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17D-015 (5) 11 VERONA ST BP-2020-1146 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-015 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category: BASEMENT RENOVATION BUILDING PERMIT, Permit# BP-2020-1146 Proiect# JS-2020-001845 Est.Cost: $17000.00 Fee: $100.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: VAL SHEVETZ - OAK RIDGE CUSTOM HOME BUILDERS INC 087690 Lot Size(sq.ft.): 12588.84 Owner: MARK JASON Zoning URB(,100)/ Applicant: VAL SHEVETZ - OAK RIDGE CUSTOM HOME BUILDERS INC AT: 11 VERONA ST Applicant Address: Phone: Insurance: PO BOX 63 (413) 374-9236 WC EAST LONGMEADOWMA01028 ISSUED ON.512112020 0:00:00 TO PERFORM THE FOLLOWING WORK.-BASEMENT RENO 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 5/21/2020 0:00:00 $100.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit cs 212 Main Street Sewer/Septic Availability t ' 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 Address: This section to be completed by office Map Lot Unit 11 Verona St Florence MA 01060 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Jessica Matthews I I Verona St Florence MA 01060 Name(Print) Current Mailing Address: 115-5595701 Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: `. -� ) > 413-374-9235 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building ,gip 000 (a)Building Permit Fee 2. Electrical 000 (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) y (J 5.Fire Protection 0 6. Total=(1 +2+3+4+5) .000 Check Number This Section For Official Use Only ate Building Permit Number: blQ �tl eli9 Isst ed: qe�Lu roil V70/ Signature . Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All information AAust Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning this column to be filled in by Building lhpannntnt Lot Size Frontage Setbacks Front Side l_.: R: L: K: Rear Building Height tildg. Square Footage Open Space Footage (Lot area minus bldg&paved parking) 4 of Parking Spaces, Fill: —------- (volume X-Location) A_ Has a Special.Permit/Variance/Finding ever been issued for/on the site? NO (�) DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds: NO 0 DONT KNOW Q YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained O , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 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, of filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO 1F YES, then a Northampton Storm Water Management•Permit from the DPW is required. F_ SECTION 5-DESCRIPTION OF PROPOSED WORK(check all ap2licable) New House F-I Addition Replacement Windows Alteration(s) Roofing M Or Doors Cl 1 Accessory Bldg. D Demolition E-1 New Signs 10] Decks [C:) Siding[0) Other[0) Brief Description of Proposed exisling basenicni,for L);e Work. Alteration of existing bedroom Yes Y No Adding new bedroom Yes Nc, 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 X Two Family -Other b. Number of rooms in each family unit: Number of Bathrooms c, Is'there a garage attached? 345X 11 d. Proposed Square footage of new construction._T�,O,,,C Dimensions . 10. e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masschet;k Energy Compliance form attached? lri. Type of construction 1. Is construction within 100 ft. of wetlands? Yes X 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 -T A as Owner of the subject property Val Shvetz hereby authorize to act on my behalf, in all matters reigAve to work authorized by this building permit application. Tjr, A Signature of Owner Date Nor- > as OwneriAuthorized 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 antipenalties of perjury. ,> _LJ Print Name 45 1 nature6i OwnerlAc 9 Ag i nt Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: Val Shvetz License.Number po box 63 East Longmeadow MA 01028 087690 Address Expiration Date 07/08/2021 Signature Telephone 4133749236 9.Registered Home Improvement Contractor: Not Applicable 0 /" /, -1,— /I "/I ,? I r(- '- S-41 kp Companv Name Registration Number 159246 Address Expiration Date Telephone 04/0912022 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted vAth this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... No.... F1 City of Northampton Massachusetts DEPARTMENT OF WILDING INSPECTIONS Yl� - 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 191, S 150A_ The debris from construction work being performed at: (Please print house number and street name) Is to be disposed of at: j (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Si&ature 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 y% www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH."THE PERMI'1 FUNG AUTHORITY. _Applicant information Please Print Leeibly Naine (Bttsiness/OrganizatiotvTndividual):Oak Ridge Custom Home Builders Inc Address:PO Box 63 City/State/`Lip:East Longmeadow MA 01028 Phone#:4133749236 Are you an employer'Check the appropriate box. Type of project(required): 101 am a employer with 1 employees(full mid/or part-time).* 7. ❑New construction 2. 1 am a solero fetor or partnership and have no ern to gees working for me in P Pr P P P S g 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 3.OI am a homeowner doing ail work myself.[No workers'comp.insurance required.] 9• ❑Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my properly. 1 will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole l Ln Electrical repairs or additions proprietors with no employees- 12.Q Plumbing repairs or additions 5Q 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet 7 13.E]Roof repairs fiese sub-contractors have employees and have workers'comp.insurance.' 6.0we are a corporation and its officers have exercised their right ofexempticnr per MGL c. 14.❑Other _ — --- 152.,1(4),and we have no employees [No workers'comp.insurance required.I *.Any applicant that checks box#1 must also fill out the section below showing their workers'compensution policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outs de contractors must submit a new affidavit indicating such. Kort actors that check this box mast 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 iv the policy and}ob site information. Insurance Company Name:Liberty Mutual Policy#or Self-ins.Lic.#:WC5-31 S-384694-039 Expiration Date:03/15/2021 Job Site Address:11 Verona St. city/State/Zip:Florence, MA 01060 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGI,c. 152,435A 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 thep;r Is and penahles of perjurer that the information provided above is true and correct. Sisnature_ - } Date: ';' 413/-374-9236 Phone#: _ Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License 4 Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.('itytl'own Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: finished space 34' 5" x10' 11" <—Smoke&CO detectors 7777= 0i ■l unfinished space 35' 3" x 13' 1" bulkhead door 5' 1" x7' 2" '; Commonwealth of Massachusetts /',�> �nvxzoirrr> f/� f.'«1Jsr' `� lGr �•' Division of Professional Licensure Office of Consumer Affairs&Business Regulation Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Construectitri`S�iptrrvisor T`EPE;IndNidual Rg '+2RI�n— CS 087590 EApires: 07/08/2021 04109/2020 1' 24o VAL A SHEVETZ VAL SHVETZ P.0 BOX#63' EAST LONGMEADOW MA'O1028 VAL SHVETZ3 41 OLD WESTFIELD RbIVI, Undersecretary WEST SPRINGFIELD,A�A 01089 Commissioner �� ,