17A-059 , NW` KV. sT BP- 2010 -1194
GIS #: COMMONWEALTH OF MASSACHUSETTS
PWU>t: 17A - 059 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- 2010 -1194
Protect # JS- 2010- 001728
Est. Cost: $1724.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: IDEAL HOME IMPROVEMENT INC 091207
Lot Size(sa. ft.): 6969.60 Owner: MCCARTHY CHARLES E III & KATHY
Zoning. URB(100)// Applicant: IDEAL HOME IMPROVEMENT INC
AT. 204 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
142 BOYLE RD (413 ) 863 -2128
GILLMA01354 ISSUED ON 613012010 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL WALL INSULATION TO R20
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 6/30/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2010 -1194
APPLICANT /CONTACT PERSON IDEAL HOME IMPROVEMENT INC
ADDRESS/PHONE 142 BOYLE RD GILL (413) 863 -2128
PROPERTY LOCATION 204 NORTH MAPLE ST
MAP 17A PARCEL 059 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
T_yueof Construction:_ INSTALL WALL INSULATION TO R20
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure f. 'Ra(LT
Building Plans Included: (�P� is ('. 7� vvb
Owner/ Statement or License 091207
3 sets of Plans / Plot Plan Cd "TRAC u (L m a `A l Sal Pim iT W ! R 1 N& A, DX4 iT
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
!✓ pproved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
Department use only
City of Northampton Status of Permit:
`� Btiiloing Department Curb Cut/Driveway Permit
�h 212 Street Sewer /Septic Availability
Room 100 Water/Weil Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413 -587 -1240 Fax 413 -587 -1272 Plot/Site 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
0 44 n 1 � E Map Lot Unit
6A ( �
/ V . ' �'l Y
Zone Overlay District
q I o rie M 14 m 10 (oa
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
�Qkr) s H e S.Q:rpt as r� r
Name (Print) Current Mailing Address:
'y- � Telephone
Signal
2.2 Authorized Agent:
,�(' In S �'l I t S ``fib 6o c i � , . C t M4
5gn (Print) Current Mailing Address:
a I k) tune Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
com feted by rmit applicant
1. Building >� r-, J� ` J C� (a) Building Permit Fee
2. Electrical � (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Onl
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Duero 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: R:
Rear
Building Height
Bldg. Square Footage °i°
Open Space Footage %
(Lot area minus bldg & paved
p arkin g)
# of Parking Spaces
Fill:
volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO ® DONT KNOW ® YES 0
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES 0
IF YES: enter Book Page; and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW ® YES
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 ® 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
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
Accessory Bldg. 0 Demolition El New Signs [r-3i Decks [M Siding [0] Other [
W e rk DescriptionV m ; d ^
o f _ � n
1 h St,t, (�1✓1� i�
Alteration of existing bedroom Yes / No Adding new bedroom Yes e---
Attached Narrative Renovating unfinished basement Yes N o
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete 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
i. Is construction within 100 ft. of wetiands? 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
I r kav - les�. H e Ca r' 1 A as Owner of the subject
property
hereby authorize I' S
to act on my beh2lforn all matters relative to wodLAWthorized by this building permit application. �
Signature of Owner ale
&k- EAU as OwnedAuthorized
Agent hereby declare that the statements and information on the foregoing application are true and agate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print me
na re of Owner /Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 License Construction S ervisor: Not Applicable ❑ -
Name of License Holder Cl rn A S S q t " ` t
MA License Number
10 11 o, ( D i e) C)
Address Expiration Date
Si attire Telephone
.
9. Istered Home Contract w: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
T eleptrone �'t3 `t."�3 - �
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G L. c. 152, § 26C(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 ...... Er No ..... ❑
11. Home Owner Exemption
The current exemption for " homeowners" was extended to include Owner - occupied Dwelliinas 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, Sk& Edition Section 1083.5.1.
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 struchrres accessory to such use and/ or farm
structures. A person who constnwU more than one home m a two -year period sball 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 ender the buildine permit
As acting Construction Sepervisor your presence on the job site will be required fi-om 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, boa 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 oflnvestigations
<+ 600 Washington Street
Z
# Boston, MA 02111
www.mass-gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Apulicant Information Please Print Legibly
Name ( Business torganization /Individual):
Address: /+,X 6 �L
City /State /Zip: C, 1 N i 0 3� Phone #: `t 3 - 3
Are you an employer? Check the appropriate boa: Type of project (required):
1. LD " I am a employer with 2 4. [] I am a general contractor and I 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
workin g for me in a ny caPacity employees and have workers'
t 9. El 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.❑ Other
comp. insurance required.]
"Arty applicant that acs box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they we doing all work and then hire outside watractom mast submit a new affidavit indicating such.
=Contractors that check this box must attached an additional sheet slowing the name of the tears and state whether or not those entities have
aMloyees. If the sub - contractors have employees, they mast provide their workers' camp. policy number.
I am an enwii?j er that is providing workers' conrmadon haww ce for my eMWoyees. Below is the policy mud job site
information
Insurance Company Name: _! L
Policy # or Self-ins. Lic. #: q1,_& ct L1 Expiration Date: /' / L'� r I L '
Job Site Address: 0 ' V ' A Wk �1 City/State/Zip: o Y� C
of the workers' con teen declaration (showing the number and a iration date).
o
Attach a copy P� Pori' Pal':e ( 1; Pow iP )
Failure to secure coverage as required under Section 25A of MGL c. I52 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 c under the ns and penaMa of perjury that the inforeraiion provided above is true and correct
i tare: mot
d YY_ S Date:
Phone
Official use onl}. Do wt write in !Iris area, to be con feted by city or town o
City or Town: PermidLicense #
Issuing Authority (circle ore):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
��►r�: Q k
Contractor
Name: �l�.t_.. mom_
Aodress: '� gle
Cit State: , /1 + t /
Phone: --,—
Property U1Nnsr Olin r / c ( a r �"� ►
Name: 7 .
Address: a .
City, State: EL( J�ncne-e
Clll t9Ir 5- (contractor) attest and affirm that the building t intend
to insulate does not have an (k
y open air nob and tube) wiring in the spaces to be insulated and
that l have provided the property owner with a copy of this affidavit.
Date
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