16A-018 (3) 478 SPRING ST BP-2017-0264
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: I6A-018 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: KITCHEN RENO BUILDING PERMIT
Permit# BP-2017-0264
Project# JS-2017-000455
Est. Cost:$31530.00
Fee: $204.95 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: EDWARD RICKEY 96159
Lot Size(sq. ft.): 14549.04 Owner: BRIDGMAN JAMES E
Zoning: URA(100)/ Applicant: EDWARD RICKEY
AT: 478 SPRING ST
Applicant Address: Phone: Insurance:
P 0 BOX 62 (413) 695-7059
WILLIAMSBURGMA01096 ISSUED ON:8/31/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACEMENT OF KITCHEN CABINETS
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:
FeeTvpe: Date Paid: Amount:
Building 8/31/2016 0:00:00 $204.95
212 Main Street. Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
► RECEIVFD Department use only
I City of Northampton Status of Permit:
--� Building Department Curb Cut/Driveway Permit
AUG 3 0 2016 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
DEPT�BUtD(NG iNSPEOT;,^z`‘; Northampton, MA 01060 Two Sets of Structural Plans
t 3RTHAMPrON'M C10`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
This section to be completed by office
1.1 Property Address:
V8Ant - idgeoh , 264 Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
•
arre(Pr rtl jC/r*64;6 "leikna-g-t-- Current Mailing 4i4dapgzeld,
I0.5j
'elephone 1!l / e .
Signa reg"4-45e-rerte"1/ X11 Co J 1 T
2.2 Authorized Agent:
•
c � -�, A,* 62 9'44 O/0 9G
Name(Print) Currert Mailing Actress:
/ 1/45 C9S-74'57
-Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item I Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 2.2 0, o- (a)Building Permit Fee
2. Electrical 3 Ye oo (b)Estimated Total Cost of
i Construction fromk6)
3. Plumbing / 4 70Oa Building Permit Fee
goy',
I�� L` 75".4. Mechanical (HVAC)
5.Fire Protection
6. Total= (1 +2+3+4 +5) 3/,53o. Gv Check Number
This Section For Official Use Only ":'
Building Permit Numb- - Date
✓ Issued: AtE 3 O 20
Signature: - JErrvrESULDAG ws"rcrGaS
NORTHAMPTON,MA 01060
Building Commissionerllnspector of Buildings _. 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 he 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 arca minus bldg&paved
parking)
#of Parking Spaces
Fill:
11 (volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO er DONT KNOW 0 YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ef 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 d DONT KNOW O YES 0
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 ll
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
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading. exc ation. or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
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 El
Or Doors E
Accessory Bldg. El Demolition ❑ New Signs [I]] Decks [E] Siding [CI] Other[111]
•
Brief Desc do of Propose i / •, , rWork:
Alteration of existing bedroom Yes I/ Nc Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Shee:
6a. If New house and or addition/to existing housing, complete the following:
a. Use of building : One Family V 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 heatirg? 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
OWNERSAGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
TA-M I, X t ,I' `4 r &R ib 6/' '6-` ✓IL . as Owner of the subject
property / ,
hereby authorize �G��GQ.ecJ
to act on my behalf. in all matt elative to o authorized by this build'ng permit application.
�� x G;u.. , aaI4P
Signatur of Owner Cate
I,4?,-d24,0e . as Owner/Authorized
Agent hereby de re that the t ements 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.
6CDZe//4/W J ir/ /lam;�
Print Name
23 20/6
S gnature o?Aoeif .:,_
Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: �,CLl�eertet� O9057
License Number
,o.,ax 62- 2� 7,14 o/°9s; / i3 2a1r
Address Ny iii Date
Signatu Telephone
9.Realstered Home improvement Contractor Not Applicable ❑
3,� /5O8%
Corn an me Registration Number
NGI( ‘2 `'d� 7 O/4 q‘ 5/3V2oir
Address ��n��� �/ Expil ti Date
Telephone y/3 695-7cj7
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152, §25C(6))
Workers Compensation Insurance affidav must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buil ' g permit.
Signed Affidavit Attached Yes No 0
. - Home Owner Exemption
The current e; .tion for"homeowners"was extended to include Owner-occupied Dwellings of one(1) two(2)families
and to allow such horn-. •.er to engage an individual for hire who does not possess a license,provi that the owner acts
as supervisor.CMR 780, Six 'ition Section 108.3.5.1.
Definition of Homeowner:Person(s) : own a parcel of land on which he/she resid r intends to reside,on which there
is,or is intended to be,a one or two family dwe ••• attached or detached structur accessory to such use and/or farm
structures. A person who constructs more than one . . e in a two-year • d shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on . .rm acce•..Ile to the Building Official,that he/she shall be
responsible for all such work performed under the building p•• rt.
As acting Construction Supervisor your presence on the jo• to will equired from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 15 ''orkers'Compensation) an. . •apter 153(Liability of Employers to
Employees for injuries not resulting in Death . the Massachusetts General Laws Anno : -d,you may be liable for person(s)
you hire to perform work for you under • permit.
The undersigned"homeowner"cert. -s and assumes responsibility for compliance with the State : ilding Code,City of
Northampton Ordinances,State -id Local Zoning Laws and State of Massachusetts General Laws Ann. .ted.
Homeowner Signatur•
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste 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.
Address of the work: 4/7e 42t elg
The debris will be transported by:
The debris will be received by: 71
Building permit number:
•
Name of Permit Applicant 10,raerZ
8/23/20/4
Date ature o ermit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
F 11'— � Office of Investigations
=°will=
+�_ t - �� 1 Congress Street, Suite 100
Sill= 11 Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeEibly
Name (Business/OrganizationAndividual):
Address: fd. &'-k‘2
City/State/Zip:? J 74/°,C Phone #: 9/3- 7az1
Are you an employer? Check the p7440/07C6f5ropriate box: Type of project(required):
1.0 I am a employer with 4• 0 1 am a general contractor and I
ce-mployees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2. LE I m a sole proprietor or partner- listed on the attached sheet. 7. Q'Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in anycapacity. employees and have workers'
P tY t 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.El I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
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: _
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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 andlor 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. Be advised that 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: 03/2.o/4
Phone#: yf3 ,s--,q57
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 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual,partnership,association,corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s)name(s), address(es)and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships (LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write "all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE
Revised 7-2013
Fax # 617-727-7749
www.mass.gov/dia
City of Northampton
filalrir
Massachusetts
r tAli
r_• DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
.rte'- �i
0.•-t Northampton, MA 01060
Loui asbrouck Chuck Mill-
Building 6.mmissioner Assistant Co • issioner
HOME OWNER EXEMPTION ACKNOWLEDGEM'. T
The State of Massachusetts a •ws the homeowner the right under 780C 108.3.4 to act as his/her
construction supervisor. The sta': defines "Homeowner" as, ' Person(s) ho owns a parcel on which
he/she resides or intends to be, a o•e or two family dwelling, attac ""d or detached structures
accessory to such use and/or farm str. tures. A person who constr is more than one home in a two-
year period shall not be considered a ho• e owner.'
The building department for the City of North: pton wants a person(s) who seek to use the home
owner exemption, to act as their own construct •n supervise . to be aware that by doing so you
become responsible for compliance with stat buildinz. codes and regulations. The inspection
process requires that the building department be c. ed • inspect work at various stages, which include
foundation/footings (before backfill), sonotube h. •s (before pour), a rough building inspection
(before work is concealed), insulation inspectio, (i required) and a final building inspection.
The building department requires these inspectio : befo : the work is concealed, failure to secure
these inspections can result in failure to obt. n a certi ate of occupancy until the work can be
inspected.
If the homeowner hires other trades to perfo• work (electrical, •Iumbing & gas) the homeowner will be
responsible to make sure that the trades . ed secure their prope eermits in conjunction to the building
permit issued, and that they get their r-quired inspections. Fail e of the individual trades to secure
the permits and inspections as require. can DELAY the project until - ch time as the proper permits
and inspections are made
I, understa • the above.
(Home owner/resident's - gnature requesting exemption)
I will call to schedule all requ. ed building inspections necessary for the buildin• •ermit issued to me.
Date
Address of work loca .on