36-002 (2) 1135 BURTS PIT RD BP-2016-1438
GIS ft: COMMONWEALTH OF MASSACHUSETTS
Mao:Block: 36-002 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Siding BUILDING PERMIT
Permit 0 BP-2016-1438
Project 4 JS-2016-002479
Est.Cost:$15179.00
Fee:$60.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MAURICE KIROUAC 097695
Lot Size(sct. ft.): 9191.16 Owner: RIVERA DELBUSTO HECTOR
Zoning: Applicant: MAURICE KIROUAC
AT.• 1135 RI JRTS PIT RD
Applicant Address: Phone: Insurance:
45 WOLCOTT ST APT 1L (603) 674-0877 SOLE
PROPRIETOR
HOLYOKEMA01040 ISSUED ON:6/7/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:SIDING AND NEW BAY WINDOW
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:
ittfV
Final: Smoke: Final: v, c Q G
THIS PERMIT MAY BE REVOKED THE I NORTHAMPTON UPON VIOLATIION OF
ANY OF ITS RULES AND RE I I
ad-"4"0 /Atm
Certificate of Occupancy ft Signature:
FeeTvpe: D to Paid: Amount:
Building 6/7/2016 0:00:00 $60.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
ilrilir&
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RECEIVED Department use only
City of Northampton Status of Permit:
JUN — 6 Building Department Curb CuUDriveway Permit
212 Main Street Sewer/Septic Availability
DEPT.OF BUILDING INSPECTIONS Room 100 Water/Well Availability
NOR-14.P.!;PiON,MA01C60 Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
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
//35 BU1t45 TIC jd Map Lot Unit
x r/02EN� f fl 0106d- Zone Overlay District
7" Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
11E42 L. Z vE/oi - 1 (&,.t 4 18-5- Ai s d 7% 1Z4'(e Mf) 0/0b2
Namfnt) k. Current Mailing Address:
/AA f t /t/it. �f�' ,u7 Telephone
gnature q� z,q
2.2 Authorized Agent: �PT
i la * , : "1- 01-)761 / 14A, r')/ 0 '16
ame(Print) Current Mailing Address:
237(0a�k �` _ �7
Sig . .e / Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building /2-1- `n 6°
(a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of — 7 ? p0
Construction from(6) /J ,
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection l�
6. Total=(1 +2+3+4+5) Check Number / S'5
This Section For Official Use Only
Building Permit Number: I sssuu
ed:
Signature:
Building Commissioner/Inspector of Buildings Date
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1.
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
/ Not Applicable ❑
Name of License Holder: �/Q�(1 C�
License Number
',s' LA)e. z4p-. l L. fia►-yovii ( a 719_5
Address Expiration Date
Si ature Telephon=
G1-� � 7
9.Registered Home Improvement Contractor: Not plicable 0
Company Name Registration Number
4)141* 4-5 14 / `q 3e)
Address Expiration Date
— Telephone 15 /
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 0
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 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 I j
Side L: R: L:!___ ! R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
Ping)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 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 O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
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 O NO O
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 ❑
.Of-Deers (7]
Accessory Bldg. El Demolition ❑ New Signs [0] Decks [D Siding Other ICI]
Brief Description of Proposes.
Wo s1L. 1 4 _ . S t sem. r: . V. _...` : StvI.JG
Alteration of existing bedroom Yes I No Adding new bedroom Yes No /
Attached Narrative Renovating unfinished basement Yes V No
Plans Attached Roll -Sheet
6a.if New house and or addition to existing housing, complete the following:
a. Use of building:One Family V 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 1/ 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, 4,643 1 . A - `Lu-S h ,as Owner of the subject
property
hereby authorize , (L1? /d.-f- 7 1l�� ,(�rv,
( , Z
to a o�ehal in all matters relative to work authorized by this building permit application.
ignature of Owner Date o2
I, `/ i gi. z• , 1 It ,a ner/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.
itilAtt re.)c_ -_- -KtRi, w„ei-c, --ir-----i-
Print Name
i%--�. 1'L,71.Zer,{-1 . ./12.//A'(
Sign.. re ofawner/ t Date
71. . i' :'1 '1I
City of Northampton 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.
j Address of the work:
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant / liettPR(2f 1<(iZo
V016 )0440-1.1:403te,_94,___
Date Signature of Permit Applicant
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The Commonwealth of Massachusetts
M
=t-TZ Department of Industrial Accidents
PA
— = Office of Investigations
„ ' _ , 1 Congress Street, Suite 100
=414=it = Boston, MA 02114-2017
wt' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ;VI jA t p ! r _
Address: S AID J�`T
City/State/Zip:ar a n(: # • Q Phone#:
Are you an employer? heck the appropriate box: Type of project(required):
1.❑ 1 am a employer with 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• 0 We are a 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,c1 % 7 A..)(
comp. insurance required.] yy
*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.
Iam 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 certify under the pains and penalties of perjury that the information provided above is true and correct.
/40 /
....1--//e >
Signature: i9. i Date: fp
Phone#:(
I /
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#:
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