29-600 (9) 50 STONE RIDGE DR BP-2020-0899
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-600 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2020-0899
Proiect# JS-2020-001533
Est.Cost: $18600.00
Fee: $120.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ROBERT WALKER 034783
Lot Size(sg. ft.): 81021.60 Owner: MARGARET R SLATER
Zoning: Applicant: ROBERT WALKER
AT. 50 STONE RIDGE DR
Applicant Address: Phone: Insurance:
36 Service Center (413) 584-1224 Workers Compensation
NORTHAMPTON MAO 1060 ISSUED ON.2/7/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.-BUILD NEW LAUNDRY, CLOSET
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 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 Occupancy signature:
FeeTvpe: Date Paid: Amount:
Building 2/7/2020 0:00:00 $120.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
.�, 212 Main Street Sewer/Septic Availability
;`_ i Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH ONE[i4L" 0(: 41 LING
I
SECTION 1 -SITE INFORMATION _
1.1 Property Address: -)0 This section o b pleted by offi'c
SZj `TD f`'� I?l {� +2�VK Map O', / �= ^�=; tI&
—}
NORTHAMPTON,MA 01060
AA A Zone Overlay District
Elm St. District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
i ;✓K q 61, IVj-^ 6�k ✓- Cot -ems 0 I o b�-
Name(Print) Current Mailing Address,
41 Sa S
Telephone
Signature
2 Authorized Agent:
(-- %3 CA z
Name(Print)) Current Mailing Address:
�— �--� 4 I:� - rf-4— ►z zeA
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
Building (a) Building Permit Fee
Electrical (b) Estimated Total Cost of
'Fob Construction from 6
Plumbing Building Permit Fee
Mechanical (HVAC) I f'
Fire Protection
6. Total =0 +2+ 3 +4+ 5) 1. ` It �' Check Number
QQ, 9TThhis Section For Official Use Only
� Q
Building Permit Number: V� ` J DatIssued:
(Signature:
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors 1:1
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other[0]
Brief Descrition of Proposed
Work: V t L h I—VEIAJ
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - heet
6a. 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
7
c. Is there a garage attached?
d. Proposed Square footage of new construction. imensi
e. Number of stories?
b
x,f. Method of heating? -'laces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.o etlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement cellar floor below finished grade
k. Will buil ' conform to the Building and Zoning regulations? Yes No .
1. 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
f/
I, ` ► ajV - (/1� J Gam`� as Owner of the subject
property J
hereby authorized
to act on my behalf, in all matters relative to work authorized by this building permit application.
1l aY
Signature of Owner Date
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 penalties of perjury.
1'' VXA i i,-�
Print Name L4- 124
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: 4Zt, 11-)6'4Lj �) �hJlllL�Lr C-S_ �j �-�r
License Number
Addre s Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
P-t5Y?x"g-V a 1 -72o 14
Company Name Registration Number
Address Expiration Date
Telephone
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...... ❑
The Commonwealth of Massachusetts
Department of Industrial Accidents
a
I Congress Street, Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual): f7b
Address:
City/State/Zip: MQ Phone #: ,V1 1,
Are you an employer?Check the appropriate box: Type of project(required):
1.[]1 am a employer with " employees(full and/or part-time).* 7. ew construction
2.M I am a sole proprietor or partnership and have no employees working for me in h. Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.[]I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 Building addition
4.[:]1 am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 1 1.[:]Electrical repairs or additions
proprietors with no employees.
1 '.E]Plumbing repairs or additions
5.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.t 1 . Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other
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.
t 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.
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.#: `�6 rJ�00 l Si) l t-t� A- Expiration Date: '7 � cit � Z z)�1' Z_
Job Site Address: City/State/Zip:,U,r-,a A,_-a-t y'hd �t tl Q
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 thepains andpenalties ofperjury that the information provided above is true and correct.
Signature: t. _ �� �—- Date:
Phone#: l -- -Y� 171E [t
Official use only. Do not write in'this area,to be completed by city or town official.
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#:
City of Northampton
Massachusetts
y { DEPARTMENT OF BUILDING INSPECTIONS y
r 212 Main Street •Municipal Building
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:
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
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.
I