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Electric, Plumbing&Gas Inspections ts--- rx. r,_,.
Northampton,MA 01060
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CITY •F NORTHAMPTON •
Construction itebris Affidavit
•
•
In accordance with the provisions of MG.L. c. 40 § 54, all debris resulting.from any work
=-- : -cover-ed=b a Building Permit shall be disposed of in a-properly licensed disposal facility, -
as defined by M.G.L. c.•111 § 1150A.
Address of Work: � ' 61)2,601v A-ve_
The-d.ebris_wilI be-transported by: . 1)/1ij p -2
er- a - -
The debris will be received at e" 6/e,/ 1
–—– Signature of Permit Applicant �L`� .A•. .��.
-----._ ...--- Gate
Building Permit Number: • •
•
•
•
•
•
•
•
•
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• The Commonwealth oftlfassachusetts
Department of Industrial AOidents
Office of Investigations . .
600 Washington Street
s --- -,---
-.. .trt.r.:-- .r.*
: 1:4: 5 Boston,M4 02111 . •
,.;... --z- .,,,
www.mass.gov/dia , . •
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.,..,.
Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information - Please Print Legibly
.-----40/1/.
:,--R
Name(Businesi/Organiiation/Individual): C IV)A A60 r- ,
. .
•
• •Address:_k3 \,'iiv--- --Puy 'TA _
City/State/Zip: Co&RAlw JIM . Phone*: t(t (a 2-11) 3 IN ----7----
. • p
Are you an eniployer?Check the appropriate'box: •
. -Type of project(requir' ed): 1
•
1.0 I am a camp/gayer with . 4.. 0 I aria general Contractor and I .
6. 0 New catistivetion.
have hired the sub-contractors
LempIoyees(full and/or part-time),
listed on the:attached sheet 7. IVrRemodeling . . .
2 am_k-lir a sole propiietor or partner-
• . ship ortdhave no employees These sub-contractors have .8. 0 Deiablition - .
lov-m--andbave wodners'
working forme many capacity. eM7---.---...---.-7". .. - - -9..;-ErBratft..ati •
[No workers'comp-.insurance
5. 0 We are a et:alio:mt.=and its 10.0 Electrical repairs or additions
, required] •• . : •
3.LI I am a homeowner doing all work officers haiie‘xereiset‘their . 11.n Plumbing repairs or additions
myself[No workers'comp. . right Of exe4tioii per MGL • .
12.0 Roof repairs . •
insurance xeiired.1 f • . : ,c. 152,§1(4),and we have no • ...,.. ,
• . • esiSPloYees [No workers'. li"1"--i°I12er
camp msmancerequired.J
'
Any applicant that checks box#1-mustalso El out the section below:hosing their-workers compensation policy infamnadom . ' . ..,..: .
1.Homeowner:yho submit tidir affidivitincraiating they am doing all work and then hire outside e contractor's mast submit anewafadavit indicat*g such.
zgootractors that check this box mustatIached an minimal sheet showing the name of the nab-contractors and state whether ormatthowentities have
anployees. If the shb-ccntracionhrtic employees;they mustprovide their wodons'comp.policyninnber. . : :: .....,: !.: , • . .,
Jam an employer that is Providing workers'compensation insurance for my einplOyees. Below ts the policyand job:site
information. .
. '
Insurance Con:Tony Name: • - . .
. • . .
Policy#or Self-ins.Lic.#: - Expiration Date:- • ,
. . .. .
Job Site Address: . , . ' City/StaterZip:'
'
Attach a copy of the Workers!:compensation policy declaration Page(showing the policy'i"-*".1'07. !io.-e:IV4"..411°11.date)-
.. .
Failure to secure coverage as iteinifed under Sottion'25A-6fNIGL-e. in can lead d the ithp—oaltiiiiiiif alinai4-Pen4les of a
fine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK-ORDER and a fine
of up M.$25000 a day against the violator Be advised that a copy of this statement may be foriFigile,it.iiy‘(:i4:ri.c, of
'Ef...-eifisificiiis ZiftliFDIA foifittliAAit8g,a6ielizieilta-ii. 7 -----7717 7717::' ..-.-a....._-';;;:':::A.,..:......;,,:..„-.:•.._17,–
0.firerlai':'riiiiikiiiiii.rinciiiiiriit;;;Ilisr7;77—.71;riarr"17-7-- i ..... .
Signature: L. /tf‘AtiNA. • • Ti5;tC:---70 1. .1 • - . ••Phone ii: ' Yt3 62t1 ?3!/1/.-5 ._ :- . :-:._.. . . . . -
I• -Official use only. Do not write iii this aria,to be Compiued by city'or tonlri.O.Olcial
City or Town.: . '. Permit/License# —— — -
Issuing Authority(circle one): •
:1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other .
Contact Person:
Phone#: f• . - .
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction S avviisor: Not Applicable ❑
Name of License Holder: �J O t) �, [ \I41J(5U G$ 0/12663
Licens/05720 umb
\J t%0 Ny5 o/D C.CLkAIIU l�A 0( 19
q s / Expirat Date
�.
ttA/j/tOCUI4 tli3 `1(9%66 709
S - e Telephone
�S �3<s+i°d tt �a� Isis =x .Ky . f ,. w ��— . _ ...555.55 ;,5 .... . ..... Not Applicable ❑
aN
M51)— /NO
Comnanv Name Registration Number
(3 `Jw' NV' Ta/AV y Z1 2O12/
Address Expi tion e
?1 R_A)IJ J I 1 Pc Telephone 7çl7L
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 Affidavi[Attached Yes ❑ No ❑
11•: -FloineOwnetEienintIon
The current exemption for"homeowners"was extended to include Owner-occupied Dweliines 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 ❑ Replacemejindows Alteration(s) Roofing ED
Or Doors ��j`
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [i] Siding 11$ Other[0]
Work a •o'qn pf Prod'EZ .DR P1�- //V fX 7/AIo- POOm / NQ(dI W/Nbo W` Doc P-
Alteration of existing bedroom Yes / No Adding new bedroom Yes No 5437/l)(„„
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a,if.Ne1 r ii011e°ilia et 4 ie iii i lia fibtl LltaOrttot i ii" + Wth :
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. Masschedc 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=TOE BE COMPLETED WHEN ,
OWNERS AGENT OR CONTRAC TOR APPLIES FOR BUILDING PERMIT
CI, 9h v'CA 41/0 Ceg ,as Owner of the subject
property U �_
hereby authorize Jcw ()i A !T'V 7 UK.
to a on my behalf,in all att rs r/eelaattiv,a to work authorized by this building permit application./,, /o/gik,7
Signs of Owner Date
I, -/-01°1/ G il 4W (JP- ,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 t pains and pe alties of perjury.
C Po!U v 1R-
Print Name
`.111►, . 11..1.1 • D
Signature of:=j Agent Date
IF
1
Section 4. ZONING AU 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 €
Frontage µ
Setbacks Front ?�` —1 i E I
Side L.' R:l r ' L: R
Rear LJ
Building Height i =
Bldg.Square Footage '� �-`�� % -- `;
Open Space Footage % _
(Lot area minus bldg&paved w ~ 7 i i 1 L_] ,,�_,,,,.K„
parking)
#of Parking Spaces , g ---------
Fill:
(volume&Location) l
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 150 DONT KNOW 0 YES 0
4
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page 1 and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO ,`4 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued: , '
___
C. Do any signs exist on the property? YES 0 NO !4
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO
)2(
IF YES, describe size, type and location: i
_ �Fm Y
E. Will the construction activity disturb(clearing,gradin•,ex - ation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO i►`'e
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
r '• — 'h s '� Sxa s
;City of Northampton
i.),` ^j , tuilding Department , _ �� �.: ,_`! �- }=V ,
\''\'' - ' �O�V (>r.+� "4,,f;''.;,..',:'
Y d 23. Sk of y.3 X--,,').„,,,,,,..i.,, f.
�O� 212 Main Street ,..�,; + -;,*,„,..„':is,? �,, K
1
Room 100 { ° 4,4, 1 ,'7'C-,.. A",,,,,' 34a
Ir,,pections ,.
Electric,Fi r mr ri�,& One ono No I I ampton, MA 01060 .3 v ti,� � >',",-
�� one 413-587-1240 Fax 413-587-1272 ,.'` -��,.,4,N _A � 7 ' ,
i t r e, `Y £}y�?k4f"4R �'8 l,i `sit t =;q �_
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
1(0 if Map Lot Unit
ivd t),kl,-,,,,e-i-Vv'1 dlk A- 0( o G Zone Overlay District
Elm St,District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
rt*t ‘`c. 1e I(0,55 ti 0 10-u f-tre , /UordZ�„� w /4/1"4"
Name nnt) Current Mailing Address:
tpf'3 - 7�}-3"4-78
J/, L�� , Telephone
Signatu`
2.2 Authorized A ent:A l Nu7s-�l0 11NSV►2— io3 VAN/ c,R•ivil, Mk
Name Current Mailing Address:
's,
Ci - 4/,'3 /76q cj7 011
Signat Telephone
SECTI* 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building // 6C)‘' (a)Building Permit Fee
/
b Estimated Total Cost.of
2. Electrical / 5-b ( )
Construction from(6)
3. Plumbing / 4
Building Permit Fee
4. Mechanical(HVAC) /
5. Fire Protection
! t)o
6. Total=(1 +2+3+4+5) I /3 7 D' Check Number ( f l b/
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Cammissioner/Inspecfoi of Buildings , - Date
File#BP-2014-0576
APPLICANT/CONTACT PERSON DOUGLAS GOODNOW
ADDRESS/PHONE 225 OLD CHESTERFIELD RD WILLIAMSBURG (413)296-4387
PROPERTY LOCATION 40 HARLOW AVE
MAP 38D PARCEL 042 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 027� l (�
Fee Paid
Typeof Construction: INSTALL NEW WINDOW/DOOR SIDING,WASHER/DRYER IN EXISTING ROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 082188
3 sets of Plans/Plot Plan
THE FOL ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I FO ATION 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
I-',• ition Dela
Si. _ of Bui ding 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.
40 HARLOW AVE BP-2014-0576
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38D-042 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-2014-0576
Project# JS-2014-000924
Est. Cost: $13400.00
Fee: $80.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DOUGLAS GOODNOW 082188
Lot Size(sq. ft.): 5706.36 Owner: KELLOGG CYNTHIA
Zoning:URB(100)/ Applicant: DOUGLAS GOODNOW
AT: 40 HARLOW AVE
Applicant Address: Phone: Insurance:
225 OLD CHESTERFIELD RD (413) 296-4387
WILLIAMSBURGMAO1096-9318 ISSUED ON:11/8/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL NEW WINDOW/DOOR SIDING,
WASHER/DRYER IN EXISTING ROOM
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 11/8/2013 0:00:00 $80.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner