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: