31B City of Northampton mmft
Massachusetts C,
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street *Municipal Building
Northampton, MA 01060
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:
S- t Vrk-6 VF—C- STS,
(Please print house number and street name)
Is to be disposed of at:
Vck 0
(Please print name an location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
§gnature of Permit Applicant or Owner Date
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 of Massachusetts
.Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Us www mass.govldia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): L e, �Z g `� (1..1� i_,�a
Address: 2D� Ij,C� .C.,t>'c'
City/State/Zip: lr o1iA"QrNPyIMM Tyr' I 11/- Phone#:Are you an employer?Check the appropriate box: Type of project(required):
1. a a employer with_.� _,..employees(full and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in $. E]Re doling
any capacity.[No workers'comp.insurance required.]
9. OrDemolition
3.[D I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 Q Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole I I.Q Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t 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 name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: Lt �1 /
Policy#or Self-ins.Lic.#: v�s 5� 7'7 Expiration Date: "7/ '>l l i q
Job Site Address: 1�' 1 V-� ��, IV t"�.. City/State/Zip: N F��'y#�^ , ✓IM
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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone#:
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 S.Plumbing Inspector
6.Other
Contact Person: Phone#:
S�CI`IOi 8•C< OWSERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑ ?
Name of License Holder: R C S 0:1 4:7 � J
License Number c�—
Address Expiration Date
Signature Telephone
Not Applicable ❑
Company Name Registration Number
Q _ -s 1 ---) ( 2�u
�4
Address Expiration Date
Telephone
SECTION 10-WORMERS 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 builtgTermit.
Signed Affidavit Attached Yes....... No...... ❑
SECTIQ<tl;_}�ER�l elION Olt PROPOSED WORK(check all applicable)
New House [] Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors D
1-
Accessory Bldg. ❑ Demolition New Signs [C]] Decks [Q Siding [0] Other[CA
Brief Description of Proposed C1 .-- e'? PC-,Lk LevA<,e,I ria 71 bv-
W ork: gel a tr^ tl C `
Alteration of existing bedroom Yes No Adding new bedroom Yes Lo
Attached Narrative Renovating unfinished basement Yes �'—No
Plans Attached Roll -Sheet
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms V
c. Is there a garage attached?
d. Proposed Square footage of new construction. PV _Dimensio
e. Number of stories?
f. Method of heating? R aces 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 ands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement o ar floor below finished grade
k. Will buildin nform to the Building and Zoning regulations? Yes No.
I. is Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENTd1k CONTRACTOR APPLIES FOR BUILDING PERMIT
1 �j�Np(Z�t y (' (( -�1 y� as Owner of the subject
property �}
hereby authorize 1 0 F'&V_� V'���
to act on my b half, in all mater relative to work authorized by this building permit application.
J
it 3�
Signature of Owner Date
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.
Print Name
L
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
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage ;rcnj 6A
Open Space Footage
(Lot area minus bIdg&paved
#of Parking Spaces
Fill: ation)
(volume&Loc
A. Has a Permit/Variance/Finding ever been issued for/on the site?
�� ��
NO ��� DONT KNOW «�� YES �~�
IF YES, dateissued:
IF YES: Was the permit recorded atthe Registry ofDeedsJ
NO ��K 0 DONT KNOW 0 YES
IF YES: enter Book Page and/or Docunnent#
��
B. Does the site contain abrook, body ofvvaterorwedd
ando� NO D0N'T%NOVV �~� YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tobmobtained »~~� Obtainedx��"~�^ ��t� Ussu��'^
�~� '
C. Doany signs exist onthe property? YES 0 NO
|FYES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
»��
IF YES, describe size, type and Location:
E. Will the construction activity disturb( ring.gnoding ion.orUUu
filling) mocommon plan
that will ��disturb acre? YES K 0 NO Ku�
��
|FYES,then aNorthampton Storm Water Management Permit from the DPW iorequired.
City Of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 F -
REC
APPLICATION TO CONSTRUCT,ALTER REP MR,RENOVATE OR DE OLIS A ONE OR TWO FAMILY DWELLING
NOV 3 3 2018
SECTION 1 'SITE'INFORMATION
1.1 Property Address: DEPT-OF suiLD
NORTHA
, r
. a
SECTIO114,2-,PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
-'2Aya_A P rte- T, ° c2" :
Name(Print) f t
A"�/ Current Mailing Address:
t1� �' SY�e' 1�y S-+v S -' GI ( I
Telephone
Signature
2.2 Authorized Agent:
_ 70 y5lrc� t"-'J�44_ G S C
Name{Priv( Current Mailing Address:
�t u--C�-. �..� Qom._ Lv
Signature Telephone
SEC'C#ON�<3-ESTII�1"AT,ED CONSTRUCTION COSTS
Item Estimated Cast(Dollars)to be Official Use Only
completed by permit applicant
1. Building ` (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
7
4. Mechanical(HVAC)
5.Fire Protection
6. Total=0 +2+3+4+5)
! (7C7(1 Check Number f 09
This Section For Official Use Only
Building Permit Number: DateIssued:
Signature;.
Building Commissionertinspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
File#BP-2019-0661
APPLICANT/CONTACT PERSON ROBERT WALKER
ADDRESS/PHONE 36 Service Center NORTHAMPTON (413)584-1224
PROPERTY LOCATION 51 PROSPECT ST
MAP 3 1 B PARCEL 132 001 ZONE URC000)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
CLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REMOVE REAR ADDITIQN,,TKEE DAMAGE
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included:
Owner/Statement or License 034783
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved 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
Demolition Delay
Signature of Building Official 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 40A.Contact Office of
Planning&Development for more information.
51 PROSPECT ST BP-2019-0661
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 B- 132 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: demolition BUILDING PERMIT
Permit# BP-2019-0661
Project# JS-2019-001079
Est.Cost: $12000.00
Fee: $78.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use Group: ROBERT WALKER 034783
Lot Size(sa.ft.): 9583.20 Owner. PETERSON SANDRA L
Zoning;:URC(100)/ Applicant: ROBERT WALKER
AT. 51 PROSPECT ST
Avvlicant Address: Phone: Insurance:
36 Service Center (413) 584-1224 Workers Compensation
NORTHAMPTON MAO 1060 ISSUED ON:12/7/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE REAR ADDITION - TREE DAMAGE
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:
FeeTvae: Date Paid: Amount:
Building 12/7/2018 0:00:00 $78.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner