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17A-009 20 STERLING RD BP- 2012 -0061 GIs #: COMMONWEALTH OF MASSACHUSETTS Map :Bloc 17A - 009 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Bath reno BUILDING PERMIT Permit # BP-2012-0061 Project # JS- 2012- 000092 Est. Cost: $4250.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JAMES VAN NATTA 040620 Lot Size(sq. ft.): 13503.60 Owner: PORTH SIEGFRIED Zoning: U RA(100) //IU /WSP Applicant: JAMES VAN NATTA AT. 20 STERLING RD Applicant Address: Phone: Insurance: 403 SOUTH MOUNTAIN RD (413) 834 -5329 (� NORTHFIELDMA01360 ISSUED ON.711812011 0.00:00 TO PERFORM THE FOLLOWING WORK.- Bathroom Renovation 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 7/18/20110:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner Cit of EIVEDQ °��,;' Building De 212 M in treet x °F Ro m 1 0 1 A 2011 t � Northampt n, A 01060 phone 413 - 587 -12 0 _`� ` "s h� ri APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address This section to be completed by office Map Lot Unit L �lZ l�l L iN1 Zone Overlay district Elm St. DM*W CIS District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record / '2- - ?> Name (Print) Current Mailing Address: -i 3 __ "_......Telephone Signature 2.2 Aut orized Accent: Name (Pript) Current Mailing Address: q r!s 4E!�--/- 5S za C Signature Telephone E T N a - ESTIMkEQ CONSTJUCTION gOSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of 2 (:L�3 Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) f ab 5. Fire Protection "- 6. Total = (1 + 2 + 3 + 4 + 5) 4 5 C:> Check Number , Cq) This Section For Official Use Onl Building Permit Number: Date [issued. Signature: Building Commissioner /inspector of Buildings Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning �L This column to be filled in by 1�►^� ��`" " ' Building Department Lot Size Frontage Setbacks Front Side L.: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg & paved p arking) # of Parking Spaces Fill: (volume & L,ocation) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW a YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW YES 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 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained U , Date Issued: C. Do any signs exist on the property? YES NO a IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® 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 ef IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 6- DESCRIPTION OF PROPOSED WORK (check all awlicabi, New House ❑ Addition ❑ Replacement Windows Alterations) Roofing El Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [l -3] Decks Siding [0] Other [p] Brief Description of Proposed Work: - TIJ 124aC=, .M VA=r«.t4 L f Alteration of existing bedroom Yes _,4 No Adding new bedroom Yes _ No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 64 WN 1:<#a i m 3 $: 1A/ # ' 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 Ta - OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, S l as Owner of the subject property herebyapthorize to act o my behalf all ative to work authorized by this building permit application. Signature of er Date 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 Na 7) 1 Signs ure f ner/Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Sup ervisor : ' Not Applicable ❑ Name of License Holder e 1r� �1y't�L 1 xF af� i4— License Number Addres Expira i n Date Signal a Telephone k Ro-alotwod Hom Irh61C4r� tractor: Not Applicable ❑ ! a - Z = - l c:.; z. Company Name Registration Number Acrdress Expiration Date c� fWTIQ U C> 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...... ❑ The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official that he /she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature _ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www. mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business / Organization /Individual): �� �_.CQ Address: - 4 —tnZA ( i> JAL <.:> City /State /Zip: Phone #: Lfi-3 Are you an employer? Check the appropriate box: Type of project (required): 1. N I am a employer with 2 4. ❑ 1 am a general contractor and I — * have hired the sub - contractors 6. C] New construction employees (full and/or part- time). 7. Remodelin 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ( g ship and have no employees 'These sub - contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10. ❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13. El Other comp. insurance required.] Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. ± 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 employ If the sub - contractors have employee 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 andjob site information. _ Insurance Company Name: 1p ( A( l Policy # or Self -ins. Lic. #.- V 4-VJ L �l� "� � 4'a Expiration Date: 6ol 4 S /< Job Site Address: - 2 L 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi n r th pains and penalt' s of perjury that the information provided above is true and correct. Si tore: Date: Phone #: 6 t`�> -� 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 #: