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03-028 (4) t ip 5-1 Lj t, h :5 .150, f a / b�m��u=nom fit -r/X-r Tjdd�v� s S f7 Lid X Z 4; 0 Wt d �7fj fN 0 q �j W V�Ojj •u a X5 Od OPW ? City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Afdavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: `� Goes MP``)'O''`J R 0' 1h k4 ©)� 6� The debris will be transported by: �f �G / e 1z� ����: �=►�c° The debris will be received by: Building permit number: Name of Permit Applicant To Ah 121 - 3--30--, 57777 Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 ftE Boston, MA 02114-2017 ,e www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): t}�h 7� �11�?ya)_ Address: 147 W l l l c� ►'►� fi e City/State/Zip: 5ke&2,n=M 11f Phone#: I3) .2-37--3IV3/ 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 b. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 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. WDemolition 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.❑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.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.❑Other QC, 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: — 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 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. l do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Situiature C-� �t r^ 41M - PtA Date .3-3Q-1f_ Phone#: 1 2-37--- 3q 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#: SECTIONS-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: 2—An ` Pie /�dL 1– 0 OVA/ License Number L47 V/41 tin m 91 t 4-14� Address Expiration Date Signature Telephone P 13 z37-7 4131 9.Realstered Dome IMPrOVement CDt►ttaCt : Not Applicable 0 Company Name nn Registration Number �-- 'Y' P-(ail L �—®oz Address l,�t!.!l Srn��-f Expiration Date _ 3 23 3L 3) Sht l by i21�.c_t-A kil, &A— 13R�-Teleph e 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 it. Signed Affidavit Attached Yes....... No...... 0 11.,- Homeowner Exemytian 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 I i SECTIC3ht 5-DESCRiRT#ON�'A�Rt�SEa WORK t>="heck a!#anclicabte3 New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors D Accessory Bldg. 0 Demolition Now Signs = Decks [ Siding[p] Other[a Brief Descri on of Proposed ors Ana hilt CXL5f,n� &_nCk030_ o R AND /-7d otF i� pe Work: pit S t-a f l I12-4k ��tk,►�a A-iy iZG,1,r%�X O'E m ' 4,4 4,44 of god. Alteration of existing bedroom Yes No Adding new bedroom Yes 7�lO No Attached Narrative Renovating unfinished basement Yes Plans Attached Roll -Sheet # =1 #itn parieltnxs # lE 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 wettands? Yes No. Is construction within 100 yr. ffoodptain Yes No j. Depth of basement or cellarfloor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. L Septic Tank City Sewer Private well City water Supply SECTitJN 7a-owta":�A€ THORIZATIt3N-TO BE COMPLETED WHEN OWN=AGEMf OR>GOAlTRl4G1`fSR APPU...ES FOR BLAL DING PERMIT I✓ ' S Co 3SP, L as Owner of the subject property hereby authorize V,4 A to act o m 7alf, all matters r alive to work a orized by this building permit appl cati on Signature of Owner Date as Own Authorized ' ent ereby declare that the statements and information on the foregoing application are true and accurate,to the best o y knowledge and Belief. Signed under the pains and penalties of perjury. Print Name r 3 s- Signature of Own Age- Date Z� 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: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (L(A area minus bldg&paved parking) #of Parkin Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ev_prl5een issued for/on the site? NO 0 DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES Q IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 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 �( 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, excav or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO 1F YES, then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton Std of Perstir ing Department COWD urls -61v a Pmt 2 Main Street Se+ e� e�trb N Room 100ilisAil Mai 3 0 2015 N mpton, MA 01060 � , phone 41 -1240 Fax 413-587-1272 IC�lteis Electric, Plumbing& - ort am ton M 1101. 1 ,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTIO t-SITE INFORMATIt�N 1.1 Proaerty Address:... T#t+s seactiott fo be ct�impleted tzy office 5-?q Co/e-5-/r` v Dull Lot i3n9€ All,- A et vh()t v-t` 41/� o/o 6 o Zone Owl►Dion SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Cj �c S !'1'1 �cam✓ n o sC �t . lCalp Name(P int) Current Maiiing Address: V- 1; Telephone Signature ` 2.2 Authorized Agent; w/11 ►4 rYl 'TD h h /n 2 .r1 she%�vn�,e r� s M Name(Print) Current Mailing Address: of- - __ �q13) z3 --3 H3/ Signature Telephone SE ION 3 ESTIMATED COt�1S FIUCTION Gt9STS Item Estimated Cost(Dollars)to be Official Use Only completed b permit applicant 1_ Building 0-0 (a)Building Permit Fee 2. Electrical �— (#�} Estimated Total Cost of Construction frost► fi 3. Plumbing , Bulkiing Permit Fee 4. Mechanical(HVAC) 5. Fire Protection �r 6. Total=(1 +2+3+4+5) { � Check Number This Section For Official Use ON pate Buddir;g Perm t Number: Issuetl: Signature: it fi Bulk ltrig: otnmis�iettlrtorofuNdr�s Date File#BP-2015-0909 APPLICANT/CONTACT PERSON JOHN M PIEPUL ADDRESS/PHONE 47 WILLIAMS ST SHELBURNE FALLS01370(413)237-3431 Q PROPERTY LOCATION 591 COLES MEADOW RD MAP 03 PARCEL 028 001 ZONE RR(100)/WSP(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 Typeof Construction: CONVERT ENCLOSED PORCH TO OPEN DECK(SAME FOOTPRINT) New Construction Non Structural interior renovations Addition to Existing Accessory Structure Buildine Plans Included• Owner/Statement or License 071381 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: roved 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 e lay Sig re o uilding O icial 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. 591 COLES MEADOW RD BP-2015-0909 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 03 -028 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-2015-0909 Project# JS-2015-001763 Est.Cost: $19775.00 Fee: $118.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN M PIEPUL 071381 Lot Size(sa. ft.): 104936.04 Owner: COLE SCOTT&LISA Zoning: RR(100)/WSP(100)/ Applicant: JOHN M PIEPUL AT: 591 COLES MEADOW RD Applicant Address: Phone: Insurance: 47 WILLIAMS ST (413) 237-3431 (� SHELBURNE FALLSMA01370ISSUED ON:313112015 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONVERT ENCLOSED PORCH TO OPEN DECK (SAME FOOTPRINT) 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 3/31/2015 0:00:00 $118.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner