38B-109 29 MUNROE ST BP-2018-1154
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:38B- 109 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categorv:woodstove BUILDING PERMIT
Permit# BP-2018-1154
Project# JS-2018-002073
Est.Cost:
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq. ft.): 8015.04 Owner: HUSEMOLLER ERICH&ALISON SINKLER
zoning: URB(100)/ Applicant: HUSEMOLLER ERICH &ALISON SINKLER
AT. 29 MUNROE ST
Applicant Address: Phone: Insurance:
108 MAYNARD RD
NORTHAMPTON MAO 1060 ISSUED ON:5/4/2018 0:00:00
TO PERFORM THE FOLLOWING WORK:WOODSTOVE
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 At 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:
F_e_eType: Date Paid: Amount:
Building 5/4/2018 0:00:00 $40.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1271
Louis Hasbrouck—Building Commissioner
RECEIVED w
Department use only
MAY - 3 �M8of orth inipton status of permit
Buildin Dep irtment Curb Cu7Dmeway Permit
i�. A, 21 ain treet SewedSeptic Availability
OF BUILDING MSPECIlONSrn 1 0 Water/WellAvailability
OBTHAMPTO MA 1 A 01080 Two Sets of Structural Plans
r w 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: 7 This section to be completed by office
29 rt'l t-tA 1-oe- 5f• MaP 3�t3 Lot IO%
NDrthco„pfot-. m/>-
P l 0 L b Unit
Zone Overlay District
Elm SL District CB District
SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: /
z i":)' Si.iklc- z5 rll �+1�o Sf,
Name(Print) Current Mailing Address-
(v1;1230 • FrY£f�i
ephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address'.
Signature Telephone
SECTION 3.ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted be permit applicant
1. Building (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee / /,
4. Mechanical (HVAC) s7/✓ 06
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number'. Date
Issued:
Signature'.
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
t
Section 4. ZONING All Information Must Be CompLted Permit Can Be Denied Due To Incomplete Informatibn
Existing Proposed Required by Zoning
This column m be filled in by
Building Dcpanment
Lot Size
Fond e _
Setbacks Front
Side L: R: . L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Cot area minus bldg&mi,ed
parking)
k of Parkino5 aces
Fill: —
(.rolume&I...me)
A. Has a Special Permit/Variance/Finding e,,er been issued for/on the site?
NO O DON'T KNOW O YES
IF YES, date issued:
IF YES: Was the permit recorded at the Reg stry of Deeds?
NO O 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 O DON'T KNOW ® YES O
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 Cl NO O
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, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO 0
IF YES,then a Northampton Ste"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 ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [Ell Decks [O Siding [13] Other[M
Brief Description of Proposed I
Werk: Wpir IS CaWplc+c, s Gc fG Ag
Alteration of existing bedroom_Yes_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _Yes No
Plans Attached Roll -Sheet
Sa. If New house and or addition to existing housing, complete the following:
a. Use of building One Family Two Family Other
n 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
1. 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
I, h( it .fUh as Owner ofthe subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Date
/��/��,v��
I, / r u""' 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 O
Signa re of 0w r/Agent Date
E
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder'. _
License Number
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor- Not Applicable ❑
Company Name Registration Number
Address Expiration Date
T:lephone
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....... ❑ No...... ❑
City of Northampton
5 --
Massachusetts a?s
DEPARTMENT OF BUILDING INSPECTIONS ,F
9m
212 Mein Street • Municipal B—ltling
Narthempton, MA 01060
AFFIDAVIT
Home Improvement Contractor Law
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: Est. Cost:
Address of Work:
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 C/'' /
Owner obtaining own permit(explain): 6AAJ n-4ww' '- 41' p Weorr4
_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 142A.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:
DiV�I
2i ) 5r /e�iiars St✓x�\G/
Owner Name and Signature
City of Northampton a
- Massa chilse tta
� t
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building y \ice
w Northampl on" ! 01060
Massachusetts Residential Building Code
Section I10.R5.L2
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 consid--red a homeowner.
Section I IO.R5.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s)
for hire to do such work, then such homeowner shall act as supervisor.
Such homeowner shall submit to the Building Official, on a form acceptable to the Building
Official, that he/she shall be responsible for at such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to
time, during and upon completion of the work to-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 injuries 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.
J
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS i
212 Main St—st •Municipal Building \�{1
„ Northampton, M 01060 yrryy, i`��4
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:
(Please print house number and street name)
Is to be disposed of at: ,V( n_ L-.r(
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
5-�aJIY
Signature of Permit Applicant or Owner Dat
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.
,per t
The Commonwealth of Massachusetts
Department oflndustrial Accidents
1 Congress2Suite 100
Boston,MA
027I4-2017
wsvw.mass.govildia
Workers'Compensation Insurance Affidavit:General Businesse
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information _ Please Print Legibly
Business/Organization Name:
Address:
City/State/Zip: _ Phone#:
Are you an employer?Check the appropriate box: Bu ' css Type(required):
L❑ I am a employer with_ employees(full arty 5 ❑Retail
or part-time).* 6. ❑RestaurantBar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp, insurance required] 8. ❑Non-profit
3.❑ We are a corporation and in officers have exercise � A E] Entertainment
their right of exemption per e152„ys'1(4),and ave 10j] Manufacturing
no employees. [No workers'comp.insurance/,., uiled)*
4.❑ We are a non-profit organization,staffed Iite--- 11.❑ Health Care
with no employees. [No workers' comp, in e req.] 12.0 Olher _
'Myappimanethvrcheck,l, #1 must aI fill ootlhe sccti0hoving their workem'componsation polfcv information_
**If thecogwete cahoots have exempted the—elves,bur ih wrp0mti0vt asoderemployees,aw0rkerscompensation policy is reclined and-ch an
¢anon should chwkbox#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: _
Insurer's Address:-
city/state/Zip:
Policy#or Self-ins.Etc.If Expiration Date:
Attach a copy of the workers'c pensation policy declaration page(showing the policy number and expiration date).
Failure to secure cove[age as re fired under Section 25A of MGL c 152 can lead to the imposition of criminal penalties of 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 he violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for nsurance coverage verification.
Ido hereby certify,under t is pains and penalties of perjury that the information provided above is true and correct
Si nature: Date:
Phone#:
Official use only. Di6mot 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.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
ww,.�as.govdo
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 of more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of e 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 of 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,p25C(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 ofthis 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 your insurance company's name,address and phone number along with a certificate 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. Han 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 ifyou 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 Of necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proofthat a valid affidavit is on file for future permits or licenses. A new affidavit
most be tilled 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 bum leaves etc.)said person is NOT required to complete this
affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Form Revised 02-23-15