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31A-142 36 FORBES AVE BP-2019-0029 GIS#: COMMONWEALTH OF MASSACHUSETTS Map-.Block: 3IA- 142 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cateeorv: ROOF BUILDING PERMIT Permit# BP-2019-0029 Project# JS-2019-000032 Est.Cost: $24862.00 Fee: $40.00 PERMISSIONIS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: TIMOTHY LUCE 100515 Lot Size(sa.ft.): 6926.04 OWner: CZOPLINSKI MATTHEW Zoning: URB(100)/ Applicant. TIMOTHY LUCE AT. 36 FORBES AVE Applicant Address: Phone: Insurance: PO BOX14 (413) 387-9800 LEEDSMA01053 ISSUED ON.7/5/2018 0:00:00 TO PERFORM THE FOLLOWING WORK.REMOVE EXISTING SLATE ROOF, INSTALL METAL 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 sienature: FeeType: Date Paid: Amount: Building 7/5/20180:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner OAF FFrFl Fn City of Northampt n SMZ#M`t Building Departm IT JUL - 2 Qytryat 212 Main St Room 100 ` . .. . Northampton, MA 0 O6�EPT oc AMP NORTHAMPTON phone 413-587-1240 Fax 413-587-127 APPLICATION TO CONSTRUCT,ALTER REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION gyp- , 9- aq 1.1 Properly Address: This section to be completed by office Map 31A LM 14- ' Unit f� Zmw Overlay District Elm SL Dfablcl Ca Dialect SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: -�/' 1 \ 7�1 Na (P i Current Mailing Address: Q7—— 7tE�-—ti/r ).J `�A Telephone / Signature L.vcO.- Name(Prim) Current Melling Address: Y/3 387 - 9&0 sumbA Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Oficial Use Only completed by permit a licant 1. Building .7�/ p� t1- (a)Building Permit Fee 2. Electrical L/ 0 (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit 1" D 4. Mechanical(HVAC) 5.Fire Protection 5. ToW=(1 +2+3+4+5) 2ur Check Number 107K This Section For Official Use Only Building Permit Number: Date Issued: /-� Signature: " - mlul nep of ulklinga Date EMAIL ADDRESS(REQUIR D; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed.Penna Can Ik Denied Due To Incomplete Information Existing Proposed Required by Zoning Thi.wlumn m be rare in by Buddies Dep mensin Lot Size Frontage _ Setbacks Front Side U R. _. L: R: Rear - Building Height Bldg.Square Footage °h Open Space Footage % (Lot see suets bids As ravel _ .. #of Parking Spaces Fill: volame a taation A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DONT KNOW O YES O IF YES: enter Book Page and/or Document N. B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conse rmatlon Commission? Needs to be obtained O Obtained © , 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 O IF YES, describe size, type and location: E. Will the oonstrudion activity tlbWrb(deanng,grading,excavation,or filling)over 1 erre or is it part of s commoin plan that will disturb over 1 acre? YES O NO O IF YES,than a Norftmpton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK Icheck all applicablel New House ❑ Addition ❑ Replacement Windows ANeratlon(s) Roofing or Doors El Accessary Bldg. ❑yedDemolition11 ❑ New Signs 01 DoCke�[[0 Sidingo]/ Other IC3] Work:Briefon of Proop mos r41 � Afteration of e>asbng bedroom—Yes_No Adding new bedroom Yes No Attached Nanative Renovating unfinished basement Yes No Plans Attached Roll -Sheet on.It New house=4 or ackNon to odsling houstra cornt>lotg 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. Dimensions e. Number of stores? I. Method of heating? Fireplaces or W oodstoves Number of sea_ g. Energy Conservation Compliance. Meascheck Energy Compliance form attached? h. Type of construction L Is construction within 100 R 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 To-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR (I APPLIES FOR BUILDING PERMIT I. Le[>) L� rfi L i .as Owner of the subject property �+ hereby authorm / to a benerc all ma la5ve to work authored by this building perms liration. � 2 Sigmaxe of Date as OwneMAutiar¢ed Agent hereby dodqe that tiro statements and information on the foregoing application aro true and accurate,to the bast of my knowledge and belief. Signed uMer the pains a pen'ardsso of perjury. L"�IIr L� Prim of Omer/Agml Dab SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor. _ Not Applicable ❑ Nameaf Licameo Holder: /T'i71„e �- L uc� _ rod Sf,�— License Number Pa eldo 7-K_-/S7_ Address Expiration Date i3 3�� 900 ne re Telephone = Not Applicable ❑ Corms"Name Registratlon Number -al 144 a S 3 dress Expiration Date Telephone SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT IM.G.L.c.152,§25C(6�) Workers Compensation Insurance affidavit must be completed and wbmitted with this application.Failure to provide this affidavit will result in the denial of the issuance of the buil0l permit. Signed Affidavit Attached Yes....... No...... ❑ City of Northampton Hassachusett8 DBYARTranrT OF BUILDING INSPECTIONS 212 Main atraat • Municipal Building Rorthanpton, 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 most be registered as a Home Improvement Contractor("HIC"). NLG.L.Chapter 142A requires that the"reconstruction,aeration, renovation,repair,modernization, conversion, improvement, removal, demolition, or construction or an addition to any pre-existing owner-occupied building containing at least one but not more then Pour dwelling units....or to structures which are adjacent to such residence or building"be done by realstered contractors. Note:If the homeowner hos contracted with a corporation or LLC,that entity must be registered Type of Work: irGSlA'r`f l Est.Cost: 0101 Address of Work:Date of of Permit Application: 1 �2 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 awn 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 RESPONSIBH.ITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: 1 hereby apply for a building permit as the agent of the owner: 7— Z—IF 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 and Signature City of Northampton Massachusetts �c r x DBPABTDffiiT or BVz=m 18SPSCTIOJS 414 [Yin Strut • Municipal Boiltling °acs Mortnsvpton, MA 01060 '�'j� 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 person(s) you hire to perform work for you under this permit. City of Northampton i -... � Massachusetts s DaPAR1}ffiiT OF BOILDING INBPSCTIONB 411 nein 8tiaat SN Lci,,l Building NorthaRp n, B8 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: Lb 'AQ-� (Please print house number and street name) Is to be disposed of at: (Please p'nt name ar location facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) ure of'PeWit Applicant 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. The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Amilicant Informations � Please Print Leath Name(Businesa/orr'gss iraHm[Indty� Address: ,., City/State/Zip: / S Phone#: pe5� Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am s e L 4. ❑ 1 am a general contractor and 1 6. ❑New construction gees(full and/or part-time).* have hired the sub-contractors 2. 1 am a sole proprietor or parmer- listed on the attached sheet._ E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp,insurance. q, ❑Building addition [No workers'camp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10,E] Electrical repairs or additions 3.❑ I am LEI homeowner doing all work right of exemption per MGL 1 —S,LPlumbi irs or additions myself [No workers'comp. c. 152,§1(4),and we have no 12. _non/f repahs insurance required.]t employees.[No workers' 13.❑ Other comp.insurance required.] •Any epplimnt that chaks box 41 must also fill out the section below showing shear warkm'compensation policy information. r Hoon sours who submit this affidavit indicating they are doing all work and tics hitt outside contreaon most submit a nm aaidavit indicating sorb. :Conuactorsthat check this box must attacbed on additiona]s showing die emus of the subconkacrms and their workers'camp.polity information. loan an employer that is providing workers'compensation insurance for my employees. Below is the pocky and job site informadon. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 a 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 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. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct Si a Date: Phone* lb 38,79izo Of/lchd 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,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 sub-contractor(s)name(s),addresses)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 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 permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple petrnitilicense 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. 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia a COMMONWEALTH OF MSSAf.`HUS• Massachusetts Department of Public Safety e • • • • .� Board of Building Regulations and Standards SHEET 6 TAL 0IIORKt5N8. = j License: nS upervi ' ISSUES TH)E.F[?LLOWINO LICENSf.�AS A Construction Supervisor VASTER-UNRES TED -•,s-, TNAOTHY J LUCE TIMIDBOXT}IV J LUCE PO BOX 14 it WO .� LEEDS MA 01063 ' I4 , LEEDS,MAS 9,1063A014,,, N-IZZ7 t-/— Expiration: 1339607hi812018 94956 Commissioner 07/1612018 Odbe 01 Canwme Allen 6 Buenas 11"U"on HOME IMPROVEMENT COMPACTOR Rplstra0on valid for Individual use only TYPE'.IndMtlual before His expiration doe. 0 found return b: Readstration F.60ttMI0O office of Consumer Affairs are Business RegulMlon 140266 12/14=19 10 Park Plane-Suite 5170 TIMOTHY LUCE Basilan,MA 02116 TIMOTHY J.LUCE 122 RD. LEEDS, Ds,MA MA 0Dross Undersecretary Not valid without signature