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29-046 (4) 15 PIONEER KNLS BP-2018-1183 GIS#: COMMONWEALTH OF MASSACHUSETTS Map'Block:29-046 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-2018-1183 Project# JS-2018-002122 Est. Cost 510650.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.class: Contractor: License: Use Group: NEWMAN'S CONSTRUCTION 64690 Lot Size(sp.ft.) 11979.00 Owner: WARBURTON DON Zoning, Applicant: NEWMAN'S CONSTRUCTION AT. 15 PIONEER KNLS Applicant Address: Phone: Insurance: 697 BRIDGE ROAD (413) 586-0273 NORTHAMPTONMA01060 ISSUED ON:5/11/2018 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF 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: FeeTyoe: Date Paid: Amount: Building 5/11/20180:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner F Department use:only City of Northampton Status of Permit Building Department Curb Cut/Driveway Permit 212 Main Street SewardSapbc Availability Room 100 WaterAVell Avallebibry Northampton, MA 01060 Two Sets of Structural Plans �l phone 413-587-1240 Fax 413-587-1272 PlattShe Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWOFAMILYDWELLING SECTION 1 -SITE INFORMATION e, 1.1 Property 7Address: 7� ��Thh�iis section to be campleted by office � y �6"f.f YL KNct7�S Map Rf Lot-12�� Unit Zone Overlay District Elm Sl.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 'n N {J.�urL�urt_E"o� /� ?a✓tffst ICno��S /j,�.sfnef Name(Print) Current Mailing Address'. O!OQZ Telephone Signature 2.2 Authoriz d A ent: C., *-,uj &J 647 I- tyu nSs Name( int Current Mailing Address:IjOl06D S€6 -109 Signal Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be // ed Oficial Use Only completed b ertnit a licanl jy7�. 1. Building (a) Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee �D 4. Mechanical(HVAC) 5. Fire Protection p 6. Total=(1 +2+3+4+5) Check Number o This Section For Official Use Only Date Building Permit Number: Issued: Signa re: -S-///X40 Builtling Cam issionerllnspectmr of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column m be ti[W m by Building Department Lot Size Frontage Setbacks Front Side L _ R: L . R: .. Rear Building Height Bldg.Square Footage "o Open Space Footage "a - -- (LMarcaminusbldg&Paved mkar #ofParking Spaces (volume&Lacunun7 A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO © DON'T KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW © YES O IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES 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 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. WII 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 O IF YES,then a Northampton Storm Water Management Penn it from the DPW is required. SECTION S DESCRIPTION OF PROPOSED WORK(cheek all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(a) ❑ Roofing I7(I Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [EJ] Other[❑I Brief Description of Proposed 11 Q Work'. fLvT ¢7lt�T(n o—/1 STR I.L Af2u R 1^a.l — Jfn�1 tCY �ua i Alteration of existing bedroom_Yes_No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement _Yes No Plans Attached Roll -Sheet ea.If New house and or additlon to existing housing, complete the following: a. Use of building : One Fari 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? If Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance farm attached? h. Type of construction i. Is construction within 100 fl. 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, �, enl �A� KlYJV,60J as Owner of the subject property hereby authorize .i1 s aAJ rN AtJ to ad on my behalf, in al afters relative to work authorized by this building permit application. sit gnatureaf Owner Date ,as Owner/Authorized Agent here declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under�thpe pains and penalties of perjury. Fu- *A A-K) Print N.she A AR Signa of Owner/Agent 0 SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction //S�upervisor. / Not Applicable ❑ Name of License Hnlder_ Ley �FW M (dry/ es —QoW 6 9� (gyp ,, I •n License Number LS l�n bc� �cX nand m���A) 4 ,� QLo6a �/�/ A Expir tionTale 9 Sign ) Telephone 9.Realstimird Home Immoement ontra r: Not Applicable 11N�., p aA�� l'�I 1l iys�a7 Chan Name Registratiojn umber ,zm t5r�'ocs �I �rJe� �nhJ � ��4 At�6o /si�R Address�— E.runatm5, Dice Telephone 143'S86 -/69 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 res Wt in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ �_ City of Northampton �• Massachusetts c F y ^' I DEPARTNR'NT OF BUILDING INSPECTIONS 212 Main Street a Municipal Building Zv` CD Northampton, MA 01060 TbW'fr"7\ 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 ofan 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 he registered Type of Work: T (( Est.Cos[: M1 ttb sem. om Address of Work: 15 anz Lvl.- Kite^ll S r T-eg 2enCe ! 1N 6r06D Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): _Sob 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 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: 1 / /fa /8 -)Iwlf-y S' / DD4le ContracItirName RIC 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 (Q8S98Ct1U9Ett9 DEPARTMENT OF BUILDING INSPECTIONS o 212 Mein Street a Municipal Building J `D xortha ton, M 01060 tijp- Massachusetts Residential Building Code Section 110.R5.1.2 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. Section I I O.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 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, during and 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 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. City of Northampton Ff P ip � Massachusetts ; D212 i. S OF S..—.i INSPECTIONS i -s 212 Mein Street •Municipal euilding \ NaxCLamptOn, MA 01060 SYjp'.ySjPJ 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: f� I/bytPfy< V e is f kdvlzfVW11 (Please print house number and street name) Is to be disposed of at: — (FIlease print nam and Iota f facility) Or will be disposed of in a dumpster onsite rented or leased from: a// a'FF (Company Name and Address) S8 /8 Signatur f Permit Applicant or Owner Dat6 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 IndustrialAccidents, ] Congress Street,Suite 100 Boston,MA 02114-1017 wnnamass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information �(` Please Print Legibly Business/Organization Name: /1EWrvknq Nl Is ` Address:_ 697 �q ° 06S �sX lll M n alaa City/State/Zip: s 'f1�-7 ! 1!F liPhone#: y/'? 10 91� Are you an employer?Check the appropriate box: Business Type(required): L❑ I am a employer with employees(full and/ 5. ❑Retail or parr-time).• 6. ❑ResomantBar/Eating Establishment 2.g_I am a sole proprietor or partnership and have no 9, ❑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 its officers have exercised 9. ❑Entertainment their right ofexemption per c. 152, §1(4),and we have 10.❑Manufacturing no employees. [No workers'comp,insurance required]*' 4.❑ We are a non-profit organization,staffed by volunteers, I I.❑Health Care with no employees. [No workers'comp, insurance req.] 12.❑Other "Any appllme,that checks bus 41 must alsn fill out dic section below showing their works.'compensation policy isimmation. —Ifthe coryomte officers have exempeW themselves,but the evrpom um hos other employees,a workers'eompemsatlon policy is required end such an mmoinuuon should check box#I. I am an employer that is providing workers'compensation insurance far my employees. Below is the policy information Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lia# Expiration Date: 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 e. 152 can lead to the imposition of criminal penalties of two,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. Be advised that a copy of this statement may be forwarded to the Office of Investigations ofthe DIA for insurance coverage verification. Ido hereby certify^under t pains and penalties ofperjury that the informs ' provided ab a is hue and correct St¢nature: l� D t ���8 Phone#: 'III ��A _/05,_S/O 73 t 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.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass,gov/dia 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 ajoint 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 ofpublic 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 maybe 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 permio'license number which will be used as a reference number. In addition,an applicant that must submit multiple pentroulicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary). A copy ofthe affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as prooflhat a valid affidavit is on file for future permits or licenses. A new affidavit most 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 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 Forth Revised 02-23-15 NEWMAN'S CONSTRUCTION 697 EkidRd. Northampton;-MA6. 01060 1244 413386.1093 PoOposht.SU 0 PHONE MTE r7 1 ,-? 7 - 3 3S r8 afHEET JOB MME R, � ajc- OW STATEvkZIPCODE JOBLOCAPM W.bemby.ulba*soadlicanorm and enlissams hor. .... .aces zqma- TIRIOIJ-X :Ir --I AV is_ -LY-V V.,11 -z, S!Akz-- --54, V LW --VL-IqI.bTL? L.W.Mill'i UY 1-47t�---- S---Ric ----------- ...... S- ---4[at-a-A- A.- PaL- --LaNi, r.o12.5 ---------------------------------------- p rOPUBC hereby to furnish material and labor—compl i ccordance with above specifications,for the sum of: -A ;Y, -4 LI is AQ, 4 0, I. Payumnalobannado M.: All oassual is guamosad to W as spsores.All wok W be co ad In A aofinsan," mon.,acs.olls,W standard!pradfloos,".lWafics.,deIad..horn abovespecil". Authmmsed �Yld,oma Was ad W exaculad 0*drool maven ordes,and An became An emm signature ohar,e over and above One esurnaW. An agonesn"WoUngent Ursa Wkes, aoldarfls Nom:This proposal may I or delays samoul our annual.Oanar to ons,fire,tornado And"r oxxAsaq ommom, by us 9 not accepted i days. As"m are fully ra red by Wonsoa Cornpossal Insumoca withdrawn Arceptaurt of PrOPUSHI--rh..Inume pnces,speoftatu,ns and cordrsons are satisfactory and are hereby accepted. Im are auttmnzed Signature at n �Y� to do the"r, as speciftoo. Payment vAll be made as outlined above. Date of Acceptance: signature