38B-182 (3) 25 FORT ST BP-2018-1189
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:38B- 182 CITY OF NORTHAMPTON
Lot;.001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateaorv:FIRE DAMAGE BUILDING PERMIT
Permit# BP-2018-1189
Project# JS-2016-002133
Est.Cost:$30000.00
Fee:$195.00 PERMISSION IS HEREBY GRANTED TO:
Const, Class: Contractor. License:
Use Group DAVID JAGODZINSKI
Lot Size(sa ft.): 5532.12 Owner. KIM MIA C&MICHAEL G SULLIVAN
Zoning,URB(100)/ Applicant: DAVID JAGODZINSKI
AT: 25 FORT ST
Applicant Address: Phone: Insurance:
P O BOX 204 (413) 230-9160
NORTH HATFIELDMA01066 ISSUED ON:5/17/2018 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE INSULATION IN ATTIC DAMAGED
FROM FIRE, STRIP AND REPAIR SIDING AND ROOFING DAMAGED FROM FIRE
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 Occuoancv sienature:
FeeTvoe: Date Paid: Amount:
Building 5/17/2018 0:00:00 $195.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2018-1189
APPLICANT/CONTACT PERSON DAVID JAGODZINSKI
ADDRESS/PHONE P O BOX 204 NORTH HATFIELD (413)230-9160
PROPERTY LOCATION 25 FORT ST
MAP 38B PARCEL 182 001 ZONE URB 1001/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
E OSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildine Permit Filled out
Fee Paid
Tvpeof Construction REMOVE INSULATIO DAMAGED FROM FIRE, STRIP AND REPAIR
SIDING AND ROOFING DAMAGED FROM FIRE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included'
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved_Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance-
Received&Recorded at Registry of Deeds Proof Enclosed
_Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
_Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
4B.
Delay
tgnaial Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
+Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
wenn
ism I
ity of Northampton Stptu8P8MM.
ilding Department G,rt}�tuty +Pt
212 Main Street Sdik�a7tLL
Room 100 W�ikA,
"sloop o ampton, MA 01060
- 87-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 PmoertyAddress: This section to be completed by office
Map 3 9B Lot / Q Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2A Darner of Record:
M,z,l�toe :S���lwan
Name ) Current Mailing Address'
Hl3 -53
Telephone 3?0 7!0
Signature
2.2 AUNorizetl ent:
Name(Pn r Current Mailing Add.":
Y13-�3v - 91� 6
Sig um Telephone
SECTION 3-ES A D CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by pemit amilicant
1. Building cJV:/� 000 &a (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) I I ✓ V
5.Fire Protection ^^�1
6. Total=(1 +2+3+4+5) 3 Oc9c7."`� Check Number pr
This Section For Official Use Onl
Building Permit Number: IIsssued:
Signatu �d _
Building misslonerlmspeotmofBuildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Must M Completed.Permit Can ee Denied Due To Incomplete Information
Existing Proposed Required by Zoning
]his column to be MW in by
Building Department
Lot Size
Frontage _.. _.
Setbacks Front
Side L: R: L: R: _.
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Int area minus bldg&paves _.
kin
ofParking Spaces
Fill:
volume&lavation
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW O YES Q
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 Bks! and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO lXJ DONT KNOW O 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 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. Will the construction activity disturb(clearing,grading,luRavation,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 Manage ant Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK Icheok all applicable)
New House ❑ Addition ❑ Replacement Windows Alteragon(s) Roonng ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [q Siding[DI OMer(I�
Brief Des ion of Proposed II ,1,` II ((�� ,�1 —k✓ S�..wS
Work: .Mn l wC llaE rNC lw /Crit Q.YV�NGN.Q V-'io • 1tivP. 5k•CJ
r oun
Alteration of existing bedroom-----Yes_No Adding new bedroomYes No
Attached Narrative Renovating unfinished basement _Yes No k•C�
Plans Attached Roll -Sheet
Ga.If New house and or add@fon to exisdna housing, complete the foltowina:
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?
I, Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
L 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, / Lt C.Via Pl SJ III Ja1 .as Owner of the subject
property (( '1
hereby authorize .Jt: ta�2t•nS�'1
fort o behalf,in all matters relative to work uthbrzetl by this building pe it ep kation.
S� l
Signature of Omer I, ' Ind Dat
1 IJaJ�I � �r✓ z-L51-I as Owner/Authorized
Agent hereby de are that the sta nts and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Si ned under the piltan] nalties of perjury.
Jyk
Print er �Sign ure of Ow r/ Otte
SECTION 8-CONSTRUCTION SERVICES
81 Lleensed Construction SSu\oervlaor: c` ,J Not Applicable ❑^' rte,
Name M�leanse HdWr: �if.VLtj rYA40�XV N Cis- i0�0009
Lice ns Nu be
�- 30 ��4 N.11aelQ Pis S Otfl(�to i t
AQpre�s /r 0 Ex,i tion Date
ignature �7 (� Telephone (1,fO
£Ill k.. 4�1 IIXeivt� ma�nl Cu11tracWIG4 ]�C��� Nol78(J�
ComoanV Name yam^ lflRegistration Number
�a3 �e�r � • 1J FCa��ie( r,� �aSs 171��
AddTelephone -7
E%Pi 4
1
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(8))
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
{
Massachusetts
vI �
s
D&PARTlffiiT OF BUILDING II2a X=ONB
212 Mein S".t • Municipal Bantling^
nortLam n, 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, modemization, conversion,
improvement, removal, demolition, or construction of an addition to any preexisting ownerbccupied building containing
at least one but not mora than/our dwelling units....or to shuchass which are adjacent to such residence or building"be
done by registered contractors.
Note:/f 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
_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:
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,l hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
Naesac6uaetta
m( i
DET� or arlIwD MP ZCTIMS
212 N n Street • Nonicipal Building yip\ 0�s
Northampton, M 01050 :yl�
Massachusetts Residential Building Code
Section I IO 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 1 I O.RS, 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
Massachusetts
c
s
212 MinNs or aor ici mseacrrma s`
212 Nsin street •Municipal Building4D
NorNampcon, ML 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
a5 rocF s�.
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
l %Occ0.W- zu.UVA-� uteJ-ecS 35a M6-ai 3(-, SVI 4'ek
(Company Name and Address) /VM55 -
0(tv s
P'Kature f Pe it Applicant or Owner at
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
Boston,MA 02114-1017
www.massgovAha
WVwricers'Compenstation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information /� r7 p Q /7 p Please Print Leaibly
Name (Business/Orgmizatiodlndividmi): A: c' a) LJ �N vkA Gtt/b! (�BN's�IXe�l YICg c�.YxG
Address: VOA ��D�t )c) -I
City/State/Zip: I (CU, SS "Phone M 11 3 956-9ZW
Are you an employer?Cheek the app e, ate box:
Type of project(required):
1.(tIp—p(1'I run a employer wllh�_employon(full md/or part-time)• 7. ❑New construction
21,R:a ma sole proprietor or partnership and base no employees waiting for me in g. ❑Remodeling
any capacity poo workers comp.insurance required.]
3Q1 am a homeowner doing all work myself.[No workers comp.insurance required.]' 4 ❑Demolition
4.❑I am a l ommwner and will be hiring contmeters to conduct all work on my property I will
10 Building addition
cruccure that all contracture either have workersavmperuatlon insurance or are sole I1.❑Electrical repairs or additions
proprierors with no employers.
12.F]Plumbing repairs or additions
5 1 am a general convector and I have hired the sub-contmetors listed oa the attached sheet 13.❑Roof repairs
These sub-contrectors have employees and have workers comp.insurance.: I
6.M We Brea smammum and its officers have excrcimaduar right of exemption per MGL. 14.�Of11Cr 1 7G
152,g1(4tmad we have no employees.Icon codas'eomp.Inmmnee retained.I Tom'
'Any applicaut that checks box#1 must also fill out the section below showing their workers wmpensetion policy information.
s Homeowners who submit this affidavit indicming they are doing all work and men hire outside contractors mum submit a new affidavit indicating such.
lCmars mrs that check this box must abeched an additional sheet showing the name of the sub-cuntmchum and mate whether or not those entities have
employes,. If me sub-contracturs have employees,they most provide their workerscomp.policy number.
I am an eMloyer lhot is providing worker.,'compensation inswance for my employees. Below is the policy and job site
information
Insurance Company Name 62 jvkt-CAO
Policy#or Self-ins.Lic.#: L e I 1 Expiration Date: 1 1 6��h����� """ .I /
Job Site Address:�� FaO/1 JL City/State/Zip:�DID/1 Atis.).
Attach a copy of the workers'compensation policy declaration page(showing the pokey numher and irvtion date).
Failure to see=coverage as required under MGL a 152,§25A is a criminal violation punishable by 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 the viol or.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verifies
I do hereby ce u he pins and penalties ofperjury that the informal an provWed/ o /Is true and correct
Signature
Phone#: 'a3
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 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,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 fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)morels),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 resumed 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 pemdt/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. Anew 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 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, Suite 100
Boston,MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 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 mother 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 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. 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 permitilicense number which will be used as a reference number.In addition,an applicant that
most submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information(if 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 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 citimn is obtaining a license or permit not related to any business
or commercial venture(i.e.a dog license or permit to bun 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