24D-214 (5) City oi'Ylorthampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
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:
The debris will be transported by:
The debris will be received by: . L
U
Building permit.number:
Name of Permit Applicant I-A tkilu
- 719
V/
Cate -'Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
a < Office of Investigations
d
600 Washington Street
f 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: �b
City/State/Zip: A' `01- ICC \ C) Ph
P— one#: LA
Are you an employer? Check the appropriate box: Type of project(required):
1.M I am a employer with 1�3 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. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
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.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] f 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.
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: bt',,��G` L l L �i Z`�jrl�e t.7 r6u p
Policy#yr Self-fns. L:c.#: Onl
� Expill wn Date: c _
Job Site Address: YCC 2� 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 v rification.
I do hereby certify the pains a°d penalti perjury that the information provided above is true and correct.
Si nature: I ` �`` ^' Date:
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#:
e t
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:__ � (1 �7i1����VVlCG'1
License Number
- - '1 C �
e
(o 12-1 1�
Address Expiration Date
S' n Telephone
9.'Redistered Home Improvement Contractor. Not Applicable ❑
Company Name Registration Number
-e___0 - ?//_7 //&
Address Expiration Date
s .n.6c ��o Telephoner )Z1F`ll~�CED
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 OwIle< E el if gn
The current exemption for"homeowners"was extended to include Owner-occupied DwelNuys of one(1) or two(2)families
and to a1mv 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 andJ 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 Oficial,that he/she shall be
responsible for all such word:performed under the beildiar6 permi!L
As acting Construction Supervisor your presence on the job site will be required ft•om 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 1`7
Accessory Bldg. ❑ Demolition ❑ New Signs [p) Decks [M Siding[0) Other[Et
Brief Description of Proposed
Work: ( r frf'' — .
(_,I PC�2A Q FS 'C'b FP-MIN�n�, () ,�ionlbb V'i n/1f
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; comblete 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.
1 I. Sepiic 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 i
hereby authorize f?Irl tJ111?E'�1�`�:�D'l S
to act on my behalf,in all matters relati to work authorized by this building permit application.
Signature of Owner Date
J
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
i and belief.
I
Signed under the pains and penalties of perjury.
1
Print Name
97
Signature of Owne A 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: L:'_. 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 ev r been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:`
IF YES: Was the permit recorded a he Registry of Deeds?
NO 0 DONT ' OW 0 YES 0
IF YES: enter Book Page andlor Document#
B. Does the site contain a br ok, body of water or,wetlands? NO 0 DON'T KNOW 0 YES 0
IF YES, has a permi een or need to be obtained from the Conservation Commission?
Needs to be obt reed Obtained 0 , Date Issued:
C. Do any signs a lst on the property? YES 0 NO 0
IF YES,/ scribe 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:
'ti _t
�. ��Vi u'ic wilSit'U iiuri a uviip dicswiu(dt;a1.1fk9,ytCU1111CJ,, excoavaii(lt`f, C iuiri4)ovci""i acrc ov is i-,paa G-i a coViliR ori Diarl
that will disturb over 1 acre? YES V NO ,0
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 Curb Cut/Driveway Permit
S� 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
' ✓ ,� Northampton, MA 01060 Two Sets of Structural Plans
one 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
CATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTI N 1 -SITE INFORMATION
1.1 Property Address:
This section to be completed by office
I M-' C0->gA— Map Lot Unit
�Lu�� kCr
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
e 1 + \,-A �acv Q(uspeC-=� Ca+ ou' wkg'.. Gto
Name( rint) Current Mailing Address:
L4 13- Nk- 39C�y
Telephone
4 ,.Signature
2.2 Authorized Agent:
�•� .'�c..xc �OLaZ r�t.�x��rzc:,�- 11`1�'•t- Cai o c��-
Nam* Current Mailing Address:
Signature Telephone j
SECTION 3-ESTIMATED CONSTRUCTION Cos-STS I
Item Estimated Cost(Dollars)to be Officiai Use Only
completed by permit applicant
1. Building q (a)Building Permit Fee
2. Electrical ( W (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Persalt Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Oficial Use Only
Building Permit Number: DateIssued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2016-0984
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522
PROPERTY LOCATION 4 PROSPECT CT
MAP 24D PARCEL 214 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid 9t 1
Building Permit Filled out
Fee Paid
Typeof Construction: REPAIR FRONT PORCH(UPGRADES) V Q��
New Construction
Non Structural interior renovations
Addition to Existingu
Accessoa Structure
Building Plans Included: IV
Owner/Statement or License 077279
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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
A —io
Sign e l 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.
4 PROSPECT CT BP-2016-0984
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D-214 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-2016-0984
Project# JS-2016-001667
Est. Cost: $9000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 3615.48 Owner: GREENLAW ROBERT
Zoning: URC(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT. 4 PROSPECT CT
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.•2/5/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.REPAIR FRONT PORCH (UPGRADES) - no
structural change without plans
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 2/5/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner