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32A-191 (2)
50 PHILLIPS PL BP-2018-1239 GIs#: COMMONWEALTH OF MASSACHUSETTS Map.Block:32A- 191 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-2018-1239 Proiect# JS-2018-002212 Est Cost: $21900.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group DICKY MATOS 105917 Lot Size(sp.ft.): 7492.32 Owner: CARSWELL CAMERON Zoning: UR 100 Applicant: DICKY MATOS AT. 50 PHILLIPS PL Applicant Address: Phone: Insurance: 3 GLEN ST (413) 530-5335 WC HOLYOKEMA01040 ISSUED ON:5/2312018 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: O y 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 5/23/2018 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner aqe� Department useiiIV City of Northampton Status of Permit: Building Department Curb Cut/Driveively Permit 212 Main Street Seyear/Sepand"liability— Room 100 WistarVilell Availability Northampton, MA 01060 TWo Sets of StructurNans, phone 413-587-1240 Fax 413-587-1272 Ploysits Plans other Spaidi APPLICATION TO CONSTRUCT, ALTER REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING 9- SECTION 1 -SITE INFORMATION FJ-0—�—r,—r t 71, jr-r, 1.1 ProruirlyAddres. �11-11 V 6LJ Is section to be completed by office I'JL-' V Lj A P 3;.?^ Lot Lqi_Unit UAY 2 2 20LB he Overlay Districit aDFPT rt�BUILDING 41�A Istri t CB District 11UHTHAMPTON.W01 0 SECTION 2.PROPERTY OWNERSHIPIAUT 2.1 Owner of Record: rna Z-01 Name(Print) �i_ntlfinj ,.,a Signature 2. Authorized A ant: Ii Aal � k )k "o 11n Name(PrMailing ignat Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only wmpleted by permit applicant 1, Building OO (a) Building Permit Fee 2 Electincal (b)Estimated Total Cost of Construction from (6) 3 Plumbing Building Permit Fee L'C6 4 Mechanical (HVAC) 5 Fire Protection 6. Total=(1 +2-3+4+5) 1 C)n. o0 Check Number This Section For Official Use Only Date Building Permit Ni.rrn Issued: SignatFe: Building missionernnspector of Buildings �Z - CL(d �( Date I CIJ-i EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4.JZONING 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 Department Lot Size Frontage Setbacks Front Side L R ._ L: R: Rear Building Height Bldg. Square Footage Open Space Footage % -- (Lot area minus We&paved ,. ron ) &of Parkin Spaces Fill: vo me.Lnnadon. A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO © DON'T 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 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 O 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 0 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 © NO O IF YES,then a Northampton Station Water Management Permit from the DPW is required. w. s r , SECTION S DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alterations) Q Roofing 0, Dooro Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [O Siding[0] Other[01 Brief Description of Proposed Work: ar r>�P CiA Leo .Ilirs1rr `nshtltir �> .ndo61 a-tort3' iA� Il��ncf�g sect PiKs4NerciS,i ndeiy<aq z,ae�n+av`+-}rc>:+.edc.be-yms n sa ..sl-..- Alteration of existing bedroom_Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement _Yes No Plans Attached Roll -Sheet Sal.If New house and or addition to existing housing, complete the followina: a. Use of building: One Family Two Family Other It, 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 L Is construction within 100 ft, of wetlands?_Yes No. Is construction within 100 yr. floodplain_Yes_No I. 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 1, 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. Signature Of Omer Date I, I L' �i `.4 1—l G'v' J w S as Owner/Authorized Agent herebyby declerethe 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. I , Print Name Signa a r/Agen Date t SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Sue isor: Not Applicable ❑0 Name of License Holder: rn- I1l'�� / I � Lice se Number t 6»+ :Xo Add s ExpiAddon Dat lure U Telephone 9.ReIjIsteMq HoEM Im rovernan Contractor: Not Applicable ❑ 0� Company Natme Regfr-atloo Number (2n 'AdLdrrerss (\p ) ( �`� Expiration Date F JILT�—1 Q \7 LND Telephon-jE _X053 5 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152'§25C(6)) ,§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.. . R3 No..__ ❑ 4 City of Northampton Massachusetts DEPARTMENT OF BIG INSPECTIONS & Z 1} 212 Main Street Municnicipal Building Northampton, LW 01060 y. J AFFIDAVIT `h 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 mustbe registered � Type of Work: y� Fst. Cost: OIn + I W Address of Work%� '� I,I I2�^5�r\YeI� Date of Permit Application: 1"J-JI C7V Cl 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 pernut(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: \ Ucb ➢ udim ) U Acic�- Dale Contractor�Pme 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 and Signature _ City of Northampton c Massachusetts c z DEPARTMENT .�\ BUILDING INSPECTIONS 212 Nam Street aNinxcipal Building Northae,[on, y� , CD MA 01060 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 110.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 persons) you hire to perform work for you under this permit. 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)I by MGL c 111, S 150A. Address of the work: , 'O Ph, � � ( '0� P l The debris will be transported by: ft1S The debris will be received by: CQ'2-00 Ul HA4 4P Building permit number: L Name of Permit Applicant � )�( '\ �o Il)5 Date Signa ure of Permit Applicant The Commonwealth of Massachusetts Department of7ndustrial Accidents 1 Congress Street, Suite 700 Boston,MA 02114-2017 www riass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organizact/ion Name: 2za Address: ") l QIP n A--`� City/State/Zip: + Phone #: 12, Are y an employer?Check appropriate box: Business Type(required): 1.�I am a employer with L4employees(full and/ 5. []Retail or part-time).' 6. ❑Restaurant/Bar/Eating Establishment 2.❑ 1 am a sole proprietor or partnership and have no q [�ftiee surlier Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] S. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees. [No workers'comp.insurance required]' l 1.❑Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers'cramp. insurance roq] 12.❑Other "Any applicant that checks box#1 must also till out the section below showing their workerscompensation policy information. "If the corporate oxcers have exempted thenuel,o,but the corporation has other employees,a workers'compensation polity is required and such an mgunization should check box al. 7 am an employer that is provi/dlinng workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: 2-Il Y lownes's Address: City/state/Zip: n Policy#or Self-ins.Etc.#[ � - (P 5ALL120 T Expiration Date: Uhliq Attach a copy of the workers'compensation policy declaration page(showing the policy numberarl expiration date). Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of 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 violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 7 do hereby ceroffsinsder the pains and nalti ofperjury that the information provided aboveis true and correct Si tuDate' Phone#: 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#: wvw.m scgov1do 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,MGC chapter 152,§25C(7)state, "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 Ill ll 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. Thinned Liability Companies(LCC)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 penrulieense 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). 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 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 I Congress Street Boston, MA 02114-2017 Tel.# 617-7274900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 www.mass.gov/dia Form R—sed 02-23-15 3Gion 51 Holyolyoko, Ma 01040 413.5305335 I1�"�"'—" GS105917 �\ HIC IM207 '> W,11.2010 50 PHILLIPS PL I. NOOrwnplon Ma 0 10 10 NEW H00F 41000 14,Iw 00 le.n _'I enlu.raa IVlvnboU _ 'ag2 roll 'J nItLEandl: IJS ✓u=n 01 1 1' I II y ] I "-0a rpa 1 II I.:IJ- m� al eFnl4r± Iri.lvllt — all p'rJr,tiI,' Ilcme.e l Liar s J JR�n� Im:.11p , moi ll>_a II s22'vi". Ikc dyraSty shrngliS 150.00 ISO cc Cnunr.ry 450.00 4`_C 00 In.'nll eaaa.inu.l lc yy, __ NEPI CE SHEAIING W00 5.34000 la•pls:e all .r.:f.±ac... CQ SAP. 521 2CC 00 Commonwealth of Matetehuodts Division of Prohesional Lkanauro Board oI BuiMin9 R""ons and Standards Consli;4*0Ktf `* visor Ca-105917 ....,FApIM:0.9/90/2020 RICKY MdRIi y DB12N B7RElfpp� IIOLYDIO:MA OA�. . . �` bf5S7dl�J CommINWNr C4 Office of Consumer Affairs and$ LLL4/4/4/mess Regulation 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Impmvemew Cotthactor k4stradon Rep"at: team] Type: IrldMdwl DICKY MATOS DICKY MATOS 8 GLEN ST. FIOLYOKE, MA Ot040 Up"Aditm.r ndn wd.Met lmN or chaW d p Address p Renewal p Ramplaymmit ❑ LatCard omaaro. sfsh+& ar ,fbinn UmwraBWmmwI � aafor ma* oe thN4n At ffspfrada dtls, KAMW reform rx a vx.Bwt Bra2me t muMwi t ussia. A 02116 n» NG(Y M47M - Russia.MA 42116 DICKY MATOB D GLEN BT. 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