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24D-300 ) ) 7 • • - , o 1 1 pv 1 o I y brac I /--- $:•-k.'‘'.;,4:',-, \‘',„-=';:-,\"""‘ ''''-' F, ' , ' - <:?: Existing damaged CMU wall ''...:„:‘,.' :::',',''' . it , :',1-.:4 , Existing grade .,,. ' ,;?4,''''-: `....,,, 'S' ,',' N'S Nak-e" - ; - " - - ' ,..' '' ' ''" ' , \ \ ,„,,,;:\ ,,,,,,,,,,,,,::,:-.„-,,,sk, , \ ‘,.,„ : : '';:,.,--,,:,- \''''''''.—,,, -,,, '' '..,<,,';\\> -, -,TZ',W.,,, • - • -N'4 ,,..,,.,'3".:,'N,„';.‘"';',,,;‘,kk,„\-,,,,,,,z-1,,;,,>,,,,,,,,:z, ,,c ' ,,, ` ;,:W ; ,,,,,:, ' N zz - ? - ' ,..,), S;:' , '. , : - C' :: ;< -= ` - ": , '"S''.- \ . ' $,::'"\N'1:,\:.',,'S,N ''''' . ,- ,,_ ,, ' , . , ,,,,,,,, V. 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Address] am: ❑ an authorized representative of insurance Company ICbnrpany Nantel (a producer' in the voluntary market) X an authorized agent of S"t" G.34-1_,:rt;11 Insurance Company (an agent (Company Namel in the voluntary market. authorized to sign on behalf of a producer) ❑ an authorized signatory of the , the Prime Contractor (Company Namel (an insured of a producer in the involuntary market pool)` n an authorized signatory of , the Sub - Contractor (an insured of !Company Name( a producer in the involuntary market pool, group, or otherwise insured)' and do hereby aver that effective -1 .4- \ \ 10 [Date]. W% i!1 e Qo ►ni- Wkhw rc he-- _ the Prime or Sub - Contractor, is insured for Workers' Compensation insurance with OCk C (LC A _ insurance Company under Policy No[s]. ■ -1-,- �j pursuant to the attached Certificate of Insurance. and in accordance with Massachusetts General Laws. ',ow Chapter 152 and Subsection 7.OSA of the Standard Specifications for Highways and Bridges of the Highway Division of the Massachusetts Department of Transportation. Sin ' * 9---:1-1.1.---- t2 Ir.. ,t -- C1` k" A Title COMMONWEALTH OF fvIASSACiIUSEi On this 12th day of July 2010 before me, the undersigned notary public. personally appeared Kimberly Balthazar [document signer), proved to me through satisfactory evidence of identification, which was /were MA Driver's License , to be the person who signed the preceding or attached document in my presence, and who swore or affirmed to me that tic ntents of the document are truthful and accurate to the best of their knowledge and belief. A EILEEN M. RYAN fi Not ary Pu ^� .71,,<;; lam" . Notary l it U commoNwEA r Or MASSACHUSETTS Eileen M. Ryan/ [Printed Name] Nay Commission Expires September 7, 2012 A producer is an insurance company that provides insurance policies directly, not an insurance agent. 4. For Prime or Sub - Contractor companies insured through the voluntary market. this Affidavit must be completed by the insurer or an authorized agent of the insurer. If the Prime or Sub - Contractor is insured through the involuntary insurance market, a pool, such as the Worker's Compensation OW Inspection and Rating Bureau. or is otherwise insured they may provide a Certificate of Insurance and this Affidavit which may be signed by an authorized signatory (company officer) of the Prime or the Sub - Contractor. Effective lO-May- 10 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: n Not Applicable ❑ Name of License Holder: 55 License Number acko. - ma y 7-t) M Address Expiration Date LS o(t93 Signature Telephone S Regsteiecf`Hbiri fnat5iovrtent. ` Not Applicable ❑ I4 WE PowMTS (e -1NCs LAC Company Name Registration Number (Oo "T3dMTE1L ST• Address Expiration Date -Q- L 0161 Telephone SSA 752 735(0 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 .i No ❑ 4, it o vrie on 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 res ' onsible for all such work l erformed under the buildin ' s emit. 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 . 4 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition 0 Replacement Windows Alteration(s) 0 Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [O] Other Brief Description of Proposed % _ Work: S'1gI�TUtPN- .RIBS '- R.V 4 t3r�cxt. 1-k- Of { Alteration of existing bedroom Yes u No Adding new bedroom Yes K No Attached Narrative Renovating unfinished basement Yes X. No Plans Attached Roll - Sheet 6a, it'ilaww: house "and or:additir n to', a tlstinq boos :inch co iplete the follow nq: 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 . 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 `/ 0/&t W� 7a or l, j ect property x �` C , as Owner of the subject hereby authorize 71>k_€1 7 /io Al l (NE 1�lt4TS 1, eD U.k3'JZ1 -(M - (l( to act o y behalf, in all matters elativ work uthorized by this building permit application. 7.....,,,,, ---- ,ejtp 2-r ) K.,-- Signat re of Owner Date • • ■� 1 �,., . _ , as Owner /Authorized Agen 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. E■)eic'i'r - N- r49ZE i 5 Oft Print Name ''`` Signature of Owner /Agent 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 Building Department Lot Size ....,..i ..._. __. Frontage :7 _. - .__ _? E.,,z.27 .,__,,.._,.k_, :.,._..,1.~. ,....v _.._. ~,__, Setbacks Front _ £ ° Side L L _il R:1::: L: I R:5 �_'_ Rear i2.-12_, 12.-1 Z . _.....F • Building Height , _ . ; � Li 6',,,1 IJA- _i Bldg. Square Footage I ° N 1 % I , µ ,I Open Space Footage _ % _ _ E (Lot area minus bldg & paved _ ~ parking) # of Parking Spaces . Fill: (volume & Location) t i A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO DON'T KNOW 0 YES IF YES, date issued:[ IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES IF YES: enter Book. Page ,.. and /or Document #' B. Does the site contain a brook, body of water or wetlands? NO 0 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 ,Date Issued: ! . C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: I D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO se IF YES, describe size, type and location: 1 µ 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. tomatt r City of Northampton f it € �� a Building Department Ct ?, q + } 2 Main Street WeC ®ttrA'�a Room 100 Waf 1 attar Northampton, MA 01060 T��s Otis phone 413 - 587 -1240 Fax 413 - 587 -1272 loyptte r -r. -. : 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 conuaieted by office 2'7 -1- 4tLLSt DE 1 & T Map Lot Unit oR Tt,`Mr1,TaT1 Zone F " � �� Overlay District Eh'n ; St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: P�+JUP EC1 - 2�' 13'cSK` 2 +1 ILLS1be' , v`• Nam / int) Current Mailing Address: 1 3•.5810 . 7 18 X / FdO � 4 1 Telep Signature f 2.2 Authorized Agent: ICC - r>`}•1 MTE'R- ST, �� «'-, O (4 o EUEVE -Pttl,P 1 k3 t /MtPI ct l`C'5 I•lc. Name (Print) Current Mailing Address: SoS 752 35 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building y/ � 2 7 g ( a) Buildi Permit Fee 2. Electrical ,9C O (b) Estimated Total Cost of Construction from (6) 3. Plumbing Buildin Permit Fee 9 4. Mechanical (HVAC) O 5. Fire Protection $ - _ - This 6. Total =(1 +2 +3 +4 +5) `ll Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /inspector of Buildings Date File # BP- 2011 -0043 APPLICANT /CONTACT PERSON EVERETT ANDREWS ADDRESS/PHONE 100 TAINTER ST WORCESTER (508) 328 -0693 PROPERTY LOCATION 27 HILLSIDE RD MAP 24D PARCEL 300 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid MO 00 Y/ az) Tvpeof Construction:_REMOVE & REPLACE BACKWALL OF FOUNDATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 55809 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: VApproved Additional permits required (see below) PLANNING BOARD PERMTT 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 7/a0 fiC) 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. . s 127 HILLSIDE iw BP- 2011 -0043 is #: COMMONWEALTH OF MASSACHUSETTS Vtap :Block: 24D - 300 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 -0043 Project # JS- 2011- 000087 Est. Cost: $41278.00 Fee: $247.20 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: EVERETT ANDREWS 55809 Lot Size(sq. ft.): 8973.36 Owner: ZALESKI PHILIP T & CAROL G Zoning: URA(100)/ Applicant: EVERETT ANDREWS AT: 27 HILLSIDE RD Applicant Address: Phone: Insurance: 100 TAINTER ST (508) 328 -0693 WC WORCESTERMA01610 ISSUED ON: 7/20/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: REMOVE & REPLACE BACKWALL OF FOUNDATION 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 7/20/2010 0:00:00 $247.20 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo