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25C-012 DSCN12951 U + �. .:.... °tom...,.. �,.. . •_ �.�' w , • ,. i,..:.fir.. � ti ! , t _ � r k 1 ¢ x k 3 t V, c. i k r- 1 � s yr, te E 4 � dt a 5 F 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 tilled in by Building Department Lot Size Frontage _. Setbacks Front , Side L J R.L._, ... L......_... R f Rear Building Height ` Bldg.Square Footage , °/U Open Space Footage _r, % i (Lot area minus bldg&paved #of Parking Spaces i .................. . _. .._.. ,__ ....._.__ Fill: volume&Location _ .__. ..............._ A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Not DONT KNOW 0 YES 0 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 Document#! B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 9-�w Obtained ,0 , Date Issued 'Dots two rvccd-to be obJcv_ -Eht dcrvw4}tx of+kc hmu-'%. 1 rCA^ mwe-4K&4-,2001 au" t caret-t more+hO^ MOO OAAMY C. Do any signs exist on the property? YES 0 NO (7) IF YES, describe size, type and location: 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: 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 NO 6 nod-f-or -,-I'K.ottnw[;*Lv-A�+k h.vu.bc ) bttk ytA �oY -1,-6c overall 1 roject,wktcVj haA vw*- bceh su�br►�i�kdyeF. 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 ❑ I�1 Or Doors O Accessory Bldg. ❑ Demolition New Signs [O] Decks [q Siding[O] Other[O] Brief Description of Propposed Work: derin�li-},cyl C>� koULS • Anjmc be 19 15. (ALJ gGotik6+rv� douk i$ xgWAr,but +Vwt. a j&a dw-Vcd 19 tb ha* c sh.ews FWV-print t�F 44ve h.crr%.4w •) Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If Newhouse and or iiWifion to existing hotis]na 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 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 I, DOLLAl" A. V—o hl as Owner/A uills __d hereby-declare that the statements and information ofi 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 C Signs a of Owner/Agent Date i SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: t Not Applicable 1h Name of License Holder: L(Ni d �A-0 A . I�C ��I L� License Number 31 � �� I } IN "A CSI©-35 1 ol[5&Z Address Expiration Date 2-5& �D Z Signature ( T e hone Registered Home Improvement Contractor:, Not Applicable Company Name Registration Number �)( r!a-7,A, t�c� �,��1�� t�/1 A D t 6 c� 71 1 10K Address ExpiExpi on 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�-Horne 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 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." ,,,. Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC) or Limited Lia�ility Partnerships(LLP)with no employees other than the members or,partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed Iegibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permitllicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy pf the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents` Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7744 . Revised 11-22-06 VvFVw.mass.govldia The Commonwealth of Massachusetts Department of Industrial Accidents W Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): yov)k LA'a l tAb k Address: 61 C_;mpLx,� ( u"J, , �Xtey , MA City/State/Zip: Phone.#: 2,5(, p-�Z l Are you an employer?Check the appropriate box: Type of project(required):_ 1.X I am a employer with 2-5 4. F-1 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. ❑ Remodeling ship and have no employees These sub-contractors have g. JKDemolidon working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.msurance.t required.] 5. We are a corporation and its 10.❑Electrical repairs or additions '3.F-1 officers I am a homeowner doing all work have exercised their 11.0 Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 131-1 Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners 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: AT W "e.l Ay 41. Policy#or Self-ins. Lic.#: *Vq M-I-S C)Q n 1 Z Expiration Date:-2- 10 OT Job Site Address: '�S V 1 ew At/,-< City/State/Zip: NOl° �- 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 file 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 mature: A l i � Date'(t> ° 2JX ` 01 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#: Department use only "'dtyr of Northampton status of Permit h Building Department Curb Gut/Dnyre�vay Permit 212 Main Street SeweISep#�Avaa�l,ty 2c�01 Room 100 1�ia#er/We�Avaiiab�t�ty3 Northampton,'MA 01060 Twp Sets o1 S#rutura Ftans w. phone.413-587-'1240 Fax 413-587-1272 Pro , ttSite Plans - � e Other �ecl 4 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE O DEMOLIS A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office V �� n�Y�'f✓ Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Tb�rine --'2)1 CA VI'k!s j'_ ,7A9A . ,airNj mA 0ib35 Name(Print) T Current Mailing ddress: Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (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 Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date f File#BP-2007-1264 APPLICANT/CONTACT PERSON Kohl Construction ADDRESS/PHONE 31 Campus Plaza Rd HADLEY (413)256-0321 C: JUN 2 9 2Q07 PROPERTY LOCATION 8 VIEW AVE .: MAP 25C PARCEL 012 001 ZONE URB L_. THIS SECTION FOR OFFICIAL USE ONLY: ----,---t PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: DEMOLITION OF HOUSE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 078992 3 sets of Plans/Plot Plan THE FOLLOWING A TION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION P SENTED: Approved 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 Co ssion 0&. e�y 2 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. DEMOLITION REVIEW APPLICATION Activity Tracking Sheet Property: MapL6L larce'l 12- Received in Building Department: Referred from Building Department: lag 7 Action Taken/ Northampton Historical Commission Action Taken Bv: Entire Commission Sub-Committee of the Commission Commission Designee/ Staff Date Action Taken: -711Q1(07 Initial Determination Public Meeting held Public Hearing Held Determination Made: Property has been determined not to be Significant according to Ordinance definition. No further action will be taken. Demolition Permit may be issued. Property has been determined to be Significant according to the Ordinance definition and a Public Hearing has been/will be scheduled. Demolition Permit may not be wed at thic time — Public Hearing has been held, Property was determined Significant but not Preferably Preserved. No further action will be taken/ Demolition Permit may be issued. ---• Photo documentation may be required. Public Hearing has been held. Property has been deemed to be Preferably Preserved. The demolition review period has been initiated. No demolition permit may be issued until the Historic Commission approves an alternative plan or the twelve month period concludes. Alternate plan has been approved/ delay terminated. Demolition may or may not be approved as part of plan. Twelve month time period has expired, demolition permit may be issued. Referred by: Date 7h i ko:z The Commonwealth oflYMassachusetts Department of Industrial Aecidents ( Office of Investigations a 600 Washington Street � �a Boston, ALL 02111 www.mass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/E lectricians/Plumbers ADRlieant Information Please Print Legibly NaMe(Business/Organization/Individual): ;^t.ti} I t _ t -� Address: 3i Iii A, City/State/Zip: Phone.#: �a - L, Are you an emplover? Check the appropriate box: . I am a general contractor and I Type of project(required): 4 1. I am a employer with L`- ❑ 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. ❑ Remodeling ship and have no e--p1loyees These sub-contractors have g_ gDemoliuon working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp.insurance comp. insurance.: required_] 5. ❑ We are a corporation and its 10_0 Electrical repairs or additions officers have exercised.their 3.❑ I am a homeowner doing all work 11.7 Plumbing repairs or additions myself. o workers' comp. right of exemption per MGL 12.7 Roof repairs insurance required] t c. 152,§1(4), and we have no li.❑Other employees. [No workers' comp.insurance required.] -Anv applicant that checks box n1 must also fill out the section below showing their workers'compensation policy information. f Homeowners 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. lam an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site information. Insurance Company Name: AT i1,f1 r-k. Policy#or Self ins. Lic. r: �<s�7 uad"� _ v �[F Z Expiration Date:- 4- S ` Job Site Address: s V ., Ate City/State/Zip: L ®° 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 fine up to S 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 5250.00 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. Ida hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Sianatt:re: Date: rT 2d• 01 _ Phone#: Offacial use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License tt Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical.Inspector Plumbing Inspector 6. Other Contact Person: Phone n: .!SECTION 8-CONSTRUCTION SERVICES r ® 8.1 Licensed Construction Supervisor: f Not Applicable ) Name of License Holder: License Number 1c)J Address Expiration Date ' Signature Telephone �9. Rep istered°Home`ImprovementContractor „ Not Applicable V Company Name g� p Registration Number � d �,� Address 1 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...... ❑ 1;L Hornei 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-vear 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 �1 Or Doors O Accessory Bldg. ❑ Demolition I New Signs [0] Decks [Q Siding[O] Other[O] Brief Description of Proposed Work: A_`'�r' 1.i l �'l p_3��Xa,,sc -1 §_ i °�"a.5v ,y ' rsse+ `,I ter;=°ms s r ,` - "vG�ar €lAk is VA �:1 4`�t`G K�w� ' 1 sa- `�'�. c6rt�4i -A K -- 'R'kO.+d" sk.l+P 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 oraaddition 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' 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 r. _ � I, ELI - Pm .lis r ^✓� � IJ13 t as Owner/ fed=. Agent hereb declare that the statements and information oh the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print NNaameJ Signals dre of Owner/Agent Date �r 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 .. } Frontage Setbacks Front Side L:,, R_-------' L: Rear _.. Building Height Bldg. Square Footage _ o/a 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 DONT KNOW 0 YES 0 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' and/or Document#' B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW a YES IF YES, has a permit been or need to be obtained from the Conservation Commission? !?)�N @ee�d.,s�to�,�be obtained 0� , Obtained a , 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 Q NO IF YES, describe size, type and location: 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 NO , `, 1; k IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit Building Department Cufp 0ut/flnveway Permit e 212 Main Street Sewed/Sept�cva�latuUty = '' Room 100 Water 011 Auallabili"W Northampton,`MA 01060 Two Se#s of Structural Ftans phone 413-587=1240 Fax 413-587-1272 PlotlSte PIa s.'.. Other Speclfy APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE 01<DEMOLIS A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office 14t tvr c, Map Lot Unit Zone Overlay District Elm St.District CB District _ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: k a -- k ti Y n `m'�,g ir°S�i ?�@,��``1 cam^'ass. W„�* Inc, Name(Print) Current Mailing)Nddress: Telephone elephone 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (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 Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date r File#BP-2007-1264 -- APPLICANT/CONTACT PERSON Kohl Construction 1 < .- ADDRESS/PHONE 31 Campus Plaza Rd HADLEY (413)256-0321 PROPERTY LOCATION 8 VIEW AVE MAP 25C PARCEL 012 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST . ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out s Fee Paid ` Typeof Construction: DEMOLITION OF HOUSE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Buildin,,Plans Included: Owner/Statement or License 078992 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRJ SENTED: Approved L"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 0. Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to compl} 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. J L JUL 1 1 2007 1 DEMOLITION REVIEW APPLICATION � I DEPT Activity Tracking Sheet ---- Property: -- Map `- Parcel 12 Received in Building Department: Referred from Building Department: Action Taken/ Northampton Historical Commission Action Taken Bv: Entire Commission ) � Sub-Committee of the Commission Commission Designee/ Staff Date Action Taken: Initial Determination Public Meeting held Public Hearing Held Determination Made: Property has been determined not to be Significant according to Ordinance definition. lbitFier acri I be taken. Demolition Permit may be issued. Property has been determined to be Significant according to the Ordinance definition and a Public Hearing has been/will be scheduled. / emolition Permit may not b- issued at this time. tihiir Hearing has been held, Property was determined Signi i Preserved. No further action will be taken/ Demolition Permit may be issued. Photo documentation may be required. Public Hearing has been held. Property has been deemed to be Preferably Preserved. The demolition review period has been initiated. No demolition permit may be issued until the Historic Commission approves an alternative plan or the twelve month period concludes. Alternate plan has been approved/ delay terminated. Demolition may or may not be approved as part of plan. Twelve month time period has expired, demolition permit ay be issued. Referred by: �° Date ' 7- ti SS The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,M,4 OZIII www.mass gov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1 Please Print Legibly Name(Business/Organiiation/Individual): Vo1g` Con s-}-Lkct LA� 1 Address: 36 C_mm12txs PJ&zee te.V , VIA Gti&1i5 City/State/Zip: Phone.#: 76(, -- 0'3 ;�J Are you an employer? Check the appropriate box: Type of project(required): 1.§Q I am a employer with 2 J . ❑ 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. []Remodeling ship and have no employees These sub-contractors have 1 g. Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance.: 9. �Building addition required] 5. ❑ We are a corporation and its 10.7 Electrical repairs or additions officers have exercised their 3.❑ I am a homeowner doing all work 11.0 Plumbing repairs or additions myself. [No workers'comp. right of exemption'per MGL 12.Fl Roof repairs insurance required]t c. 152,§1(4),and we have no employees. [No workers' 131 Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. IContractors 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. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_ A3 �A �./�,t_l`►"�S Policy#or Self-ins. Lic.#: VY M 1)C)n-12- Expiration Date: i 0 .Job Site Address: —A V t Eu; AIJ"Z City/State/Zip: LV 01, liL1V, iL ^ 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 file 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 they pains and penalties of perjury that the information provided above is true and correct Signature: � w�k bAy rqS o Date: G— `Zk ' 01 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: /� I/ Not Applicable Name of License Holder: LzkIA 4 Id�+S A . f-1,h I License Number 31 Vakd AIeu I/tA Address Expiration Date 25& - � 2� Signature Tele hone / , Re istered Home Irri rovemenfContractor - Not Applicable LA. VIC Company Name Registration Number ( -J 1 � Ml A, 16 71 I !DK Address J Expi tear on Date Telephone Z'S- 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.-°H0me 0 wn6 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 l SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ED Accessory Bldg. ❑ Demolition PK New Signs [O] Decks [Q Siding[O] Other[O] Brief Description of Proposed Work: derno►i-hon (5� kou,se. 6i,141,m. Acmm � 19I (&b1:AA C�1rta. d ,e,rdAk is tAA%rVnkr)Ipu{ +Iwr-t a- plo-n�cd IIIrb skeZ5 Fw',prim of•+,,c.kov-ac•) Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 4-Jf.New house x and or addition'fo>existing housind .complete: fie 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, 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 I, t)OUial owy .A. Vp 61 _ !AiA �v�.o A�SrS Uakc. —n C, as Owner/AWb Reel hereb declare that the statements and information o lithe foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury.KtAil Print Name , c�41 Signs a 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 This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L:` _ R.w_ L:w " . 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 � DONT KNOW 0 YES 0 IF YES, date issued:- IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW 0 YES 0 IF YES: enter Book Y Page` and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Q , Date Issued _. Dots rmy- heed-o be ob-6. -�w--hc duvwli}t�►o�+1u lt.au c-� kre&m n%orc avj 20D'aumy ) u 0i"ui4 vvwrt+hO^ 11,001 AAAMY C. Do any signs exist on the property? YES 0 NO 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 IF YES, describe size, type and location: 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 n*for - Vv-ektOWL►*h"bF+i1t hou be ) Fxt} y �y +A-c overall protect)wh.CCl t has v►o� been subw,*4 a ye IF YES,then a Northampton Storm Water Management Permit from the DPW is required. i h flepa/tment tise only I bf;Northam Northampton p Status ofi Permit r JBuildin6`',Department Curb ut/Driveway�Permlt WA 212rn Street $ewerlSep0c`Ava+lab �tyx � Room `1100 WaterlW611AVabbitity k h Northa�pton,WIA 01060 IoR �phon 3: $ 1 240 ax 413-587-1272 t�Stte Plans f` , APPLICATION TO-CONSTRUCT,ALTER,REPAIR,RENOVATE O DEMOLIS A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section lobe completed by office. G ` I i w A ftYw� Map Lot Unit Q V f Zone Overlay District Elm St.`District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: d Assouaks . JnG. 1 a, s p _PA k6zil v MA nw35 Name(Print) Current Mailing ddress: Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by rmit applicant 1. Building (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 Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date " v File#BP-2007-1264 APPLICANT/CONTACT PERSON Kohl Construction ADDRESS/PHONE 31 Campus Plaza Rd HADLEY (413)256-0321 kJ'OP ' THIS SECTION FOR OFFICIAL USE ONL'. PERMIT APPLICATION CHECKLIST ENCLOSED R1 ZONING FORM FILLED OUT Fee Paid Buildinp,Permit Filled out Fee Paid LI-1 _ T_ypeof Construction: DEMOLITION OF HOUSE New Construction Non Structural interior renovations Addition to Existin. Accessory Structure Building Plans Included: Owner/Statement or License 078992 3 sets of Plans/Plot Plan THE FOLLOWING A TION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION P SENTED: Approved 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 Co ssion Z. 23/ 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.