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17D-047 (7) 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 am phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 6," 1.1 Property Address: / This section to be completed by office Map Lot O 7 Unit Zone Overlay District Elm St. District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 5��� MUerS 1�-1 rC�v� eve �1o�e�C ,MP Name(Print) Current Mailing AddrestAQA)HS\- W 0 Telephone Signature 2.2 Authorized Agent: - A?- S I tF. S� duo _ Mil Olb� Name( int) (Current Mailing Address: Si�n Adre Teleph e 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) u 5. Fire Protection 6. Total = (1 +2 + 3+4 + 5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER H �� l OWNER OR CONTRACTOR) )'l1A � � i 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 u Side L: R: L: R:= Rear 0 Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO © DON'T KNOW O YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW © YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO O 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 O 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 © NO O 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 Windows Alteration(s) Roofing Or Doors F-1 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding [0] Other(�Q] Brief Description of Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes \_No Plans Attached Roll -Sheet 6a. If New house and or addition toe housing, complete the following a. Use of building : 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? 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, Jaye MUeY s as Owner of the subject property J hereby authorize to act on my behalf; in all matters relative to work authorized by this building permit application. .4,e�e,/—� 1 I 1!& 1201 Signature of Owner Date I, 1 \ 1 F.J� �`�1 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. y 1 Print Name 2-CA121\ Signatur f Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: y Not Applicable ❑ Name of License Holder:T2CIL ���O License Number v-E y M 102.1 zoo, Addre Expiration Date ig ure Telep ne 9. Registered Home Improvement Contractor: Not Applicable ❑ EPG l C I(51(OF Company Narod Registration Number 2 111 to 12Z Address Expiration Da e Telephon 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...... ❑ City of Northampton j •� SS`s .:".:.s��� Massachusetts ��f• ''.c� DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building yJ•'•.y .Cly 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: '11, aY" INcnE (Please print house number and street name) Is to be disposed of at: N W ec\ \6z�s £ 'LI��P�� �1d V\A O M"A (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) 4 SignaX of Permit Applicant or Owner at 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. AC CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLD201 THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the Poticy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the Policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu Of such endorsement(s). PRODUCER The Dowd Agencies, LLC NAMEACT Ma Conro 14 Bobala Road PHONE Holyoke MA 01040 A! No �r•413-538-7444 FAX EMAIL AIC No), ADDRESS: PRODUCER ENELL INSURED INSURERS AFFORDING COVERAGE Energia, LLC INSURER A:Evanston Insurance Company NAIL Suffolk Street 242 Hol INSURER B:Commerce Insurance Com an 353788 Holyoke MA 01040 34754 INSURER C:StarStone National Insurance Company ..INSURER D:Guard Insurance Group25496 INSURER E: 8281 COVERAGESCERTIFICATE NUMBER: 1131630225 INSURER F: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED IONAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES F SUCH POLICIESLIMITS SHOWN DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS O . MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP A GENERAL LIABILITY POLICY NUMBER MMIDD/YYYY MMIDD/YYYY 2DB4466 LIMITS X7/1/2018 7/1/2019 EACH OCCURRENCE COMMERCIAL GENERAL LIABILITY S1,000,000 DAMA ENT CLAIMS-MADE X OCCUR PREMISES Ea oc-unence S50,000 MED EXP(Any one person) S 1,000 PERSONAL 8 ADV INJURY S1.