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36-284 (11) 610 BURTS PIT RD BP-2020-0631 GIS#: COMMONWEALTH OF MASSACHUSETTS MQ Block: 36-284 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BASEMENT RENOVATION BUILDING PERMIT Permit# BP-2020-0631 Proiect# JS-2020-000406 Est.Cost: $5800.00 Fee: $100.00 PERMISSION IS HEREB Y GRANTED TO: Const.Class: Contractor: License: Use Group: FITZGERALD BURGLARY_ Lot Size(sa.ft.): 33454.08 Owner: GANDARA MENTAL HEALTH Zoning: Applicant: FITZGERALD BURGLARY AT. 610 BURTS PIT RD Applicant Address: Phone: Insurance: 50 GERRARD AVE (413) 537-3644 EAST LONGMEADOWMA01028 ISSUED ON.11/14/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-UPDATE FIRE & SECURITY SYSTEMS AND INSTALL CAMERA SYSTEM POST TH I S CA R D 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 11/14/2019 0:00:00 $100.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only �,,�:►..�;-►�r City of Northapt0�q4e rmit: �� r > Building Depa met iveway Permit 212 Main S reet. p is Availability ' Room 160l Availability Northampton, MA0f Structural Plans phone 413-587-1240 fax 413N5ans ify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING L SECTION 1 -SITE INFORMATION /vP—;)-o G 31 1.1 Property Address: This section to be completed by office Map Lot Unit 610 Buf � Zone Overlay District A- /�' f� P, Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Gandara Mental Health 147 Norman Street West Springfield, MA 01089 Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature 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 2. Electrical $4000.00 (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee J 4. Mechanical(HVAC) ` 5. Fire Protection x"88 6. Total=(1 +2+3+4+5) p() $8000-00 Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date mfitzgerald58 @ live.com EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 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 Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location) 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 O DONT KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DON'T 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 O , 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 1 acre or is it part of a common plan that will disturb over 1 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 Windows Alteration(s) ❑ Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[0] Other[DJ Brief Description of Proposed UPDATE FIRE AND SECURITY SYSTEMS AND INSTALL CAMERA SYSTEM Work: Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes x 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? 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 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 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 I, as Owner/Authorized t ereby declare the atements 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 , nature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Michael Fitzgerald License Number 50 Gerrard Avenue East Longmeadow, MA 01028 880C,2152D,S000860 Address Expiration Date 07/31/2022 Signature Telephone 413-537-3644 9.Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone 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....... Id No...... ❑ The Commonwealth of Massachusetts F Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www massgov/dia kkwtkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Annlicanl Information Ple9se Print Legibly Name (Business/Organization/Individual): Fitzgerald Burglary Installations Address: 50 Gerrard Avenue City/State/Zip: East Longmeadow MA 01028 Phone #: 413-537-3644 Are you an employer?Check the appropriate box: Type of project(required): I F-1 I am a employer with employees(full and/or part-time).' 7. ❑New construction '_.®I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]f 10'F-1 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 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs These sub-contractors have employees and have workers'comp.insurance? 14.®other Fire Upgrade 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 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 subcontractors 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: Policy#or Self-ins.Lic.#: 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$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: 11/12/2019 Phone#: 413-537-3644 Official use only. Do not write in this area,to be completed by city or town ofciaL 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#: