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36-093 (4) Sloe (Y DepaNnent"as only y 00 Status of Permit Bulldin f-y1�} rt nt Curb CuNDivesday Pp)vnit ,y - jwt 1%wfr t Sewer/Septa Availability Room 100 Water/Well Avaaabllty 106 Two Sets of Structural Plans hon 0 3- 7-1272 PloUBite Plans �.— OtheSpeCify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION ,6)0-1 t- lag l 1.1 Property Address: This section to be Compleettled by office �Sl Tloren(JL 1' Map �� Lot ® r" Unit F lore ncx I M R t Zone Overlay District O l0(o Z. Em St Dlstrin CB Distdot SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: "t WA RCO I&A-0 1 "^ -1 83K Address Name(Prin) /l Current 15 - Address' 0-1 ,/t' Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Sigrature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bpermit applicant 1. Building SOO (a)Building Permit Fee 1 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing _ Building Permit Fee 4. Mechanical(HVAC) V'D �D 5.Fire Protection — 6. Total=(1 +2+3+4+5) t $04 Check Number This Section For Official Use Only Dale Building Permit Number: Issued: Signatur Buildin mmissioner/rapectorof Buildings Date GOUT—Enet� �/1�Gt� � QI�hGtn / orr EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed.Per it Ca Be Denied Due To Incomplete Infer anon Existing ropesd g1UbiRiout/�by Zoning. Thismum robe filled) by Building Departmem 4 Lot Size Frontage Setbacks Front Side L R: _ L: R: .... Rear Building Height Bldg. Square Footage % -- - -- Open Space Footage (L.r ora mins bldg&paved rk4n J 4 ofParking Spaces -- — Fill: _. ('.lame&L.aliovJ A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW © YES O IF YES: enter Book Page and/or Document#'' B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained Q , 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 t acre or is it part of a common plan that will disturb over t 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 WindowsAtleration(s) Q Roofing Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [[M Siding[E3) Other[� Brief Description of Proposep /� r Work:Y_,_'.4�-H+ rtu.A .� o ! 0J,- Jucc,r �r Alteration of existing bedroom_Yes / No Adding new bedroom Yes No� Attached Narrative Renovating unfinished basement _Yes No Plans Attached Roll -Sheet Its.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? f. Method of healing? 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_ Pri,alewell City water Supply_ SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, ,as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date l�vI, as Owner/Authorized Agenther y clar al the tatements and information on the foregoing application are true and accurate,to the best of my knowledge and belie . Signed under the pains and penalties of perjury. Me ar` 1�oa land Print am i9 r s Si to of O ner/Age t Data SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction SupeMsor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Data Signature Telephone 9.Registered Home Improvement Contractor. Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 70-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.752,§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...... ❑ City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 2. ® c 212 Main Street • Municipal Building 9 d. \ Northampton, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of conractors and subcontractors performing improvements or renovations on detached one to four family homes.Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered. Type of Work: anA S i�M o+r ra tI a J,Ie.c.— Est. Cost: Address of Work: S�3 q ��O ren ee I� Date of Pcmtit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): Job under 51,000.00 �pp� v'Owner obtaining own permit(explain) WZ a,..t � AG lnl .a_,1J: . I _Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.C.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice,I hcreb app y for a Idi permit as the owner of the above property: fs 6 X �-a u Date Own I VNar*and Waturp City of Northampton Massachusetts i DEPARTMENT OF BUILDING INSPECTIONS y 212 Main Street a Municipal Building �, r Northampton, MA 01060 rhk- 1" Massachusetts Residential Building Code f/�ection I I O R5.1.2 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. Section 110.R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. 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. City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS SF 212 Main Street •Municipal Building x _ Northampton, mi 01060 Pri'lY'3`-'t"a Debris 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. The debris from construction work being performed at: 8sq r Ior4n R rj (Please print house number and street name) Is to be disposed of at: (PI se print lame 7 location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address)Al i ' // L�a `� l� Sign r of P6anit Applicant or Owner Dat4 If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. The Commonwealth ofMassaehusetts Department oflndustrial Accidents s I Congress Street,Suite 100 til Boston,MA 02114-2 01 7 www.mass.govildia \4 orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information �pp Please Print Legibly Name(Business/Organivation'lndividual): atl Address: Jt'�)�,�r-� T(ofeAc4 �M City/State/Zip: �-�y.� , h/l.( ,,�Phoue#: qts- 4l tlyy Cl Are you an employer?Check the appropriate box: Type of project(required): 1.❑I an a employer with countesses(full anderpart-time)1 9, ❑New construction z❑1 am a sole proprietor or panversM1ip and have no employees workivg forme iv kers'comp 8. ❑Remodeling any cnpaciry [.V ower, p -nsumnec required.] v C..MmmWI 1 ❑ DeAmolition l amahomc.wvdoing all work mysdo workcrs' mp_insureerequir ' 4-❑I v a ho mid will b to ing contractors to conduct all wak on my property. t will ID❑Building addition ensure that an contractors either have wmkerseompensatmer insurance.,are sole 11.❑Electrical repairs or additions propticmrs with no employees 12. Plumbing repairs or additions 5.r7 I am a general contractor and I have hired are subcr oneraw.rs listed on the attached snee13. These rvb-contraa.rshave empl.yeu Roof reairs and have workers'comp.insurance) ❑ p 6 F1 We are a corporation and its officers have exercised their right of exemption per MGL a 14.❑Other 152,51(4),and we have no employees.[No workers'comp.insurance required.] 'Any appr,cannhat checks box 41 mon also fill out the s,armr below showing their workers'compensation policy information. 'Homeowners wM10 submit this amdavit indicating they are doing all work and that hire outside controi must submit a new affidavit indicating such :Contractor,that check this box must attached an additional sheet showing the name afthe subcontractors and were whether or not those entities have employees. Ifese sub-ovem rmar,have employees,they must provide their workers armspolicy number_ I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site information. Insurance Company Name: Policy#or Self-ins.Lia#: 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 MGL c. 152, &25A is a criminal violation punishable by 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 5250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations ofthe DIA for insurance coverage verification. I do hereby certify n th p in�ganit enallies ofperjury that the inshrmadonprovided abovejs rue and correct. Signature � � Date �� g Phone#'��l°i) /} Z - g8 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work an such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6�also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." .Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)morels),addresses)and phone number(s)along with their cerltficate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation polity,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permlNicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or pemtit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves eta)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because ofsuch employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply your insurance company's name,address and phone number along with a certificate of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. ]fan LLC or LLP does have employees,a policy is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. .Also be sure to sign and date the affidavit. The affidavit should be resumed to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or ifyou are required to obtain a workers'compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bosom ofthe affidavit for you to fill out in the event the Office of luvestigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary). A copy ofthe affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proofthat a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture(i.e.a dog license or permit to bum]caves etc.) said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax #617-727-7749 www.mass.gov/dia Form Revised 02 23-15