22B-066 (8) 123 MEADOW ST BP-2018-1251
GIS 9: COMMONWEALTH OF MASSACHUSETTS
Mau:Block:22B-066 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Perron Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: REPAIR BUILDING PERMIT
Permit# BP-2018-1251
Project JS-2018-002227
Est.Cost:$9500.00
Fee:$100.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sa.ft.): 98010.00 OWner: LEIGHTON JACQUELINE
Zoning:URA(107)/WP(107)MSP(102)/App/%Cant: LEIGHTON JACQUELINE
AT. 123 MEADOW ST
Applicant Address: Phone: Insurance:
123 MEADOW ST (413) 695-8468 O
FLORENCEMA01062 ISSUED ON:5/24/2018 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR AND JACK UP 1/3 OF BARN, REPLACE
SILLS AND RESIDE THE EXTERIOR
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 5/24/2018 0:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Northampton status of Permit
-> -- Building Department Curb Cut/Omnway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Avellsbility,
\ Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plousita Plans
.. Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
(ze tudQ6�
1.1 Prooerte Atldress:
see to be completed
t a3 Iv ICN I A3 S�L t sP°✓ Lot ✓ l.G Unit
Flo re vs Q-e Un +} CANO �—
n et Dlatrkt Overlay Distcricl
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
S�cc�, Eve l-F-tGRTD J t 23 w1 w S eed
Name Pnnt) Current Mailing Address:— q�
Signature Telephone 413 O ,F (2.2 /�
�Autfh�rczedAaent: 6d 'M _ ! _ S+ --hbviMmgl MI9
Name(Pool) Current Melling Address: V✓ 7 010bZ
� 3 -335 - � I �S
Signature Telephone
73--E M TED CO STRU O S
Estimated Cost(Dollars)to be ORual Use Only
com letedb ermita licant
9 -80 (a)Building Partna Fee
al �da (b)Estimated Total Cost of
Construction from 6g NBuilding Permit Fee
Nical(HVAC)tection
6. Total=(1 +2+3+4+5) 7 cf�o-o , 0Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
.Ut —Wi4 I Q�
Building Commosionernnspeclor 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
Tito column to be filled in by
^ l�q^^ qq Building Do amomnt
Lot Sim d •r-d' IVQ N�,L US
Frontage -70D 'VV ' �(
Setbacks Front
Side U R: L: R
Rem
Building Height
Bldg. Square Footage `7 k II
Open Space Footage �� % I�nn
(lom inae t ambldg&pevol 1
tin 1
4 o Parkin Spaces
Fill: It'/(A-
.
tl
vol &Location)
A. Has a Special Permit/Variance/Findingever been issued for/on the site?
NO O DONT KNOW a YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES Q
IF YES: enter Book Page and/or Document N
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW O YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained O , Date Issued:
C. Do any signs exist on the property? YES ® NO O
l ut Lu PAY"
� _
IF YES, describe size, type and location: �j X I Q fi Sfre.�fin 4wrFv -2t-
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,excavation,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 Stonn Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(cheek all applicable)
New House ❑ Addition ❑ Replacement ntlows Alteration($) Roofing ❑
��ppII Or Doors
Accessory Bldg. (C]f Demolitlon ® I.New 519na �j (� Deeks (O Siding N1 lye Otheee1r,[%
Brief Work: ascription of Proposed r tY FAS Id-C/- Ar f13 r /CSO j �(�ia 5i,n>aMd.le-6lr� 4k Or—
Alteration of existing bedroom I—Yes d No Adding new bedroom Yes-`-C. < No
Attached Narrative Renmaling unfr$shed basement Yes —,2!,—No
Plans Attached Roll -Sheet
ea.If New house and or addition to existing housing, complete 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. Dime ions
e. Number of stories?
f. Method of healing? Fireplaces or Woodstmes Number of each_
g. Energy Conservatlon Compliance. Masscheck Energy Compliance form attached?
In. Type of construction
I. Is construction within 100 ft.of"Hands?,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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR AP�PL,IES FOR BUILDING PERMIT
1 -�et, WJA I f(ri as Owner of the subject
property tt ,,�� �__
hereby authorize L�L'it,
Mb on my behalf,in all matters relative to work authorize by this buildi g permit application.
gnaturemOwner f Op Data
1 C � as Owner/Authorized
Agent hereby declare that th tatements and informatio on he foregoing application are hue and accurate,to the best of my knowledge
and belief.
Si d u the pains and penalties of pepprjury.
Pdn
� 2
Signature of 0, IfAgem Dele
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Suoeni�syor: Not Applicable ❑
Name of Licence Holder: 1 �.VY11 Ai S�\rlV V 1 L s — ) I ZD l0 3
_ License Number
113 VYl 6� fjoyN0Q Mfg 01062— 2-02-z-
'113
0z-Z'f( -335 -1 1e5
Signature Telephone
S.Realstered HMO Improvement Cont—m0or. Not Applicable ❑
Comoanv Name Registration Number
Address Expiration Date
Telephone
SECTION 110-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,5 25C(e))
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...... ❑
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City of Northampton
Massachusetts
OBPABTN&NT OF BUILDING INBP6CTIONS
212 Nair Su«t •Muni P4 euUdtnq t�
Nortbam n, MA 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:
a3 WAAgnu ST Rrfgm M r16 Ol06 Z
(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:
Mid f- Mc�s
(�PliryS}Name and t d
-1 -7 -e-U, Mn- Glom,
W
Sign Pe licant or Owner Date
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.
L\ The Commonwealth of Mussachusetts
Department of IndustrialAccidents
I Congress Street Suite 100
Boston,MA 02114-2017
B'wramass.gov/dia
ulkirkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Amillicautbaformation Please Print Legibly
Name(Bovines./OrgmizatiorAndividpua_l): Vuw
Address: IL�j M� -ew S+r1'�'� 1' I �
City/State/Zip: l}f V- M 0V ZPhone#:
Are you an employer?Cheers the appowrine box: Type of project(required):
1.❑i son a cnryloyer with employces than swear pan-time)' 1. ❑New construction
2.❑Iamasoleprapdetorrorparmasbipmdluveneemployecsworking formem 8. DRemodeling
say capacity.IN.workers'comp.bromine. regaiI
3. 11-.hovent crdaingallwmkmyself.[Neworlren'comp.insurenccrequired.i` 9' Demolition
40 1 am x homeowner end will be M1iring covtremars m coMua all work on my property. 1 will 10❑Building addition
mm all coma .eimcr have wonkco'mmpcnsaron i.e.,um sale II,Q Electrical repairs or additions
detars with no employees.
12Q Plumbing repairs or additions
5.C]I run a general conractor and I have hired the sub-eoarselms listed on the mucked sheet. 13.❑Roof repairs
These sub-conmm er,have emprs
loyces and have worke 'eomp.inwereacc� _
6.❑We are a coneramot and its aficms have exercisW Meir fight ofexempfien per MGL c. 14.®Other�!IG, ArS
152,§I(4),and we have rm employees.[No workers'camp.insurance required.] bdby^
'Any applicant that checks box#1 must also fill out me rection below showing their workers'compersmion policy informence.
t Homeownere who school this andeva indicating they are doing all work and then hire outside conracars most submit a new of hissit indicating such.
1Conractem that shack this ax must touched an additional sheer showing the name of me sub<anracmrs and slow whether or not gave cadres have
employees. If the su s earacctom have employces,they must provide their workers'comp.policy number.
I am an employer that is providing workem'compensation Insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Sim Address: city/State/zip:-
Attack a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year impriscrunem,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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cera u r the pains ancipers coldes,isfinerjury,that the information proWed above Is we and correct
hate- !!::;I_
Phone#
-------------
Ojlicial 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 W.
City of Northampton
-v' Massachusetts
DSPAa'l9aSNT OF BOZLOWG WSPIrCTIOBe
212 Mein Street a Municipal Building
Nortb, ton, Mx 01060 =Jury acm
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("CCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one w 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 pra-exisffng 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: Q/W(JU/Yi)�,����,G/j1r,^��,rf�`� LL��{� t-IY /�j,��/'Ersstt. Cost:
Address of Work: 7'3 mta4�w OAA l YINUI�I%f"IC r M�
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 /I // � qq /� np �y�
Owner obtaining own permit(explain): �' NNSL'Yfe7e��� d, a &Jrnm r"e u'�wl-
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.C.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:
Date -
�^ Owner Name abAignature,