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06-010 (3)
595 HAYDENVILLE RD-Route 9 BP-2020-1206 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 06-010 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2020-1206 Project# JS-2020-002024 Est.Cost: $2600.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JAMES NATLE 057516 Lot Size(sq.ft.): 5488_56_.00 Owner: SYMONS HELEN E zoning: SR(103)/ Applicant. JAMES NATLE AT: 595 HAYDENVILLE RD - Route 9 Applicant Address: Phone: Insurance: 494 S GULF RD (413) 348-0383 SOLE PROPRIETOR BELCH ERTOWNMA01007 ISSUED ON:6/4/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSULATE ATTIC SPACE 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 6/4/2020 0:00:00 $65.00 212 Main Street, Phone(413).587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner dotloop signature verification: e •.� gepartmt3ni use ority City of Northam�ton,,G, ` &tsWs of Permit <_,. Building Depta., ent pwo ut/Driveway Permit 212 Main�S{� Q rlSepiJtAv>ttlebltlty ( Room 1 r y �i^ �n�0NgWAvaii0biltty Northampton, M ' , ethof Structural,Pians phone 413-587-1240 Fax 413- .79 Piotl to Pians °opo%ti a er&petty, APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVA O EMOLISW A ONE OR TWO FAMILY DWELLING SECTION 1 -StTE INFORMATION i.1 Property Address: This section to be completed by office map � Lot fJ r6 Unit 595 Haydenville Road, Leeds MA, 41053 zone Overlay district Elm St.District— CS Dlatrlct SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: Helen Symons 9 High Street, I-Iaydenvilie MA, 01039 Name Print Current Mailing Address: 413-237-7$56 0 cop vera ie �.vay 05M4 MI K_L PM EDT V M4�MIRK-LBOI-6RN0 Telephone Signature 2.2 Authorizer!A entc Name(Print) Current Mailing Address: y/3- 2y8_0103 Signature Telephone sE TId(N -ESTIMATED CON TRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1 Building $2,600 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee b� 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) $2.6(10 Checic Number This Section For Official Use Only Date Building Permit Number Issued: Signature: Building Commissionerlinspector of Buitdings tate Jnate7007 @ WIXOM EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) dotloop signature verification: 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: L:. ... Rear Building Height Bldg.Square Footage % Open Space Footage (Lot area minus bldg&paved parking) #of Parkin Spaces Fill: (volume&Location A. Has a Special.Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW Q YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW (F) YES Q 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 a NO 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 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. dotloop signature verification: r.._.. SECTION 5 DESCRIPTION QF PROPOSED WORK(check all applicable New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [©j Decks JM Siding(01 Other[Eg Brief Description of Proposed Insulating of Attic Space Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet so,if New house and or addition to existing housing,cQmgiete 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 1. 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. 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 Helen Symons owner of 595 Haydenville Rd. I ,as Owner of the subject property James Natie hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. 0 oopvera ie +fel.v�s.,o 0529/206 PM EDT VP-W F- FK- WD Signature of Owner Date 7-e-e- ,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. Print Name s z IZG)2 e,) Signature of r/Agent Dale dotloop signature verification: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable Cl Name of Liconse Holder: James Natle License Number 494 S. Gulf Rd. Belchertown, MA 01007 CS-057516 Address Expiration Date James Natle 7/31/2021 Signature Telephone 413-348-0383 8 iteuistered Home lIM-pr nIXIOntContractor• Not Applicable O Company Name Registration Number 163318 Address Expiration Date Telephone 5/31/2021 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.182,§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....... ET' No...... 0 dotloop signature verification: City of Northampton r." Massachusetts �r }; DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street a Municipal duildlnq ° Northampton, MA 01060 �.`.4 ;:V. AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OC:ABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes, a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L. Chapter 142A requires that the"reconstruction,alteration, renovation,repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work: 9-m4, �i,IS,�Z r✓ Est. Cost: Ile �iOd Address of Work: gd ��r Date of Permit Application: I hereby certify that: TTT Registration is not required for the following reason(s): Work excluded by law(explain): Job under$1,000.00 T Owner obtaining own permit(explain): – _Building not owner-occupied Other(specify):-- - —. OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE DOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PACE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: 000 ly'viz- Datc Contractor Name HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature dotloop signature verification: City of Northampton Massachusetts F3 DEPARTmWT OF BUILDING INSPECTIONS 212 Hain Street •Municipal suilding Northampton, HA 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 119, S 150A. The debris from construction work being performed at: ALA, • ILCc5 02d t ei5izs (Please print h number and street name) Is to be disposed of at: (Please print name and location of facility) /-/f� 'S- &V4f r2f? v��+; •7W Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) S Zif Sign a 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. dotloop signature verification: The Commonwealth of[Massachusetts Department of Industrial Accidents � l 1 Congress Street,Suite 100 Boston, MA 02114-2017 :y www mass.gov/dia Wurkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Btisiness/Organization/Individual):James Natle Address:494 S. Gulf Rd. City/State/Zip:Selchertown,MA 01007 Phone#:413-348-0383 Are you an employer'!Check the appropriate box: Type of project(required): 1 ❑lam a employer with _ ____employees(trill atidlor part-time).• 7. ❑blew construction 2❑1 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.) 9. El Demolition 3,[DI aw a homeowner doing all work myself.(No workers'comp.insurance required.]t l0 E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct ail work on my property. l will ensure that all contractors either have workers'compensation insurance or are sole l l.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.Q t am a general contractor and I have hired the sub-contractots listed on the attached sheet. 13.❑Root repairs These sub-contractors have employees and have workers'comp.msurancc.t 13.[]Roof 14,❑✓ Otltcr Insulation of attic 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'Bump.insurance required.] *Any applicant that checks box Iii must also fill out the section below showing their workers'compensation policy information. t I lomeowners who submit this affmdavil indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. iControctors that check this box must attached an additional sheet showing the name of the subcontractors 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 rise policy andjob site information. Insurance Company Name: Policy#or Self-ins. Lic. ll:_ , „ _ Expiration Date: Job Site Address: City/State/Zip: Attach a copy or the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required tinder MGL c, 152,§25A is a criminal violation punishable by a fine up to S 1,500.00 anti/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 a pains and penalties of perjury that the information provided above is true and eorrec� Signature: Date: 57/Z� 2iJZ0 Phone 11:413-3 -0383 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 S.Plumbing Inspector 6.Other Contact Person: Phone#: