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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: - --� Not Applicable ❑
Name of License Holder : ./1 /� 4 L�fC j1 O 6"6/(9 9
License Number
6567 7.6/ ) 7>✓r 1 //j /C 2.6 /,
Address -- Expiration Date
5
Signature Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
'S J 1 0. f (.ir
Address Expiration Date
Telephone .4 ®0g$7
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 ❑
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
The Commonwealth of Massachusetts
Department of Industrial Accidents
�9jr!►." — _ — Office of Investigations
= ;clHl°
600 Washington Street
=af
Boston, MA 02111
'=•:_).-- www mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Le gibly
Name ( Business /Organization/Individual): ` P 4 411Y1 a
Address: 53 7 ; 2e i i t,y •
City /State /Zip:2.40t /e6Z Phone #: SZ< t3/}.
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. 0 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 g, ❑ Demolition
working for me in any capacity. employees and have workers'
g Y P h'• # 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5Z7 We are a corporation and its 10. ❑ Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t u. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.] _
Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Hometown= who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
2 Contractors that check this box must attached an additional sheet showing the name of the subcontractors 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 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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Si_ nature: s /l Date:
Phone #: 53 f- 1386 •
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 #:
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s5' Roofing
Or Doors K'
Accessory Bldg. ❑ Demolition❑ 0� New Signs [ ] Decks [ ] Siding] Other [ ]
Brief Description of Proposed Work: .Zlls /' / e C et)fti OG" . tVec .5)44
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Ci Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet ❑
6a,, If New house,aad or addition Ito. 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. Mascheck 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
I,
Z. - , as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative o work authorized by this building permit application.
Signature of Owner I Date
I, )7,4) , as Owner /ftttrIWi?.. d 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 Name
Signature of Owner Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF 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
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location) _
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DON'T KNOW YES
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
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: _
F ........, ;. ......— ,. , .... ,. ........„..,
r
k
4 f. 4 °' P Said
N .
a P
•
R E 7 >r Department use only
i ity of Northampton Status of Permit:
Fri) .6102 : uilding Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability
Room 100 Water /Well Availability
of Wu►aio®o ► • hampton, MA 01062 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
rq ) e-t Map Lot Unit
1"241 :7" e h r� ri 'ss 0/ Q‘ Z
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
7t1t V 2 C c SS's' ,e- .for,c); e.). -c;.0
Name (Print) Current Mailing Address:
s
Telephone
Signature
2.2 Authorized Agent:
—. ✓r74 d e 4 /: J7 tt_
Name (Print) Current Mailing Address:
s,3 def‘
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 4'�5 p
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) ,3 Q ° Check Number C 7
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature: / -` ' —/
B missioner /In-oecto of Buildings Date
/ 25_ ---> C S by C..)c) 2.4eirt
551 FLORENCE RD BP -2012 -0698
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 37 - 001 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2012 -0698
Project # JS- 2012 - 001228
Est. Cost: $5000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD DENNO 066189
Lot Size(sq. ft.): 40467.24 Owner: DENNO KAREN H
Zoning: SR(100)/ Applicant: RICHARD DENNO
AT: 551 FLORENCE RD
Applicant Address: Phone: Insurance:
551 FLORENCE RD (413) 584 -0852
FLORENCEMA01062 ISSUED ON:2/7/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL NEW WINDOW,DOOR,SIDING, ROOF &
7/12 PITCH ROOF - TRUSS SPECS BY RGH INSP
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 2/7/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner