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13-009 (4) 534 NORTH KING ST BP-2019-0053 GIS#: COMMONWEALTH OF MASSACHUSETTS Map-.Block: 13 -009 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-2019-0053 Proiect4 JS-2019-000082 Est.Cost: $4000.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use croup: Homeowner as Contractor_ Lot Size(sa.R.): 43995.60 Owner: LOPEZ CARMEN& RODRIGUEZ RICHARD Zoning: Applicant: LOPEZ CARMEN & RODRIGUEZ RICHARD AT: 534 NORTH KING ST ApplicantAddress: Phone: Insurance: 534 NORTH KING STREET (413)219-6172 0 NORTHAMPTON MA01 060 ISSUED ON:711212018 0.00:00 TO PERFORM THE FOLLOWING WORK:REMOVE OLD SHINGLES AND REPLACE WITH NEW, ENTIRE 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: FeeType: Date Paid: Amount: Building 7/12/20180:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner D to a*t(Iln Af 4m1rC x UI Ing epa m ht 212 Main Stre 1 JUL Ijoprt$(1�0 =: aiei7We11,+Amal Hca s 'l jNortham ton, MA 0 06 7xo Setr'id � p x :.t 9, + a L �axo-c wig p o 3-5 7-1272 bVSq�Plass° ta '1 ; Nodham Iah MA 01080 APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE O\(.RR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 7 -SITE INFORMATION 1.1 Property Address: This section to be completed by office 137 ;'\ N�<� �\ S� Map(_ Lol�� Und {�b t c) Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: ocLhl aSSU p�nY �(u� s�, �1DY�b,RF o h ame(Poop Current Mailing Address: LI IL-2.t � ,7 Lb�1 � ielep one atom 2.2 Authoril Agent: Name(Pent) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed b permit applicant 1. Building co (a)Building Permit Fee 00� ' 2. Electrical 0 (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) / V O 5. Fire Protection 6. Total = (1 +2+3+4+5) QpU. 00 1 Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Co ' sinner/Inspector M Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be completed. Permit Can Be Dep4aw Information Existing Proposed Required by Zoning nul'lI�olumn m be filled in by Erui�ping Depamd d_ Lot Size` Frontage Setbacks Front Side L R:-- - L:: R:— Rear :Rear ---- Building Height ---- —'—" Bldg. Square Footage _�,., —',— % Open Space Footage _— � % (Lot arca minus tilde&paved arkiv ) k of'Parking Spaces - ---- Fill: (volume&Location) - ---� ---- +— A. /acre? YES s a Special Permit/Variance/Finding eve been 'slued for/on the site? O DONT KNOW O S O IF date issued: IF Was the permit recorded at a Registry of Deeds? O O DONT OW O YES S: enter Book '.. Page and/or Document# B. the site contain a b ok, body of water or wetlands? NO DON'T KNOW O YES O ES, has a perm been or need [o be obtained from the Conserv. ion Commission? _—___ ds to be ob ined O Obtained © , Date ssued: C. y signs ist on the property? YES O NO O ES, scribe size, type and location: D. a any proposed changes to or additions of signs intended for the property . YES O NO O ES, describe size, type and location: E. e construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or Is it part f a common plan ill disturb over 1 acre? VES O NO O IF YES,then a Northampton Storni Water Management Permit from the DPW is required. i SECTION S.DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Aaeration(s) E] Roofing ©/ Or Doors 3 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[l7] Other[01 Brief WorkDescription of PropoeQ_ (�� n11 (,'\� , Alta tion ting I( V(� new bell \ I C (P Atlac "at" Renovatin Ishad bas Yes No Plans Attached Roll -Sheet aa.ht New house and or addition to existing housing, complete the foltowinn: a. Use '[ling : One Family Two Famity Other b. Number of rooms h family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new cons[maio Dimensions e. Number of stories? f. Method of heating? Fir s or W ocdstoves Number of each g. Energy Conservation Compliance. Masscheck En Compliance form attached? h. Type of construction i. Is construction within 100 ft.o ands?_Yes No. Is construction within 100 yr. dplain Yes No j. Depth of basement ellar floor below finished grade k. Will build conform to the Building and Zoning regulations? Yes No . 1. SeptIcTank CilySewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT / I, 1 _ 111�� as Owner of the subject property ` ' 1 p hereby authorize C1/(� Q /n V"v7 to act on my behalf all matters to coo thodzed by this building permit application. ID bl Signa Opwneerr, Date I, I I r`�rZ as Owner/Authorized Age e y declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. S' ned under the pains and penalties of perjury. if l (,z Qcz P ' )Name ID Signature er/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable Name of License Holder: License Number Address Expiration Date Signature Telephone 9.Ranistered Home Improvement Contractor. Not Applicable Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L C.152,§2506)) 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 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 by MGL c 1f11, S 150A. nn Address of the work: l ',M I / r � 0j0(ep The debris will be transported by: Vi C rOrPv Con t-0I'✓UrS The debris will be received by: -4 Building permit number: II T Name of Permit Applicant '1 bbl Date Signature of Permit plicant City of Northampton J Massachusetts L ' DEPMTlENT or BUILDING INSPECTIONS a vn 212 Main Straat * amicipal Buildin4 e F 001 aertnampton, eR 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, modernization, conversion, improvement, removal, demolition, or construction of an addition to any preexisting 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 corporadon,,or LLC,that entity must be registered Typeof Work:�p\q [( ) n4 0h\h4Q4 Est. Cost: Address of Work 52�\ pJ 0 f b f�INy V' C_SI N CO A bJ D(0, ,0 Date of Permit Application: I I o` I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): in under$1,000.00 _v_ wner 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, I hereby apply for a building permit as the owner of the above property: I �v) LOaJ rve� ( 7)�L L(2 Date Owner Name and Signature City of Northampton _ Massachusetts c s DEPARTXEliliT OF BUILDING INSPECTIONS 212 Nin Street • Nonicipal Building t C1 Northampton, NB 01060 1P 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 thejob 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. The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 700 Boston,MA 02114-2077 www.arass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED N'ITU THE PERMITTING AUTHORITY. Applicant information Please Print Legibly Nme (Business/Olrgmintionandiivvi1d�ual): y�� `L t t k) ,, Address: S'bu City/State/Zip: Are you an employer?Check the approprivle box: 'Type of project(required): L�l an a employer with ernployem(inn aurfor parttime).• 7. ❑New construction 2❑1 am a sole proprietor orpmmerstip and have no employees working forme w g. ❑Remodeling y/amrapacity.[No workers comp.ins. tequvM.] 3[9'fa homeowner doing all work myself[No worwo'compinsurance required.]t 9. [1 Demolition 4.❑1 am a hommwner and will be haing connn=tors to conduct all work on my property. I will 10 ❑Building addition crop,thatall contractors either have worker'=ompeoaaeon waurame or oresole 11.❑Electrical repairs or additions torturous s wiW an cmployees. 12.❑Plumbing repairs or additions 5❑I no a general contractor and I have hired the sub-contractors herid on the atmched sheet. these sub-contracmrs have employees and have workerx comp.unmancel 13, oof repasts 6 r We are a owroanon and its officers have cxereised thea right ofexempdou per MGL c 14.❑Other 152,§I(4),nud we have no employees.[No workers'comp.insurmce re uirvil] .Any applicant that checks box#1 count also till out the seccon below,showing thea workers compension.policy iufprnm4on. 'Homeowners who submit this affidavit indicating they an,doing all work and then hue outside contmebrs must submit a new affidavit urdicating such. tCon inctor that check this his now attached on addirwou sheet showing We none of the sub-contnemrs and smm whether or not those entities have employees. Ifthe sub-conn aeon have®ployees,they must,wide Wen workers'comp.policy—bor. I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site information. Insurance Company Name: Policy#err 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 MGL c. 152,§25A is a criminal violation punishable by a fine up to 51,500.00 and/or one-yew 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.A copy of this statement may be forwarded to the Office of Investigations of the DLA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provide,-tllabove is true and correct Sienature:� l Date- I �I�IOU-t�C) Phone Official use only. Do not write in this area,to be completed by city or town offuint City or Town: PermittLicense# Issuing Authority(circle ane): 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,anemployee 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 tmstee 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,§25 C(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 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 sub-cormactor(s)na ne(s),address(es)and phone numbers)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 retumed 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 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. 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 ent's address,telephone and fax number The Cornmortwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-NIASSAFE Fax# 617-727-7749 Revised 02-23-15 wxvWnmss.gc is