31A-074 APPLICATION ON HOLD . 1 Nele 71' ZA t f n K_I- \
,. 00 ---7
14 The Commonwealth of Massachusetts
m1 1 6 Rnard of Building RPaiilatinnc and Standards FOR
A Massachusetts State Building Code, 780 CMR MUNICIPALITY '
USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
One- or Two-Family Dwelling
This Secti For Official Use Only
Building Permit Number: €?é'1" 1-- A / i Date Applied:
Building Official (Print Name) Signature Date
SECTION 1: SITE INFORMATION
i.i r pert tsa s.: 1.G Assessors Map ice Parcel N
Wad rn9101) 1 p uin rsQ
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
7nnina Dictrirt Proposed I ice I nt Area (m ft) Frnntaan(ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c. 40,§54) 1.7 Flood Zone Information: ' 1.8 Sewage Disposal System:
Public 0 Private CI Municipal Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ova} Pof Recor
-" ,OrilPT-69 11,9c, '
Name (Print) City, State,ZIP
y 1A}C6A,g n s+ 53/ q33?
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2 (check all that apply)
1 I!New Lonsiruciion u , existing Building Es . L caner-Occupied Es 11I Repairs(s) u I Ii Aiteration(s) u iII Addition Ct
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Wor 2: t :' f P b 5 &i ►ce a a' i A
..
� i . C - ' a e ita RE "' # :� • I S •
• i `f�'! r uTIMMINIZIEN
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
I•l .Stanriarrl rite/Tnum Annli rat inn Pan
Electrical $ 0 Total Project Costa (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Gmnraccinn' $ Total All Fee :,$
--rr---'-_. ) jj�j�j
Check No. 5 tJ' 'Check Amount: V Cash Amount:
6.Total Project Cost: $ 5 d( Q i 0 Paid in Full 0 Outstanding Balance Due:
•
SECTION 5: CONSTRUCTION SERVICES A ja(ell
,,,,,i ) ?14%.4 License Number pira on
Name of CSL Holder
t),.3 1e ,o� G List CSL Type (see below)
No.and Street v Type Description
LJ` •U.` 'e L f t I!�5 5 0((�(0(� 'v unrestricted (Buildings up Co 15.uuv cu.n.)
C J� J" 1, v `�-� R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Telephone Email address D I Demolition
5.2 Registered Home Improvement Co actor(H ) /67 Q G y 1701
1 \ 4 % Z,J4k( k itiA(p It i v- HIC Regi(sttraattion Number(1134 )
6(
`v
HI �Name or legit Name
. a (mil
No.anlf�StrT a..(``Ci 'A\�SS ( t r l V� _1/ Email address
City/Town, State,ZIP 1 Telephone
SECTION 6: 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 X
No .0SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
r
1,as Owner of the subject property, • -• a orize TO i,J J4 ) 2tA5 itto act o f •f behalf, in all matters rela • to ork authorized by this buildinpermit application.
�& _.
Print •ma _'s Name(Electronic Signat ii,�� Date
SECTION 7b: ilir NEW 0 AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties • •erjury that all of the information
contained in this application is true and accurate to the best of my , • • . ed:• and understanding.
i
/ -Print Owner's or Authorized Agent's Name(Electronic Signature re/N Date
re
NOTES:
1. An Owner who obtains a building permit to do his/her own •rk,or an • er who hires an unregistered contractor
(not registered in the Home Improvement Contractor (HIC)Program , '11 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other importan formation on the HIC Program can be found at
2. When substantial work is planned,provide the information below:
Total floor area (sq.ft.) (including garage,finished basement/attics, decks or porch)
Gross living area (sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
'type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
City of Northampton
.,s\s 7 ,*-
Massachusetts 4-w _..
* . c
wl Ir.
• DEPARTMENT OF BUILDING INSPECTIONS y,
\ 212 Main Street • Municipal Building $
Northampton, MA 01060 71
1f1 arD\11,
CONSTRUCTION DEBRIS AFFIDAVIT
(Ff R AT.T.TIFM(IT.TTT(IN AND R F N(IV A TT C)N PR Q TFC'TS
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
propproperly licensed waste disposal facility,, - defined I- , MGL n 111, c i AA
erly lice nsed vvaste disyposal facility, as de!ineed by er4'L +, a 1„ 0A,
The debris will be disposed of in:
•
Location of Facility: VG, 1 . e Cy C I r
tfl 9
The debris will be transported by:
Name of Hauler: 5 /7;'e.1-11C4rSV
Signature of Applicant: Date:
Town of Williamsburg 141 Main St Haydenville
Solid Waste 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.
Address of the work: if LJoc1iivivi 4ç/
The debris will be transported by: At ch i
The debris will be received by: IA 1(r? Zecicle
Building permit number:
Name of Permit Applicant 1 .X� Z�6�/
pP u ,CJ�
/I/k1'2t q
Date Signature of Permit A ppl.' ant
l
The Commonwealth of Massachusetts
_ I Department of Industrial Accidents
1 Congress Street, Suite 100
,` Boston,MA 02114-2017
4,,,� www mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
A licant Information lease rint Le i
Name(Business/Organization/Individual):
Address: i l 0 , ept acy-
...,
City/State/Zip: -t (—fat(fe t.0( AS)Phone#: 11( -) t 6 ' 716 0
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.1:1 I am a sole proprietor or partnership and have no employees working for me in K. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]+ 9. El Demolition
I 10❑Building addition
4.❑I 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 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.12 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ROOF repairs
These sub-contractors have employees and have workers'comp.insurance.
6. We aze a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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.#: - 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 ve ' .
I do hereby certify unde t pains d,enal ' of perjury that the information provided above ' true nd correct
Signature: lie: l l i`1 ar
Phone#:
Official use only. Do not write i 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#:
1