --DONT KNOW ® YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained ® , Date Issued:
C. Do any signs exist on the property? YES ® NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the,property? YES ® Nd—
IF YES, describe size, type and location:
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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 kj
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
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New House ❑ Addition ❑ Replacement Windows Alteration(s), Roofing ❑
Or Doors E3
Accessory Bldg. ❑ Demolition ❑ New Signs [[ ] Decks [Q Siding ] Other[0]
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Brief Description of Propoed
Work: CJ nN� S
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Alteration of existing bedroom YesPlo Adding new bedroom Yes �'Z No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa. If New house and or addition to existing housing, complete the following:
a. Use of building :One Family Two Family Other
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b. Number of rooms in each family unit: Number of Bathrooms i a�
c. Is there a garage attached? ��
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d. Proposed Square footage of new construction. AAA= Dimensions
e. Number of stories? Q
f. Method of heating? 6t�5 �ur�' �— Fireplaces or Woodstoves umber of each
g. Energy Conservation Compliance: Masscheck Energy Compliance form attached?
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h. Type of construction EKrA, j
I. Is construction within 100 ft.of wetlands? YesAlo. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade A/0—
k. Will building conform to the Building and Zo ' 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 ,Jcurd mo!-- /dllr7
to act o�ehalf,in a afters re tive to work authorized by his building permit application.
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Signature of Owner Date
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as Owner/Authorized
Agent hereby declare that the statements and information o 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 o ner j Date
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City of Northampton
r Massachusetts
t3 i z LO
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building yv`y fib.r
4M a Northampton, 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 properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
Or-
house number and street name)
Is to be disposed of at: I ' ,
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(Please print name and.location of facility)
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Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name add Address)
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Sign ermit Applicant or Owner Dat
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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.
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: � Not Applicable ❑
Name of License Holder � 1 �1a
Licenseumber
Address Expiration Date
aro '1\ -r)G c)•
Si ature1 le hone
i9.Registered Home Improv(e__ment Contract
Not Applicab7le ❑
���'�c✓�s �t�l ��5� �� 67 O�
Company Name RegistTc lumber
)aoq
Address Ekpiration Dat
Telephone L{{ fP�7Pn7_�
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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....... No...... ❑
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The Commonwealth of Massachusetts
u Department of Industrial Accidents
M a 1 Congress Street,Suite 100
Boston, MA 02114-2017
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www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WiTH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):kitchens by prestige/matt maynard
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Address:1209 springfield st
City/State/Zip:feeding hills;ma 01030 Phone#:413-262-7676
Are you an employer?Check the app Ir•opriate box:
Type of project(required):
1.E]i am a employer with 2 employees(full and/or part-time).* 7.1 ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in g. ❑Remodeling
any capacity.[No workers'comp:insurance required.]
9.' El Demolition
3.O I am a homeowner doing all work myself.[No workers'comp.insurance required.]'
10❑ Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will I
ensure that all contractors either have workers'compensation insurance or arc sole I .❑Electrical repairs or additions
proprietors with no employees.
12.n Plumbing repairs or additions
5.❑1 am a general contractor and i have hired the sub-contractors listed on the attached sheet.
13.�Roof repairs
These sub-contractors have employees and have workers'comp.insurance.* 1
6.❑We are a corporation and its officers have exercised theirright of exemption per MGL c. 14,'OOthervinyl siding
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
fi Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new 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 entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. `
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I ane an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:remillard insurance
Policy#or Self-ins.Lic.#:mpt5'1555v W GcI�y�9�� Expiration iDate:1/22/20
Job Site Address:15 brierwood'dr City/State/Zip:northampton ma
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 certifj nder t pai d pen 'es of perjury that the information providedi above is tr a and correct.
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Si nature' �' Date:
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Phone#:413-262-7676
Official use only. Do not write in this area,to be completed by city or town official.
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City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Buildiing Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: