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38B-121 (5) 160 SOUTH ST BP-2017-0532 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B - 121 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: window re.laced BUILDING PERMIT Permit# BP-2017-0532 Project# JS-2017-000866 Est.Cost: $3500.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: TODD D PEASE Lot Size(sq. ft.): 8276.40 Owner: SHEARER ALICE M Zoning: URB(1001/ Applicant: TODD D PEASE AT: 160 SOUTH ST 0%33 g Applicant Address: Phone: Insurance: ltotrCAT Y '-/CraSS Jf. $* RJif (413) 210-1476 WI! 1144eci tRPhaoA1096 ISSUED ON:70/19/20160:00:00 TO PERFORM THE FOLLOWING WORK:17 REPLACEMENT WINDOWS - ENTIRE HOUSE EXCEPT FOR NEW ADDITION 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 rt 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: FeeTvpe: Date Paid: Amount: building 10/19/2016 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner 0 '1'1' 5303 203 city of Northampton SOW!:of Mitt 1;1!;1 8 - B, Ming Department 'i CDtt palma : ' '12 Main Street Bew'pf 5'ap&Po aHebildy '. Room 100 Wat9dlWell AvatleArd'114 oe f Northampton, MA 01060T SetsofSiflflf� ' phone 413-587-1240 Fax 413-587-1272 bkSite Plans ,., ,,,,; Meier Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 •SITE INFORMATION 1.1 Property Address: This section to be completed by office 60 Scv' St?"€4 t Map Lot Unit F `,--vte"1 rnhs� ' Zone Overlay District ei C'C 0 Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner Of Record: • u r \ c s.•:Th Si- nortc,,,,81r- Name(Print) 101- Current Mailing Address' Lf/( - S8/ - �JCv9 / telephone Signature S i 2.2 Authorized Agent: �e1d Pe't c c. y Ccoc r Sues 1 Lj Theis Name(Pont) Current Make Address CI 37c5 0'1"}/1 ; t//3 -ra;c - 15/76 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only d�completed by permit applicant 1. Building W 3s-oo. 00, (a)Building Permit Fee 2. Etectroal �+•� ,•J (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) ��'(jj��/-��J- 5_Fire Protection ,- 7 — fi. Total=(1 +2+3+4+6) Check Number m (1. This Section For Official Use Onl Building PetmS Number Date Or Signature: - _ /J��/ Building Commis/nor,'insf�of$outings Date SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement W' Bows Alteration(s) n Roofing n Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs (CO Decks [p Siding[C] Other IOI Brief Description of Proposed I � Work: Il RcovAccrlrnt w• nAow) ( Ptirak 5 tO 1z;•— ^ S ) ) Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Ba.If New house andor addition 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 Na 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Oa✓rA 5^ LAfe( ,as Owner of the subject property hereby authorize TGA Pec c to act on If,in all mar rrs�pfgelative to work authorized by this building permit application. Signature o' n�'v j e Jc /eV 18/o20f6 I, TOP A Peas( ,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 the pains and penalties of perjury. tnArl Pu;c C Print Name 1 io/6 do J6 Signature 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 Tats column to be find in by Building Depanment Lot Size Frontage Setbacks Front Side Rear Building Height Btdg,Square Footage o - Open Space Footage lint area minus bldg&paved parking) N of Parking Spaces Fill: _....... ... (volume&Location) A. Has a 5 tial 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 O YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT 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 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO d IF YES,describe size, type and tocatlon: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO d IF YES, describe size, type and Location: E. Will the construction activity disturb(clearing,grading,(�exyovation,or filing)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO IP YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Peel Applicable ❑ Name of License Holder: TcA A reel - 1613W License Number V Cass S17eft &Gkleni) mA , , Jai /.air Address Expiration Date cC P-- vfl -a1G — /Ylb Signature Telephone 9.Registered Home Improvement Contractor Not Applicable ❑ Company Name I o�>G 1 11JJ I� (� Registration Number Peart 71w yt')(I 1 )( (✓1 LQ� 1 /raZU /doj 7 AddressI Expiration Date y ((GSr S}, woo-) (b4S5 Telephone W 'c lo '/fr)f 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 buil ing permit. Signed Affidavit Attached Yes No ❑ 11.- Home Owner Exemption The current exemption for'homeowners"was extended to include Owner-occupied Dwellings of one(I) or rwo(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 198.3.5.1. 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..4 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 City of Northampton 212 Main Street, Northampton, MA 01060 Solid Wastc 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: 16 0 SoA \ st. lccfl pT-' en'S'S The debris will be transported by: + j a,„A See, The debris will be received by: Tr F� c ' •}t Building permit number Name of Permit Applicant Tcako1 Pe<, r,c_ ]o/ ao/b dna4 Date Signature of Permit Applicant n The Commonwealth of Massachusetts Department of Industrial Accidents � T Office ss StrInvestigationsute. 7 Congress Street,Suite 100 Boston, MA 02114-2017 www.ntass.gov/dia Workers'Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/individual): 1-cito1Pecs.(,,. Address: t( CCcs5 sr , $.,Cks � ._ Gf33e _ City/State/Zip: Phone#: _ / —v c —/9176- -Are von an employer?Check the appropriate box: Type of project(required): I.Vel am a employer with 4. ❑ I am a general contractor and 1 employees(MI and/or part-time).' have hired the sub-contractors 6. 0 New construction listed on the attached sheet. 7. 0 Remodeling 2.171 i nm a sole proprietor or partner- ship and have no employees 'These sub-contractors have g. ❑ Demolition working g for Incme in anycapacity. employees and have workers' cam .insurance. 9. [0 Building addition [No workers' comp.insurance P required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL Y P - I2.❑ Roof repairs insurance required.]` a 152,§1(4),and we have no ,,/' employees. [No workers' 13.(✓I Othertyaesitad {�i4Yntnr comp. insurance required.] "Any applicant that checks huh 01 must also fill ora the section below shoring their workers'compensation policy information_ <Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an uddi Lionel sheet showing the name of the sub-<nmnctors and state whether or not those entices have employees. If the sub-contractor have employees,.they must provide their workers'er g-policy mute- /am an employer that is providing workers'compensation insurance for my employees. Below is rhe policy and job site information. Insurance Company Name: 9ACr'1'c C.Jv'} Policy or Self-ins. Lie. A: oO i tJ}Ge,ta, Expiration Dale: 3 Je) / o17 Job Site Address: I 6 0 SeAdttin S+.,,,,,_ City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). `'let G Failure to secure coverage as required under Section 25A of MOL c. 152 can lend 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 DR for insurance coverage verification. I da hereby certify/under the pains and penalties of perjury that the information provided above is true and correct. Signature: �I tre11 c !F- pate: /4[76771 /e4 Phone Phone; if/ - 7 v76 -� Official use only. Do not write in this area,to he completed by city or town official City or Town: Permit/License ti 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 t: