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31B-154 s « 4 6asrcnu n4 ealg af`._ �itasaeAa4 CS Board of Building Regulations and Standards License or registration valid for individul use only Jo if HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: at ° Board of Building Regulations and Standards Registration: 151614 One Ashburton Place Rm 1301 ",;. ' Expiration: 6/15/2010 Tr# 268040 Boston, Ma. 02108 Typo: OBA TANNER HOME IMPROVEMENT SERVICE „ ' `. JOHN TANNER JR l.. '� �, - - ... i 212 HUNTINGTON ROAD WORHTINGTON, MA 01098 Administrator Not valid without signatu s t 9 M o- � . nF r'rR k ,N i zy ry1i4 iw' ' , The Commonwealth of Massachusetts 4 " 1)epartmnent of Industrial Accidents } . , ,,,, ,a Office of Investigations i� - . ,� ' 600 Washington Street � x Boston, MA 02111 ,-, *"" • :' . www. mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name (BusinessrOrganizatio Ind Jo ividual . 0p ` ,/ 9 %['i r Address: ) a / ` IL ) 65 /0 R City /State /Zip: WO 6 (O on e # / 3 _ ?C) U / � Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors 6. ❑ New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub - contractors have g ❑ Demolition working for me in any capacity. employees and have workers' g p $ 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its I0.0 Electrical repairs or additions 3. ❑ 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.KRoof repairs insurance required] ± c. 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. Homeowners who submit this affidavit indicating they are doing all IN 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 employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. I am an enrpkyer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: 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 imprisomnent, 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 ' nder a pains and penalties of perjury that the information provided abov is tru and correct. Signature Date: 7 1 6 7 Phone #: & i / 5 - r-) / l 0 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 8 - CONSTRUCTION SERVICES I 8.1 Licensed Construction Supervisor: or: �1 �� Not Applicable ❑ J Name of License Holder : o Oki �7 / / A-Lue ""� License Number l Address Expiration Date t049 ti ° Cs & Al v Signature / 4/(7 _ aI _ J c?C 9. R red Home Improvement Contractor: J -J Not Applicable ❑ in N NEN fti416 inp4 uie) fen Ui ct / .S 76 Company Name Registration N mber 'i;�6� G /51/1 Address Expiration ate _ X1 3 LdL) ( 111146.: j i ( /1 p/ 0 ? Telephone c 9_3,57-0190 — 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 J 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 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 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 J Section 4. ZONING All Information Most 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 // )., 701 1 Frontage Setbacks Front Side L: R 7 L: R: Rear 457) Building Height a5 -- Bldg. Square Footage old y 3 Open Space Footage ,. ^ (Lot area minus bldg & paved 6/62°? �`f / parking) / # of Parking Spaces Fill: / 15. (volume & Location) _ 67) ,4LL J g f vC . C 4i A. Has Special Perm' /Variance /Finding ever been issued for /o the site? L ,�/ � ot- p - NO DONT KNOW 0 YES IF YES, date issued: 6 / Z5 kf t i APPler/vz-IJ AT 4 O/" ' I 7-5 1°6'1 IF YES: Was the permit recorded at the Registry of Deeds? a ") - D � �l r , NO 0 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 O 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 © NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, e - vation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES © NO #o. 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 0 Or Doors 0 Accessory Bldg. ❑ Demolition El New Signs [CO Decks [0 Siding [0] Other [II Brief Description of Proposed / L dY - — � ` P� ii, i Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No 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 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, S pcvz. _Y C- `V , as Owner of the subject property hereby authorize 3R>'4 V \ i to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I JO i140 7 ,tie , as Owne uthorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my edge and belief. Signed under the pains and penalties of perjury. Print Name 6 ,_„r I i C) 7 Signature of Owne Age ) Date Department use only City of Northampton Status of Permit Building Department Curb Cut/Driveway Perna 212 Main Street Sevier/Septic Availability Room 100 Water/Well Availability, Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans \., Other TifiC , APPUCATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOUSB A ONE Git TWO FAMILY DWELLING 4 2009 SECTION 1 - SITE INFORMATION Thos„ seal, gn j_ to Ut. be compiets_",1 . 9ffil ce 1.1 Property Address: /3 7, gt-tLL Map Lot ---- ---- Unit /A l iq 11/ 1,0 A /11A Zone Overlay District ( Elm St. District CB District SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 2A-R S-rei / 3 C LL 4 Name (Print) CurrentMAdclre_ssi " /n4 Telephone Signature — Vrcit 2.2 Authorized Patent "AA A/7714167.°AI Jjij 7 jitle2ie 6,0o er \ A) 6--- 6/69e Name (Print) Current Mailing Address: • Signature ( OF Telephone SECTIO - ESTIMATED CONSTRUCTION COSTS 1 Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant oe} 1. Building 7 51I) ' (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 Only Date Building Permit Number: Issued: Signature: C:>' a ?kilo Building Commissioner/Inspector of Buildings Date 13 TRUMBULL RD BP- 2010 -0046 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B - 154 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit # BP-2010-0046 Project # JS- 2009 - 001432 Est. Cost: $1650.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JACK TANNER Lot Size(sq. ft.): 12719.52 Owner: STUBBS SUSAN L & BARRY S GOLDS J :,.v. P ^/1 (\l! A...N,% r : .ii n< NN7 -=-- '-- _-- -- -( v�� . . .s 1 . , AT: 13 TRUMBULL RD Applicant Address: Phone: Insurance: 212 HUNTINGTON ROAD (413) 238 - 0190 WORTHINGTONMA01098 ISSUED ON :7/15/2009 0 :00 :00 TO PERFORM THE FOLLOWING WORK: RE -ROOF MIDSECTION OF ROOF ONE LAYER PRESENT 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: Rougi: vi:; Insulation: Final: Smoke: Final: OK 0 $'IO6109 (At4 THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLAT ON OF ANY OF ITS RULES AND REGULATIONS. � 0 •ir Certificate of Occupancy / Signature: FeeType: Date Paid: Amount: Building 7/15/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo