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23B-086 37 HATFIELD ST BP-2020-0942 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23B-086 CITY OF NORTHAMPTON Lot: -601 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: REPLACEMENT WINDOWS/DOORS BUILDING PERMIT Permit# BP-2020-0942 Proiect# JS-2020-001604 Est.Cost:$8000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ED JAZAB 050099 Lot Size(sq.ft.): 10846.44 Owner: Patricia Duffy Zoning: URB(100)/ Applicant: ED JAZAB AT. 37 HATFIELD ST Applicant Address: Phone: Insurance: 9 SHEPHERDS HOLLOW (413) 222-4910 0 LEEDSMA01053 ISSUED ON.212112020 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE DOORS, WINDOWS AND 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 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: FeeType: Date Paid: Amount: Building 2/21/2020 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only t rr City of Northampton / Status of Permit: ` Building Departmen�r FCB Curb'Cut/priveway Permit 212 Main Street 4?0 Sewer eptic Availability y n Room 100 VVater ell TC y Northampton, MA a1�b�Gvi,� Two ets oft5tructural Plans phone 413-587-1240 Fax 413- ''i>�, Plo Site ans er S ecify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOkISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be complete`!/office a �6 Lot Unit Map 00100 Zone Overlay District 1 Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ,tJl^i C/ q 6 L1't / l� U f'l{Ccayl S Name(P7119I t) Current Mailing Address: Telephone 5 �y /y 3 � Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (• (b) Estimated Total Cost of Construction from 6 3. Plumbing _ Building Permit Fee _ 4. Mechanical (HVAC) l J` 5. Fire Protection Ae 14 6. Total =0 +2 + 3+4 + 5) Check Number /��/ This Section For Official Use Onl Building Permit Number: n" �o- -{ /,)- Date Issued Signature: �/ Building Commissioner/Inspector of Buildings Date 01 da LV CL4 G,[; @ EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) t 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: S L:........__. R:- Rear Building .RearBuilding Height Bldg. Square Footage j 040 Open Space Footage % (Lot area minus bldg&paved arkin ) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DON'T KNOW ® YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO � DON'T KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES0 NU NO 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 0 NO 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 Wipdows Alteration(s) Roofing Or Doors L Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[0] Other[[3] Brief Description of Proposed Work: ren-- — ''' ' P �ct�►7�i s f� Alteration of existing bedroom Yes___)/No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes uol No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Familyy 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? 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 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, &I(- as Owner of the subject property C� hereby authorize r�`�=_�d 76Lb to act on my behalf, in all matters relative to work authorized by this building permit application. &&L Z i Signature of Owner Date I, CA4 as Owner/Authorized Agent hetel5y declare that the sta ements and information 777foregoing application are true 4nd accurate, to the best of my knowledge and belief. Signed nder the pains and penalties of perjury. I C Print Na � q Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: G17 JA71=11� cs — D 500 99 License Number S ��l� D'S I-IoLLo.w I��S , M� . � to5.3 QLA - 02- 202L AdML, Expiration Date LWT - 222- X1'914 Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ 5166Q0 Company Name Registration Number a�,w \--I'S 1--I'Sr_ I &ERT E 511 I Zi Address Expiration Date C C i �E-V�/YN JT JOuT�j 14f3DLt`/ Telephone ,l 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....... $t No...... ❑ City of Northampton tt , s! Massachusetts r' Y DEPARTMENT OF BUILDING INSPECTIONS t 212 Main Street •Municipal Building L 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: (PI ase print rfamea location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) PAAjX'k'&t t A'tj�vw — Signature of Permit AppricwATrpwner 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 1 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): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction ❑I am a sole proprietor or partnership and have no employees working for me in 8. ©Remodeling any capacity.[No workers'comp.insurance required.] 3.®I am a homeowner doing all work myself.[No workers'comp.insurance required.] 9. ❑Demolition' 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions ❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.® p Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑OtherW l'`1 DO`y' + b 0,)Q5 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I 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.#: 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 cern under the pains and penalties of perjury that the information provided above is true and correct Signature: I/Zi Date: I//f 6 Phone#: H 13 .'� g 3,`, 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#: