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05-062 (11) 503 AUDUBON RD BP-2021-0097 GIs#: COMMONWEALTH OF MASSACHUSETTS Map-Block:05-062 CITY OF NORTHAMPTON Lot:-001 111'ItSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate og U: Sk, jj& BUILDING PERMIT Permit# B.P-2021-0097 Proiect# JS-2021-000149 Est.Cost:$12000.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sc.ft.): Owner: PACILIO MARTHA N Zoning RRO 00)/WSP(7 1)/WP(9)/ Applicant. VALLEY HOME IMPROVEMENT INC AT. 503 AUDUBON RD Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON:7/24/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE 8 SKYLIGHTS 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 Sip-nature: FeeType: Date Paid: Amount: Building 7/24/2020 0:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Q�- Department usaCity of Northa pion s of Pemrtt ' , 3 Building Dep rtme r e 'rnreway Permit i ` 212 Mai tre Se Y tic vailability Room fl�FAr �� Water z!E A� abilrty Northampton, MA �� Tvo ts=of uctural Plans47 P �� phone 413-587-1240 Fax 41 - ��, PIa Srte P v ns APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVAT DEMO ISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Property Address. - This section to be completed tsy office SJ x .�1�(" (2c, Map Lot unit ' t Zone Overlay District Elm SLID istrict CB District '. SECTION 2:-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: boo r so� o t2 Leals TAA a I cam Name(Print) Current Mailing Address: �p¢_- t4l-2,— c?Lx.x IGC E C Gi VTelephone 4 )jtj Signature 2.2 Authorized Agent: i I\Jf,.rrnan Storer-)c_r, M(1 - 010G,2- Name(Print) Current Mailing Address: 41-1x-58y-��22 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 . C'onstructonfrom 8: 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) a 5. Fire Protection S. Total=0 +2+3 +4+5) ri Iry I. Check Number This Section For Official Use Only Building Permit Number: IU1 Date Issued: Signature: Building Commissionertinspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To incomplete information Existing Proposedl Required by Zoning Ibis column to be Wed in by Building Department Lot Size Frontage Setbacks Font L—j Side L:= R:=- L:= R? I Rear Building Height Bldg.Square Footage % F— Open Space Footage % (Lotiuca minus bldg&paved piifidng) #of Parking Spaces Fill: 1 (volume&Location) A. Has a Special Permit/Variance/Finding ever be9l issued for/on the site? NO 0 DON'T KNOW 0 YES 0 IF YES, date issued:i IF YES: Was the permit recorded at the R istry of Deeds? NO 0 DONT KNOW YES 0 IF YES: enter Book Page= and/or Document#1 B. Does the site contain a brook, bqUy of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been/0�need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 Date Issued: lr C. Do any signs exist on/&property? YES 0 NO 0 IF YES, describ "ize, type and location: D. Are there any�roposecl changes to or additions of signs intended for the property? YES 0 NO 0 IF YES, dscribe size, type and location: E. Will thq,r'onstruction activity disturb(clearing,grading, excavation,or filling)over I acre or is it part of common plan that')eill d'sturb over 1 acre? YES NO 0 lf"YES,then a Northampton Storm Water Management Permit from the DPWis required, SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacem Windows Alteration(s) Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [a] Decks (Q Siding [0] Other[pj Brief Description of Proposed t y {ir N i>;UpY� } 1 i 1Y4 ti , Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basemen; Yes No Plans Attached Roll -Sheet sa. ff Newhouse and.-or addition to extirSg fousing, complete the falCowme: a. Use of building: One_Family Two Family Other b. Number of rooms in each family unit: Number of Sathroo 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. Mas.. 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. 1. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION.-TO BE COMPLETED WHEN OWNER&AGENT OR CONTRACTORAPPLIESFOR BUILDING PERMIT as Owner of the subject property hereby authorize 6)�V C✓MC�r� to act on my behalf, in all matters relative to work a horized b this building permit app4catiop. 112- 2- Signature of Owner Date I, ltt"Xl S I�VCe'majo' V 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. v,e►- Print Name r jj+ Signature of Owner Abe t Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Constructions Supervisor: Not Applicable ❑ Mame of License Holder: �{'��J eA� l' �Yl'��f 1 0-1-70--19 License Number C' tat Jat Address Expiration Date Sign ture Telephone 9 Reaisteretl°Home[tna�+suernenYGoritractor. _ Not Applicable O Company Na#he Registration Number D(0 7 �--t Of6-7t R U l C)b2 7 t k zo Address Expiration Date Telephone -Z � - ! ZZ SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25CM) 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.....- ❑+ i i City of Northampton _ MassachusettsY *'r DEPARTMENT Oa' BUILDING INSPECTIONS ?f � = ` 212 Main street • Municipal Building Northampton, MA 01060 AFFIDAVIT Rome Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")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 a$a Home Improvement Contractor("IEC")- M.G.L. "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.urLLC,that entity must be registered Type of Work. =��� WEst.Cost: 12� l� Address of Fork 0 5 0k� ' Date of Permit Application: I hereby certify that: Registration is not required for the following reasora(s): Work excluded by law(explain): Job under$1,000.00 Owner obtaining owe permit(explain): Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERN11T OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR A-ND 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 PERNIIT.SEE NEIN PAGE FOR MORE IN-FORAIA flON. Signed under the penalties of perjury: I hereby apply for a buildingpermitas the agent of the owner: \! 1't'd l 1�UYY1 G1r14 r�cC t 11t°'T ��F'l �dcJ c�L/3 Date Contract6r 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 City of Northampton Massachusetts ^� 3 I DEPARTMENT OF BUILDING INSPECTIONS 212 Main S:seet •Municipal. Building �r 4x1 Northampton, MA 01060 s Y 1R Debris Disposal Affidavit- In ffidavi.fiIn 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: (PleaVe print nd e and�loca4t on of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) r 1 / LVV/ 7Ir Signature 6-Permit Applicant or wner 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 �u .Department of IndustrialAccidents ' 1 Congress Street,,Suite 100 Boston,MA 02114-2017 wKw mass.gov/dia N'l'orkers'Compensation Insurance Affidavit:Builders/Coutractor"lectricians/Plumbers. TO BE FILED ANTM THE PERMTl'TFNG AUTE1ORM. Applicant Information Please Print Legibly Name(Business/0-ganizatiowTndividual):_ iybry) M 1 C. Address: ko R. City/5tate,,`Zip: V\cweryx, t>t{ b2- Phone 4: Lt Are you an employer?Check the appropriate box: Type of project(required): I.91 am a employer with 1__employees(fall andtor part-tune).* y. D New construction 2.o I am a sole proprietor or partnership and have no employees wortcing for me in 8. ®Remodeling anycapa.ity,jNoworicers`camp,io urence require&] 9. ❑Demolition 3.7 I am a homeowner doing ail work myself.iWo workers'comp.insurance regrired.j t 10 Building addition 4,M I am a homeowner and will be hiring contractors to conduct all work on my property. I WM ensure that alx contractors either have workers'compensation insurance or are sole 11,[]Electrical repairs or additions Proprietors with no employees. 12.Q Plumbing repairs az additions 5.[7 I azo a general contractor and I have hired the sub-coat-actorrs lisrxA on the attached sheet. 13. Roof repairs 'mese suh-contractors have employees and have workers'comp.insztance. 6❑we are a corporation and its otxicers have exercisedtheir right of exemption per MGL c. 14.Q Other i52,§1(4),and we have no employces.NNo workers'comp,msur^^e requiredl *Any applicant that check.box#1 must also fill out the section below showing their workers'compensation policy infomation. 7 Homeowners who submit this affidavit indicating they are doing all world and then hire outside contractors mast szbmit a new affidavit indicating such, lCont actors that check this box muse attzched an additional sheet shou�ng the name of the sub-contractors and smte whether or not those entities have employees. Ifthe sub-contractors have employees,they must provide'their workers'comp.policy camber. I am an employer that is,providing workers'compensation insurance for my employees .Below is the polu_}l and oh site information. J/��Y_ Insurance Company Name:)� .. Policy#or Setf-ins.Lic.#: � C}�✓f}'�\�J Expiration Date: OIL, _ 121 Job Site Address: �) t i __- City/Statelzip: n �, Mn- 01 -3 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 m and/or one-year imprisonment,as well as civil penalties in the forof a STOP WORK ORDER and a line of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investgations of the DIA for insurance coverage verification_ Ido hereby certify under the pains and penalties of 7*ury that the information provided above is true and correct Signature: Gf£ � �1f�/' Date:. l { C1 Phone#: Official use only. Do not write in this area,to be completed by city or torn official, City or Town: Permit'Licease# Issuing.Authority(circle true): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone 4: r Commonwealth of Massachusetts Cirision of Prcressional licensure Board ofSuilding Recuiations and Standards Const, Ct Cr7 Oervisor t� CS 077279 E fires: 06121120260 STEVEN A SIL-VERfidAf'x 258 FON€ER RQ}tD : SOUTNAMPTOV-A 01673.- OI.�S330 Commissioner �. dffi e of Consumer Affairs and Business Regulation One Ashburton Place -Suite 1301 Boston, Massachusetts 02108 Home lmproveme t tractor Registration Type: Corporation VALLEY HOME IMPROVEMENT ING Registration: 106543 P.O,BOX 60627 17i Ex iraion: 07/1612020 i€ _ F` `.} FLORENCE,MA 01062 r, Update Address and Return Card. office of Consumer Affairs&Business Regulation NOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:-,C ormratios before the expiration date. if found return to: Registration Expiration � Oboe of Consumer Affairs and Business Regulation 1005 07116/2020 One Ashburton place-Suite 1301 'ALLEYHOh�ii=J�t'ipRO _ ING Boston,MA 02108 TEVEN A.SiLVERM71�� "1 2Q, —• � 'f!/ / � f'A i +0 RIVERS!DEO ©RTHAMPTi71i,MA 04n 2 undersecretary Not valid without signature