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 �� ,