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23B-008 (10) 15 STRAW AVE BP-2017-0770 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23B-008 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2017-0770 Project# JS-2017-001281 Est.Cost: $5000.00 Fee:$100.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JAMES ROBERTS 99404 Lot Size(sq.f): Owner: PERMAN GARY Zoning SI(I001/ Applicant: JAMES ROBERTS AT: 15 STRAW AVE Applicant Address: Phone: Insurance: 30 Edwards Rd (413) 527-6078 W ESTHAM PTO N MA01027 ISSUED ON::I/5/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:REPAIR SMALL SECTIONS OF ROOF 8 SQUARES 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: OI: 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 1/5/20170:00:00 SI00.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Version1.7 Commercial Building Permit May 15,2000 Department use only City of Northampton Status of Permit:. Building Department Curb Cutf06veway Permit �� 212 Main Street SeweoSeptic Availability Room 100 Water/Well Availabltfy \ Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLI •TION TO CONSTRUCT,REPAIR,RENOVATE, CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Property Address' This section to be completed by office Map Lot Unit Zone Overlay District -- -- - - Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Re/co}rd�: f(� /� eet Name(Print) / f Current MailingAddress Signature .41,....€4-dor ,,,/// 1 Telephone 2.2 Authorized Age /' Name(P(nt) f Current Mailing Address 4. Signature T.. Tom/ 7 / /C2 ear Telephone � 7 v t/ SECTION 3-E 1fIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only col deted b •ermit applicant 1. Banding f� (e)Building Permit Fee 2. Eledncai (b)Estimated Total Cost of ..' Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) - -- - 5,Fire Protection 6. Total= (1 +2+3+4+5) Check Number jr�j '�� This Section For Official Use Only Building Permit Number Date Issued Sig ���/ r /7 . ! SNltlln:om iss• ernspecturni6uldtngs I ate /36 _dot Version].7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs 0 Additions 0 Accessary Building 0 Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use Other 101 Brief Description Enter a brief description here. Of Proposed Work: f mauu o /;n(( 01 yVi py... / _. SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ Al- 0 A-2 0 A3 0 IA 0 A-A ❑ A-5 0 1B 0 e Business ❑ 2A ❑ E Education! 0 2E I 0 F Factory 0 F-I 0 F-2 0 2C i ❑ H High Hazard ❑ 3A 0 Institutional ❑ 1.1 0 1-2 ❑ 1-3 ❑ 3B r ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 0 R-2 0 R-3 0 5A ❑ S Storage ❑ s-1 ❑ S-2 ❑ 5B ❑ 'I u Utility ❑ Specify _... . .. .... . _ ._ .... . M Mixed Use ❑ Specif". S Special Use _...p Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS.ADDITIONS AND/OR CHANGE IN USE Existing Use Group: _ ..... Proposed Use Group: __.... Existing Hazard Index 780 CMR 34) _._ __. - ._ Proposed Hazard Index 780 CMR 34)SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 2" aro _... Total Area(sr) sets!Proposed New Constructionist) Totsl Height(ft) _ Total Height ft 7.Water Supply(M.G.L.c.40,§54) 7A Flood Zone Information: 17.3 Sewage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone❑ i Municipal ❑ On site disposal system❑ Versionl.7 Conumeicilal Building Permit May 15, 000 fi. NORTHAMPTON ZONING Existing Proposed Required by Zoning This stluv:n tete filled m by Building Department Lot Size _ Frontage . .. .. _. Setbacks Front - Side I R-_. _ - L: R pni Building Height Bldg Square Footage Open Space Footage - .... % _._. ........ (leg area minus bldg&paved 'laking) P of Parking Spaces ---- hell. ,volume&tocabon) _ .. ..._ _. A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DON'T KNOW 0 YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW Q YES Q IF YES: enter Book Page and/or Document k B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO Q IF YES, describe size, type and tocat ion: D, Are there any proposed changes to or additions of signs intended for the property? YES Q NO 0 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 ofa common plan that will disturb over 1 acre, YES Q NO Q IF YES,then a Northampton Storm Water Manageme_Permit from the DPW is required. Version 1.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: _. ..__., _.... _.,. Not Applicable 0 Name(Reoistrani): R9 trabon Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineers): Name Area of ResponMbl ty Address Registration Number Signature Telephone expiration Date Name. __. _. _... _. Area of ResponsibilN Address Rey mrat on NumGe' Signature Telephone Expiration Date Name _.. Area p£RaspCnSibitity Address _.._. ...._.. Registration Number __... Signature Telephone Expiration Date Name Area of Responsibility Ndtlress _. _. _... _ Registration Number Signature Telephone Expiration Date 9.3 General Contractor Nut Applicable Company Name Responsible In Charge of Construction 4drl rebs _.. .. _. Signature Telephone Version'7 Commercial Building Permit May 15, 2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) /`� YIndependent Structural Engineering Structural Peer Review Required Yes 0 N U SECTION 11 .OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, _5. i 'as Owner of the subject property hereby authorize i� . ;l/. --- // .. air_. _ _. _ .. . to act on my behalf, in all ma relative to w�orpk authorized by this building permit application Spate of Owner / Date i _ ,as Owner/Authorized Agent here. de •re 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 permi rf fi %AP -, -_ Prim Name _. / signature of Cwmxiaaent.-...... Cate / / - ....-...- SECTION 12-CONSTRUCTION SERVICES 10,1 Licensed Construction Supervisor: Not Applicable LI Name of License Holder , if......... „a., ? !�i. '” - D 4 t- ee- r License Number ,_, Expiration Date / ..� ,� - .(17 6_____Address /9/5d &gnats i Telephone SECTION 13-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 0 Na 0 --- The Commonwealth of Massachusetts Department of Industrial Accidents - Office of Investigations =r '--t ; 600 Was/Sown Street Boston, MA 02111 www.in ass,govkfia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(3151ess/OS nstion.andivid.at): y,y dA i/ 'ale ..da ss 3 ; c� -• � ir 1 i City/State/Zip: ,/� Phone:i: .e; — .I Are you an employer" Check the ..proprlate box: Type of project(required): 1.C._ Iamaployer with 4. I I am a general contactor and I �x 5. ❑New construction emnt nes(Pali andtor part-time,).' have hired the sub cnnvacmrs 2. am a sole proprietor or gamier. listed on the attached sheet. 1 7. 0 Remodeling ship and have no employees These sub-comractors have 8. 1 Demolition workingfor me in anycapacity. employees and.have workers' [No 9. 1_ Building addition workers' comp.insurance Wecoarp.e La corporation required.] 5. I I W e area corporation and its 10.0 Elec ical repairs or additions officershave11 rPlumbing repairs or ations 3.� I am a homeowner doing all work exercised their =-� ddi ' myself [No workers' comp. right of exemption per MGL 12.1 Roof repairs insurance required] t c. 152, §1(4), and we have no employees. [No workers' 13.: ] Other comp. insurance required.] Any applicant the:checks box pl must also fill out the section below showing thew workers'compensation Policy inita:manon. f'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 nano of the sub-contractors and state whether or not those entities have e mployees. If the sub-contmcters have employers,they must provide their wodtrs'comp.poly number I inn an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �J/ (✓' ,,._ _ Policy 11 or Self-ins.Lic.fir 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 Station 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 Investigattions of the DLA for insurance coverage verification. I do hereby certify under II • Joins and penalties of pedal),that the information provided above is true and correct Siengeme: Date: Phone r: Official use only. Do not write in this area,to he completed by city or town official City or Town: Permit/License d Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. CitvlTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone 4: 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 150k Address of the work: /517-C4-010/79---. The debris will be transported by: The debris will be received by:0, ` -4? r Building permit number: Name of Permit Applicant / 714 40P" C -j Date V/ Signature of Permit Applicant