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31A-074 (3)
4 WASHINGTON AVE BP-2017-0721 GIS#: COMMONWEALTH OF MASSACHUSETTS Mao:Block:31A-074 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:ROOF BUILDING PERMIT Permit# BP-2017-0721 Project# JS-2017-001188 Est.Cost: $3500.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RONALD KEITH 085204 Lot Size(sq. ft.): 10628.64 Owner: JEFFWAY LOUISE E&ROBERT W JR Zoning: URB(100)/ Applicant RONALD KEITH AT: 4 WASHINGTON AVE Applicant Address: Phone: Insurance: 5 BIRCH MEADOW DR (413) 584-5589 HADLEYMA01035 ISSUED ON:11/28/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLAIR & REPLACE 20X15 SECTION OF ROOFING 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 1128/2016 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Oeto5r r//-zl / City of Northampton !9 " � t,, , ' t Building Department , ,4 �. 212 Main Street Room 100 4Witc//al.t ifr jt'1'1a , ''"``"mss "¢ �: Northampton, MA 01060 '(`�j� ` *-r = ` r phone 413-587.1240 Fax 413-587-1272 ' -�' Lid 3 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 try office N- ( y5 JIU61oJ AVG Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ovt . —631-- CirTh22Rc__ 32.y Q.LrA 31 00:.--,1-41TOri 1 ng Name(Print) Current Mailing Address'. Telephone Signature frm,+j f t 72 Authorized Agent: j"..4 .Ye/ .tr' 3 !�%.4/1)/ /!1eci2o.-✓ ck. .44 Name(Prnt) Current Mailing Address: Signat rJe 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 (b)Estimated Total Cost of Construction from(6) 3, Plumbing Building Permit Fee �j 4. Mechanical(HVAC) f/ O o 5.Fire Protection ,r _ 6. Total=(1 +2+ 3+4+5) � Check Number 3O c'Q This Section For Official Use Only Building Permit Number: Date ssued: Signature: / // Building CommissionerMspector of Buildings Date Section 4. ZONING Alt 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 Deparonent Lot Size L ( ____i Frontage — - -1 Setbacks Front C I • l-1 Side L.: J R:i L:i_..,_, R:l _.) J_! Rear Building Height I [ Bldg.Square Footage - 1 ) °" I _J� Open Space Footage % -. (Lot,veaminus bMg&pried ( .J (_ J I —... _parking) I #of Parking Spaces J I -I Fill: I —. —I. _-_- __..._ (volume&Lmmion) -..— A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW YES 0 IF YES, date issued:! 1 IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book Page J and/or Document#! B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained © , Date Issued: I C. Do any signs exist on the property? YES O NO Q • IF YES, describe size, type and location: [ D. Are there any proposed changes to or additions of signs intended for the property? YES © NO O IF YES, describe size, type and location: I E. Will the construction activity disturb(clearing,grading,excavation,or filing)over I acre or is it part of a common plan that will disturb over 1 acre? YES 0 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 n Addition ❑ Replacement Windows Alteration(s) E Roofing Et Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other(C] Brief DeGs {iption of Proposed Work: CF®o Vu. c Iteplaz ,lox IS ?CC1to4 og RW7`I Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet i 5a If New house and or adiiitioh to existing housing;tomplete 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 ftof 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 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. //-ZZ— // Signatuer o((JaGner '' V Date I, rowpv,r: t<2i- , 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 ( kac - i5 Signatur of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES _ l 8.1 Licensed Construction Supervisor: Not Applicable ❑ same of License Holder'. QT l‘14-0 (.7-y-CFSciY1 License Number Address { _ Expiration Date Signature Telephone 9.Reaistered Home Improvement Contractor:, Not Applicable ❑ Ct`dueL.0 4.0\-) lig 18R Company Name Registration Number i bla- ( Dao a94,-1 1 - g Address Expiration Date Telephone 5c -5h _ 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..... ..`isi No...... ❑ 11; -Home-Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellinks of one(1) or two(2)families and to allow such homeowner to engage an indiidual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 1083.5.1. Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner'shall submit to the Building Official,on a form acceptable to the Building Official,that be/she shell be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,duringand upon completion of the work for which this permit is issued, Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to Employees for buries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with de State Building Code,City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated, Homeowner Signature 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: 9 ui i zh.., 14k The debris will be transported by: The debris will be received by: V,CIleil�ycl 1-Lap Moa-M14- Building Building permit number: Name of Permit Applicant to- cij 1-1,e,w j)24 4-- ll-7 16 Date Signature of Permit Applicant r The Commonwealth of Massachusetts a Department of Industrial Accidents pp i Office of Investigations G � 1 Congress Street,Suite 100 = Boston,MA02114-2017 www.mass.govldia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(BusinesslprganiiatiomrtirASviGual): fPaPt43 t'�4 t ; Address: 6 ±r tdlLP Ts-sae r 041—• City/State/Zip:,,�?tt'a., Mad Phone#: -5---s v– 5-7,5r/ �,. 5. New — Ara an employer?Check the appropriate box: I. I am a employer with C1 4. Q I am a general contractor and I Type of project(required): employees('full and/or patty time).` have hired the sub-contractors construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity, employees and have workers' .iinsurance.; 9. 0 Building addition cam [No workers' comp. insurance p required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 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.n Roof repairs insurance required.]t c, 152, §i(4),and we have no employees. [No workers' 13.0 Other comp.insurance required.] `Any applicant that checks boxer I must also EU out the section below showing their workers'cvmpensalion 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. tContractorsthat 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 mixt provide their workers'comp.policy number. Lam 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.tic.#: 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 fine up to$1,500.00 and/or one-year imprisonment,as welt 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. Si ¢ lore: ((ix—x,(01Date: I(-- 22— k4 phone#: 5Y7` 5ticr7 ...., Official use only. Do not write in this area,to be completed by city Of 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 er 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 he deemed to he 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,MOL 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 till 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 Partnership (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 Depaitruent 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 permitflicense 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 I Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-7274900 ext 7406 or I-877-MASSAFE Fax# 617-727-7749 Revised 7-2013 wwwmass.gov/dia i City of Northampton _ . . , a r to Massachusetts6'{r\ c. , DEPARTMENT OF WILDING INSPECTIONS o \ ,,, .y. q ys,.� 212 Main Street . Municipal Bulling Ce. t Northampton, Me 01060 R. t11 INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner EON(: 0 _ E' = _ P ION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two- year period shall not be considered a home owner." The building department for the City of Northampton wants any person(s)who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings(before backfill) sonotube holes (before pour). a rough building inspection (before work Is concealed}. in ula i on i . .e .'on '. .' ed .nd a final buildin i s tion. The building department requires these inspections before the work is concealed, failure to secure these inspecti ntns ,can wafers failure to obtain a certificate ofscou.an un th- •rk .n .- inspected. If the homeowner hires other trades to perform work(electrical, plumbing &gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location -- 1 ® DATE mMIDDIYYYY) A RI CERTIFICATE OF LIABILITY INSURANCE 11/22/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: Christina Barrett Aquadro & Associates PHONEINC NO EMI. (413)586-7373 A2 No):1413)5e4-0859 BridgeP. 0. Box 357 EMAIL 355 St. , ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC p Northampton MA 01061 INSURER ATref erred Mutual Insurance Co 15024 INSURED INSURER 6: RONALD KEITH DBA KEITH CONSTRUCTION INSURER C: 5 BIRCH MEADOW RD INSURER O: INSURERE: • HADLEY MA 01035 INSURER F: • COVERAGES CERTIFICATE NUMBER:CL1652007645 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADOLIAUBR POLICY FEE POLICYEXP LIMITS LTRJNSD',W VO POLICY NUMBER IMMIDDMIYYI IMMNDIYYYYI X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 50,000 A CLAIMS-MADE X OCCUR PREMISES IEa occurrence) $ 30P0100726174 4/12/2016 4/12/2017 MED EXP(Any one person) $ 10,000 PERSONAL B ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 X POLICY PRO JEQ LOC PRODUCTS-COMPIOP AGG $ 2,000,000 OTHER- $ AUTOMOBILE LIABILITY EOMaBIN4EED1jINGLE LIMIT $ ANY AUTO BODILY INJURY(Per Pevml $ ALL OVMED SCHEDULED BODILY INJURY(Per accident) $ AUTOS TOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _ AUTOS (Per accident) S UMBRELLA LAB OCCUR EACH OCCURRENCE $ — EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION H AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ OFFICER/MEMBER Mandatory in NH) E L DISEASE-EA EMPLOYEE $ tty deaoibe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached IT more apace Is required) CERTIFICATE RUDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF NORTHAMPTO. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN - _ - ACCORDANCE WITH THE POLICY PROVISIONS. •NORTNAMPTON, MA 01060 AUTHORIZED REPRESENTA E ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401)