Loading...
43-116 BP- 2011 -0510 GIS #: C OMMONWEALTH OF MASSACHUSETTS � 416 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category BUILDING PERMIT Permit # BP- 2011 -0510 Project # JS- 2011- 000831 Est. Cost: $11300.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor. License: Use Group: BARRON & JACOBS 030739 Lot Size(sq. ft.): 94960.80 Owner: DOHERTY JOHN C & KATHLEEN M Zoning: SR(100 )//WSP II Applicant. BARRON & JACOBS AT. 217 PARK HILL RD Applicant Address: Phone: Insurance: 70 OLD SOUTH ST (413) 586 -8998 Workers Compensation NORTHAMPTON MAO 1060 ISSUED ON. 121112010 0:00:00 TO PERFORM THE FOLLOWING WORK .-STRIP & SHINGLE ROOF 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 12/1/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner . Department use only City of Northampton Status of Permit: Building Department Curb CutlDriveway Permit 212 Main Street Sewer /Septic Availability N0) d 3 0 2010 Room 100 Wat er/Well A vailability Northampton, MA 01060 Two Sets of Structural Plans phon6 413: -587 - 1240 Fax 413 587 - 1272 PloVS'tte Plans Other Specify 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 A 1� �j r � �- 19 c,, I AA -1 l i I I K o J Map Lot Unit 1' 1 1 o r ( vNc e) j r 1 A U � U G a Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Ci 1 O6 a Name (Print) l Current Mailing Address: �c.,�V%Ak - / PS4 �� S�C��r,� .,xjt � Telephone Signature 2.2 Authorized Anent: rCA _c- s D j �n�j� S t #('.'aC4k Q1060 Name (P t) Current Mailing Address: �1I ;. 5 � 6, ggqc6 Signature Telephone SECTION 3 - EST M ED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building 00 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee (yt; 4. Mechanical (HVAC) (� 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Oo' ° Check Number 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 This column to be filled in by �! Building Department Lot Size i Frontage A// A Setbacks Front Ap / /IX Side L: R: ��!� L: VIR:.�Y f1 Rear /V Building Height Ali Al Bldg. Square Footage �� % N o Open Space Footage (Lot area minus bldg & paved fl�li 0 C? C" arkin # of Parkin Fill: volume & Location A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO O DON'T KNOW YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © 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 © YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained © , Date Issued: C. Do any signs exist on the property? YES © NO • IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, xcavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO 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 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other [o] Brief Descr of Propo e( I Work: ��r�n cv. '��,lnt�� ©If �.On�UXIy��� .I�, �� S IfGG Alteration of existing bedroom Yes X No Adding new bedroom Yes x No Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roll - Sheet 6a. If New house and or addition to existina housing, complete the followina: 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 4 v ',L tC as Owner of the subject property hereby authorize to act on my behalf, in all ma tters relative to work authorized by this buildin p rmit application. L ' /-e c_ vvv t, T C ( L 0 h C I t" Signature of OwnaO Date as Owner /Authorized Agent hereby declare that the statements and information on thb foregoing application are true and accurate, to the best of my knowledge and belief. Signed under he D2ins and penalties of perjury. G s( 5 Print Na Sig ature of Owner /Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor ` Not Applicable ❑ Name of License Holder C i �� I.CV U S — C S -� 0 License Number oxw � (11120 11 Address u Expira oon date Signatu Tele hone 9 Reciistered p Home vement r: Not Applicable ❑ 1� U.r r ca n Lc l-" Combs /—I 5.�zc2 L �. r_ 100 qo Company Name Registration Number C) o Sv S ' c� A c 61 a3 /`aoI �, Address Expirat on D to Telephone 4 3 . A, UK 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....... 0 No...... ❑ 11. - Home Owner Exemption 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 SIGNATURES By signing below, you agree to items A, B and C. DO NOT SIGN THIS AGREEMENT IF THERE ARE ANY BLANK SPACES. A. Altemative Dispute Settlement (Arbitration Clause): The Seller and the Buyer hereby mutually agree, in advance, that in the event of a dispute concerning this Agreement, the parties shall submit such dispute to a professional, state - approved arbitration service (cost, if any, to be paid by the submitter) prior to either party proceeding to legal action in the courts. 3 Hy signing this agreement, you,�as the owner of.record, are hereby, authorizing Barron & Jacobs Associates I nc. to alt as your authorized agent in all matters pertaining to the building permit application. C. This is a binding Agreement. You may not cancel it except as stated. This Agreement covers and supersedes all conversations, statements and agreements, expressed or implied, between the parties, their agents or representatives. You, the Buyer, may cancel this t r } ' / a t transaction at any time prior to Bu e Date midnight of the third business day � ���/ (, after the date of this transaction. -f �ut�T tkip, #1 Pek' k'A' � l-� getz 1 See the attached notice of cancellation Buyer T D e form for an explanation of this right. Seller retains an equal right to cancel. Ze ,, ce 11,12 b y 1 5 Barron & Jacol6ri?epresentative Date ************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Designer /Salespersons Registration Numbers ❑ Cecil R. Jacobs MA HIC 100809 ❑ Christopher R. Jacobs MA HIC 100809 CT HIC 0518617 CT HIS 0554397 MalkiAd 1, Satkowsld MA HIC 100809 ❑ William J. Bonini MA HIC 100809 CT HIS 0554600 CT HIS 0553918 Barron and Jacobs - Key Personnel Contact Information: Office Cell Home Office Manager: Sandy Scavotto 413.586.8998 Operations Manager: Bill Bonini 413.586.8998 413.672.1009 President: Cecil R. Jacobs (Jake) 413.586.8998 413.250.2357 413.584.4447 Purchase Agreement Page 11 of 11 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 4 s• www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers Applicant Information \\ ,( P _, lease � Print Legibly Name ( Business / Organization /Individual): L �_I, I + �S A JJO� 1�.t eh, c1 y�S Address: 10 O LD S O .l j W S ) City /State /Zip: N t„rr, of ,;, A a i u cso Phone #: 41 6 7) 6 .- H! Y Are you an employer? Check the appropriate box: Type of project (required): 1. I am a employer with I_ 4. ❑ I am a general contractor and 1 6. ❑ New construction employees (full and/or part- time).* have hired the sub - contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. * 7 . ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.0 Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions c. 152, 1(4), and we have no myself. [No workers' comp. § 4 () 12. Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] Any applicant that checks box #I 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. *Co ntract o rs that check this box must attached an additional sheet showing the name of the subcontractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. _ Insurance Company Name: 4? of : Policy # or Self -ins. Lic. #: Q� J < `, Expiration Date: (� Job Site Address: - 11 3 1 LJ K I l (+ � d , C_ L,-ett[ C_ , Al J O I b G)� City/State /Zip: �c, e � � � o 1 o c d 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 cove verification. I do hereby certify er the pai nd pen ties of perjury that the information provided above is true and correct. Si nature: Date: I 30 ac U Phone #: 1 5 6 Official use only. Do not rit 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 #: E a ; . � ...._.V..,..t��.a�- ...- ��...�.: �n aCCOr:?ai t�s 1:'if2 - I the provisbris GI I IGL G W, §54, I ac rJwledgge, as a Condition of Vie Bu ding pemilt, all debris resul'Un( fro:'1`i Comslr uction ac-'L V ty governed by flhis Fuilding hermit shall be caisposed of as. 0 i 9 a p oper l} f ics3nse d sol ld ` y- i �� a ar; 6t C '1 11 I i E i n yr4ci5!e TU�.II(� c.S �L7:= 8C� f 'Ly '�� � �50A. 3 �` 0 . �' —t .�- F�+`i:F:i.'P�° irT ri - lfiz�i f- :t� + j � 1 I E - 't. �f_i E �YP . - t om � 4t:31�J1: Jf' i_5irSi E J -, 3 t ` G il.- ..'�eJ i 1 n f * :J;! }LV JrSC :: 17— C_ F I cA.►��� - -- (TYPE OF MA T Lz i`t: � C =`.Sr�� >S�f� OF rl FOPER i `f A lr DRES �t F t 7 f t L'Ci Cc:i�LC;7.4S:L1�L �JilJ7f ?lRr• �.4liC?= :aI:JR�in - i -� rl..- �.�.r -, in J