36-309 (6) 125 CARDINAL WAY BP-2020-1190
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:36-309 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Above ground pool BUILDING PERMIT
Permit# BP-2020-1190
Proiect# JS-2020-001997
Est.Cost: $10000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JDR BUILDERS 074.105
Lot Size(sa.ft.): 19776.24_ Owner: BAYUK JONATHAN L
Zoning: Applicant. JDR BUILDERS
AT. 125 CARDINAL WAY
Applicant Address: Phone: Insurance:
P O BOX 66 (413) 665-7587 WC
WHATELYMA01093 ISSUED ON:6/3/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.SWIM SPA WITH ELEVATED DECK
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 Franc:
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 silinature:
FeeType: Date Paid: Amount:
Building 6/3/2020 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
/ Department use only
City Of NorthBmptoyf �/G status of Permit:
Building Department �/�� ° )'rb:Cut/Driveway Permit
A , 212 Main St t 9 �r/Septic Availability
Room 100 c�Q19a W er/W I Availability
�-
Northampton, MA 0� ,�, o Sits of Structural Plans
phone 413-587-1240 Fax 413 'Y p Plot//to Plans
07, Ott}er Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR. RENOVATE-OR D,_MOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This section to be cornp,'ated by office
W 41 Map Lot
q Unit
L `;- , Zone Overlay District
Elm St. District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: ; � —
,� a � z� L
Name(Print) Current Mailing Address:
Telephone
Signature i
2.2 A Korized Aae'nL
Name(Pr' ) Current Mailing Address:
Signa re Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS-7
Item Estimated Cost (Dollars)to be Official Use Only
completed by permit applicant
1. Building bect (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total =(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number: ` _ Date
Issued:
Signature: - 3- &2O
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK (check all applicable)
New House 7 Addition (7 Replacement windows Alteration(s) 0Roofing 0
Or Doors 13
Accessory Bidg..0- Demolition ❑ New Signs [p] Decks [Cj Siding [o] Other[E:�
Brief D ript- n of Proppo ed
Work: �j �1
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes 4 No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing complete the following
a. Use of building :One Family T%Vc Fam!y 0", ,
b. Number of rooms in each family unit: ti": b�r c?Ba',hcoms
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
n
I' --AA,1 4>�`/L; �]'"-� as Owner of the subject
property
hereby authorize
to act on my behalf, in tters relative to work authorized by this building permit application.
6 '
Si of O e 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
Signature of owne 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 s
Frontage
Setbacks Front
Side L: R: L:-.- R:
Rear 4—
Building Height S/
Bldg. Square Footage
We 5&Pr
Open Space Footage
(Lot area minus bldg&paved
ark-inp)
4 of Parking Spaces
Fill: /V7
(volume&Location)
A. Has a Special, Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW () YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained C Obtained Date Issued:
C. Do any signs exist on the property? YES No
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES No ot.
0
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? YES0 NO
V-7—
IF YES,then a Northampton Storm Water Management Permit from the DPW is required,
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Halder �.lt-!il f-, �S r�(fa,-
License Number
Address f Expiration Date
Signature/ Telephone
9_Registered
-�Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Rj17 1-2
Address Expiration Date
Telephoney/
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....... 2K, No...... ❑
City of Northampton
`¢¢* Massachusetts
it DEPAR77-M T OF BUILDING INSPECTIONS r
r 212 Main Street • Municipal Building �I
Northampton, MA 01060
AFFIDAVIT
Home Improvement Contractor Lawn
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors 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: ,5p .r)I Est.Cost: rz5#r:30
Address of Work ;_2 � CgL 1yI
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under$1,000.00
Owner obtaining own permit(explain):
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.G.L.Chapter I42A.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 hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
s.
Massachusetts -%s
DEPARTMENT OF BUILDING INSPECTIONS
212 main Street •Mwnicipal 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:
Wjq ,�
(Please print house number and street name)
Is to be disposed of at:
I/
,/, //v'-4/� 4 ,
41f-
Please p,4nt name and'' cation ofjo:ility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature 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
rj Boston,MA 02114-2017
www mass.govv/dia
NVUrlters' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): IM ;_4AP
Address:
City/State/Zip: v' oar , ox";)9 Phone#: �A 3 p 3 7V 7fS?
Are you an employer?Check th appropriate box: Type of project(required):
I. Lam a employer with employees(full and/or pan-time).* 7. []New constriction
2 I am a sole proprietor or partnership and have no employees working for me in
�❑ 8. [-] Remodeling
any capacity.[No workers'camp.insurance required.]
9. ❑Demolition
3.[:]l am a homeowner doing all work myself.[No workers'comp.insurance required.l'
10 0 Building addition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will
ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs or additions
proprietors with no employees.
12.E]PIumbing repairs or additions
5.❑1 am a general contractor and I have hired the sub-contractors Iisted on the attached sheet. 13.❑Roof repairs
These sub contras wrs have employees and have workers'camp.insurance,. 1�
6.Q We arc a corporation and its officers have exercised their right of exemption per NIG1.c. 14. Other
SPA
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 helow showing their workers'compensation policy irtformation.
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 note of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they roust provide their workers'comp.police number.
I am an employer that is providing workers'compensation insurance for trry empke gees. Below is the policy andjob site
information.
Insurance Company Name: 1 C()
Policy#or Self-ins.Lic.#: [� Q l "� Expiration Date: Ik � 2/
Job Site Address: JV 1+�2` City/State/zip:
Attach a copy of the workers' compensation policy decl ration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGI,c. 1.52, §25A is a criminal violation punishable by a fine tip to$1,500.00
andior one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250A0 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.
Ido hereby certify under a am pei 1 es of perjurh that the information provided above is true and correct.
-_-- �
Sir=nature: zo
-
-� Date:
Phone ii: / 3"_ l
Oficial 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 g:
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