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2.000,000 POLICY X PRO" LOC PRODUCTS-COMP/OP AGG S 2.000,ODO B AUTOMOBILE LIABILITY S BHOPBJ 7/1/2018 7!1/2019 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) 51.000,000 ALL OWNED AUTOS BODILY INJURY(Per person) S X SCHEDULED AUTOS BODILY INJURY(Per accident) S X HIREOAUTOS PROPERTY DAMAGE X NON-OWNED AUTOS (Per accident) S S C X UMBRELLA LIAB X S OCCUR 75750H180ALI 711/2018 EXCESS LIAR 7/1/2019 EACH OCCURRENCE CLAIMS-MADE $1,000.000 DEDUCTIBLE AGGREGATE 51,000,000 RETENTION S D WORKERS COMPENSATION S AND EMPLOYERS'LIABILITY ENWC952172 7/1/2018 S ANY PROPRIETOR/PARTNER/EXECUTIVE Y f N 71112019 X WC STATU- OTH- OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory In NH) E.L.EACH ACCIDENT $1.000,000 I!yes,descdhe under DESCRIPTION un OPERATIONS below E.L.DISEASE-EA EMPLOYEE $1.000,000 E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION 30 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. To Whom It May Concern AUTHORIZED REPRESENTATIVE f ACORD 25(2009/09) The ACORD name and logo are registered marks9so ACORDORD CORPORATION. All'rights 3 Commonwealth of Massachusetts Division of Professional Licensure Board Of Building regulations and Standards Construction SuAervisor CS-092540 Exp i res: 09/02/2019 THOMAS B ROSSMgSSLER 100 MAIN STREET ' HATFIELb M4 olo38 Commissioner Ll--r • r��--- /A Office of Cm onyucrAffairs&Bus/ iness/Regulation f, �-ROME IMPROVEMENT CONTRACTOR License or registration valid for individul r Peglstration: 16516, before the expiration date. use only Expiration; 1/11/2018 Type: Office of Consumer if found return to: ENERGIA LLC LLC 10 Parit Plaza_ Affairs and Business Regulatrdn Boston Suite 5170 MA 0211G THOMAS ROSSMASSLER 242 SUFFOLK STREET HOLYOKE. MA 01040 �.�•� . _ Vndersecretary Not valid Ivithout signature / The Commonwealth Of Massach usetts 67 Department of btdustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wwwanass.govId= Workers' Compensation Insurance Affidavit: Build s/Contractors/Ele A licant Information ctricians/Plumbers Name(Business/Organization/Individual : Energia, Please Print Le ibl � Ener is LLC I Viv Address: 242 Suffolk St. City/State/Zip: Holyoke, MA 01040 Are you an employer?Check the appropriate box: Phone #: 413-322-3111 1•VI am a employer with 1_9 _ 4. ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors6. 2•❑ I ata a sole proprietor or partner- listed on the attached sheet. 7. ❑ New construction ship and have no employees These sub-contractors have ❑ Remodeling working for me in any capacity. employees and have workers' 8' ED Demolition [No workers'comp. insurance compinsu . rance.$ required.] 5 9• El Building addition ❑ We are a corporation and its 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their myself. [No workers'comp, right of exemption per MGL 11 ❑ Plumbing repairs or additions insurance required.]t c. 152 14 12.❑ Roof re § ( ),and we have no pairs employees. [No workers' 13.❑ Other comp. insurance required.] "Any applicant that checks box I{I mast 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 =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and stale whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number, ndicating such. I am an employer that is providing workers'compensation itrsurance for my employees. Below is theolio a information. P y nd job site Insurance Company Name: Guard Insurance Group Policy#or Self-ins. Lic.#: ENWC952172 Job Site Address: kve, Expiration Date: 7/01/2019 City/State/Zip:_V)X j�(�P• Mn �J" Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration Failure to secure coverage as required under Section 25A of MGL c, 152 can lead to the imposition fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WOR ER a date). Of up to$250.00 a day against the violator. Be advised that a copy of this statement tna be for of criminal penalties of a Investigations 0 the K ORDER and a fine A for insurance coverage verification, y warded to the Office of I do hereby cerli tnder the pains and penalties of perjury that the information provided above ' true an Si nature: orrect. Phone#: 413-322-3111 Date: l Q Officiol use only. Do trot write itr tItls area,to be completed by city or town OfficialCity or Town: Issuing Authority(circle one): Permit/License# I. Board of Health 2. Building Department 3. CitY/rown Clerk 4. Electrical inspector 5.Plumbing Inspector Contact Person: Phone#: RISE ENGINEERING" OWNER AUTHORIZATION FORM I, Jane Myers (Owner's Name) owner of the property located at: 74 Straw Avenue (Property Address) Florence, MA 01062 (Property Address) hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. Owner' Signature Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 1 Canton, MA 02021 1339-502-6335 www.RISEengineering.com