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43-003 408 WESTHAMPTON RD BP-2017-1304 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:43-003 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Bath rend BUILDING PERMIT Permit# BP-2017-1304 Project# JS-2017-002161 Est. Cost: $13746.00 Fee: $89.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RONALD LAMAGDELEINE 8067 Lot Size(sq. ft.): 26397.36 Owner: ECKSTEIN JOHN ALFRED&PHYLLIS KLEIN Zoning: Applicant: RONALD LAMAGDELEINE AT: 408 WESTHAMPTON RD Applicant Address: Phone: Insurance: 112 LAUREL HILL RD (413) 527-8169 WESTHAMPTONMA01027 ISSUED ON:5/1I/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:REMODEL 1ST FLOOR BATH ALL FIXTURES TO REMAIN IN SAME LOCATION 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 5/11/2017 0:00:00 $89.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck- Building Commissioner File Id BP-2017-1304 APPLICANT/CONTACT PERSON RONALD I.,AMAGDEI.,EINE ADDRESS/PHONE 112 LAUREL HILL RD WESTHAMPTON (413)527-8169 PROPERTY LOCATION 408 WESTHAMPTON RD MAP 43 PARCEL 003 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICAT ON CHECKLIST �[�E . OSED REQUIRED DATE ZONING FORM FILLED OUT V� Fee Paid Building Permit Filled out Fee Paid Typeof Construction: REMODEL 1ST FLOO 'ATH . FIXTURES Q REMAIN IN SAME LOCATION New Construction Non Structural interior renovations Addition to E 'stint Accessory Structure Building Plans Included: Owner/Statement or License 8067 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: ,...‹Proved 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 Demoli 'in Delay /Iesditt d s/// Sig o'.uilr g • rcial 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 40k Contact Office of Planning&Development for more information. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability 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 Atltlress''' 1 ,�,,//� P U' T1his section to bt mzo/.leted by office 'o& u)eST�)i,oror "'cad Map 1 Lot 1 Unit `fc'e telt• /44 0' '/2 Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 1(7 Owner of Record: t =0"-Ey kctit)cog Lid)s&/3111el..e>o•1 �,4 6 CArr /414 Cita_ Name(rri^ Current Mailing Address:i/�y y n Ciet:1 Telephone Signa . - 2.2 : orized A!ent: � .. c S e NL y/Z L/Q U / / n eL �/ // ✓�i� tort7FmvrL.rin» Na e(Print) Current Mailing Address: 0/0 27 Bl� a//3 37y 3716 Si. ature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fee ?z/v. 49 2. Electrical (b)Estimated Total Cost of jg30,D O Construction from(6) 3. Plumbing Building Permit Fee �-- 300. 00 4. Mechanical(HVAC) MAY — 9 '210 5.Fire Protection �/�7 6. Total=(1 +2+3+4+5) /37//6 nit Check Number e� g . Np9 This Section For Official Use Only Building Permit Number Date Issued: Signature: Building Commissionermnspeclor of Buildings Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: / Not Applicable ! Name of License Holder:Fob) I , mrag del etNe CS- oOa p[.7 U License Number )/ 2 I nu el /-hi/ /2v we nnizo 1m.* oia z7 z//y/7o/A Address� Expiration ate .ent <�,(/oOLx. y/3 _ 7y 727s� Signature (/ Telephone 9.Registered Home Improvement Contractor: Not Applicable � ) ln... L1nvn/ #'fr. /o/ Toy Company Name Registration Nufiber /17 / AU We Z. /1/// /21-) ele9j/ A70./ Address // - Expiration Date L✓e2..5 1M l /.'l,. inn 0/077 Telephone y/3T)` 1?9 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.V<! No . 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 S-DESCRIPTION OF PROPOSED WORK(check all applicable) New House n Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑ Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [IZ) Decks [0 Siding[CI] Other[OJ Brief Ddption of Proposedrr Work: Xe M ame / / frAv« iist/+soK'H A/l Ft Tvttrr Te ala741N /ice-C/IM e Lecnra‘f' 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, 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? 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. 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 " tneN F.K l I, ,as Owner of the subject property hereby authorize �Or Lam O 5191? /1a-- to act on my b half, in all tters relative to work authorized by this building permit application. ter /y/a,/ Signature of r JJ Date I. (/[�p/N ttnn/� 1 IA-'-- ,as Owner/Authorized Agedt hereb°dare th f he 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.Print a Signa re of /Agent Date 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: 708 Ldr27L .f i fb ce y s o too z The debris will be transported by: ev ` Awipyldan,. The debris will be received by: (/y, 1/7 P(r y c 1e7 Building permit number: Name of Permit Applicant 22 Ll9ntA davc //2c/7 < v 714l lGne- Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of IndustrialAccidents =' T/!=Ci Office of Investigations =1 �te 7 Congress Street, Suite 100 • "ig— Boston,M4 02774-2077 �� www.mass.gov/dia Workers Compensation InslranceAffidavit: Builders/Contractors/Electridans(Plumbers Applicant Information Please Print Legibly Name(Rosiness/orgxnizetlon/Inaividnap: rib rid I p4n,A-1.�e/e A Address: 112 [ ,Cct U City/State/Zip:(,,7ej4 m ' C+.' M Alt O/ce 7 Phone#: 1�/ij y /S3 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 4.I am a employer with ❑ I am a general contractor and 1 6. ❑New construction sw ployees(full and/or part-time).* have hired the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet. 7. lirkemodeling ship and have no employees These sub-contractors have g, [' Demolition working for me in any capacity. employees ab harewcrkere [No worker& comp.insuracomp.insurance.t 9. El Building addition nce 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 I1.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL I2.0 Roof repairs insurance required]t c. 152,61(4),and we have no erj oyes [No works& 13.0 Other comp.insurance required.] 'Ary ypli cat Mat daksbox#1 must also fill out the section balm showing their wakes carpe eaim poll of infamstim. t Homeowners who submit this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicatingsuch. tContractors 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 submtlraotors a.e9ryloyea,they mast providethdr votes comp.policy rumba. I am an employe that is providi ng works& compensation insurance for my employees Below isthepd icy and job ate information. Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a ropy of theworke-& 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 ce under a pains and penalties of perjury that the information provided above u true and correct Signatunk !'� /54,1,11./.1.w. Date: .6//70/7 Phone b: dy/2 ?7y ?75'1"- Ofcial 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#: