32A-048 City of Northampton '
/..7#°_,...A.--4,- , Massachusetts ��S'S : s;�r`4
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I +�t � `f DEPARTMENT OF BUILDING INSPECTIONS 5.
�$, 212 Main Street • Municipal Building J�., 4'' .b'
�N.-:40;_t-'-'3• Northampton, MA 01060 sst ;
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
;;p-
w °�� Boston, MA 02111
+ www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #:
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. El New construction
2.® I am a sole proprietor or partner- listed on the attached sheet. 7. fl Remodeling
ship and have no employees These sub-contractors have 8. E! Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp.insurance.T 9. ❑ Building addition
required.] 5. ❑ We area corporation and its 10.0 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 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners who submit this affidavit indicating they are doing all work 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 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 certi nder the pains and penalties of perjury that the information provided above is true and correct.
�gnature: t;�Z����% Date: ./L7--2— /_S
Phone#:
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
8.1 Licensed Construction Supervisor: J Not Applicable £
Name of License Holder: 14a/"e H g_ �i ct, 7�'�I' C S" 0 00 s-'6.?
J License Number
33 dA It/ueQ-. Rd 14a..01 ley Ma . ofo3,f' 3-4t- Zo6y
Address Expiration Date
Y/3 - K Z 2- 36 73
i" / Telephone
9.:Registered Home Improvement Contractor _ ._ _,, ,, ,.a_ Not Applicable £
Company Name Registration Number
Address Expiration Date
Telephone
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.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House [] Addition Replacement Windows Alteration(s) Roofing ❑
Or Doors C7
Accessory Bldg. ❑ Demolition ® New Signs [0] Decks [M Siding [0] Other[0]
jr9-jr, air Iv
Brief DescrCT on oqf Proposed
Work: c 0-LA-1-1" +rS gt or/'d gl7'/µ✓f
Alteration of existing bedroom Yes No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes Ot No
Plans Attached Roll -Sheet
6a'a If:New house and<or•addition tO`exi5flnq::housiiliq, complete"the IOU°Wiha:
a. Use of building: One Family Two Family x Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached? AlO
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? Tt...)O
f. Method of heating? Qa.5 , �'L F,e f r C- Fireplaces or Woodstoves 'V0 Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction W 0 O D
i. Is construction within 100 ft. of wetlands? Yes )C No. Is construction within 100 yr. floodplain Yes X No
. j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? pc Yes No.
I. Septic Tank City Sewer fie. Private well City water Supply Xe
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
,as Owner/Authorized
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
Signa ure of Ow r/Agent Date / 3
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 2 / 3a 2 4 t _ _ ... ____._____ i
FrontageL__._-___. . —_._..__...i _—_.____ __,__..t i_ ....._...______ _ _____{
Setbacks Front E-_-- 1 i 1 I
Li �
Side L:` R:� L:L,.. ..._...! R:= 1 1 1 1
Rear ....___.
Building Height 1 ! L= 1 i
Bldg.Square Footage ; % --- = -
Open Space Footage r % E
(Lot area minus bldg&paved L_____,J -� __ .,._ i L.__i
parking)
#of Parking Spaces
Fill: I It
(volume&Location) 1
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW le YES 0
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW fs, YES Q ..
IF YES: enter Book — Pagel . and/or Document#1
B. Does the site contain a brook, body of water or wetlands? NO : DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q I
, Date Issued: �_ __ _
C. Do any signs exist on the property? YES Q NO op
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 •
IF YES, describe size, type and location: 1
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 Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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Northampton, MA 01060 Twa�s2ts dfSti'trCtrii'al Pans"'' " ; Y �� ,
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Electric Plumbin e 413-587-1240 Fax 413-587-1272 Plot/Ste Plans`5 4i, G!{!';' { ', O` k '
Plumbing&Gas Inspections Other 5pemfy' h z 7 „y'aka R�' !
Northampton,MA Insp _.:._ -+'._.. ;:
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE.INFORMATION : .
This section to be completed by office
1.1 Property Address:
�5 M'4i k£T St Map Lot Unit
Cr aka MR a N
fa 4 Zone Overlay Drstrrct
;Elm St:District CB•Dlstnct
. SECTION 2•-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
(�3 manta 7- r2 a A ry LC. C //$q//a#o( S t s'�l�A►-►p7���, /1(4 o ,oc 7
Name(Print) Current Mailing Address:
Lt(4,4�d /fr e 1•e..^ y/3 K Z 7 3 0 9 3
�'� Telephone
Signature'
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
•
Signature T=lephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed byo permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated m(6 Cost o f
:
Construction fro )
3. Plumbing Building Permit Fee o
4. Mechanical(HVAC)
tom:
o
5. Fire Protection o.4 (9
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number: . Issued: •
'
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0411
APPLICANT/CONTACT PERSON HARRY E WIATER
ADDRESS/PHONE 33 CHMURA RD HADLEY (413)427-3093
PROPERTY LOCATION 65 MARKET ST
MAP 32A PARCEL 048 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE ,I
ZONING FORM FILLED OUT �L v
Fee Paid
Building Permit Filled out //(3 41)L O
Fee Paid
Typeof Construction: INTERIOR DEMOLITION
New Construction
Non Structural interior renovations /)Q
Addition to Existing 0i
Accessory Structure
Building Plans Included:
Owner/Statement or License 000563
3 sets of Plans/Plot Plan
THE FOLL G ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION 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
II- lay
V../.°°°°°°°..- 7
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Sign ofBuildm_•fficial 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.
65 MARKET ST BP-2014-0411
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A-048 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INTERIOR DEMOLITION BUILDING PERMIT
Permit# BP-2014-0411
Project# JS-2014-000704
Est.Cost:
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HARRY E WIATER 000563
Lot Size(sq. ft.): 20429.64 Owner: WIATER JOHN E TRUSTEE
Zoning:URC(100)/ Applicant: HARRY E WIATER
AT: 65 MARKET ST
Applicant Address: Phone: Insurance:
33 CHMURA RD (413) 427-3093
HADLEYMA01035 ISSUED ON:10/15/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INTERIOR DEMOLITION
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 10/15/2013 0:00:00 $60.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner