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38B-313
5 -7EASTST BP-2019-0170 GIS#: COMMONWEALTH OF MASSACHUSETTS Mao:Block:38B-313 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-2019-0170 Proiect# JS-2019-000285 Est.Cost $10000.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const Class: Contractor: License: Use GIOnn: RONALD KEITH 085204 Lot Size(sa.ft.): 14984.64 Owner: MARDAS PAUL A Zoninz URB(100)/ Applicant. RONALD KEITH AT: 5 - 7 EAST ST Applicant Address: Phone: Insurance: 5 BIRCH MEADOW DR (413) 584-5589 HADLEYMA01035 ISSUED ON:8/10/2018 0:00:00 TO PERFORM THE FOLLOWING WORKSTRIP & 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: 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: FeeTvne: Date Paid: Amount: Building 8/10/2018 0:00:00 $40.00 212 Main StrecS Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner City of Northampton Building DepartmentCwbCP M—,it 212 Main Street �'' I('i'"Illj Rom 100 Northampoton, MA 01060 Till Jill i�� , phone 413-587-1240 Fax 413-587-1272 li APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION I -SITE INFORMATION t6P- tq-170 1.1 Property Address This"i to be cm~by office i-7 rl5l '51 Map Lot alir ;12. unit otc'60 Zone_Overlay District El.at District CS District_ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Vwi- M qj)g W7 15+ WgIR4 �M.0�6 Name(Pont) Currant Mailing Address Telephone Signature 2.2 Authod.ed Agent: Tit.x:K-o Name(PrCurrent Mailing Address ;�� j Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item 0 Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 441/0 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3-4.5) '61 C) CIO Check Number This Section For Official U"Only Date Building Perm' Issued: Sithi ,jiwini im-lonerlinspectoriABuildings Date I VIA @ 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 This column to be filled is by Building Dependent Lot Size Frontage Setbacks Front Side L R — L:_. R: Rear _. _... Building Height ' Bldg.Square Footage Open Space Footage % -- (Lot mea minus bldg&paved mkin #of Parking Spaces - — Fill _....... "_. . (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW O YES O 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 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 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 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 O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION S DESCRIPTION OF PROPOSED WORK(check all applicablel New House ❑ Addition ❑ Replacement Windows At anatiun]s) ❑ Roofing Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0[ Other[M Brief Descri tion f P o osetl 1t W p �i r, ct to utcr.x 11 36 ,.a I ti{.AKO C,EL S iJ H�-t><} Alteration of existing bedroom_Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Ba.If New house and or addhim t4 existi holuIn cam Tete the followirum a. Use cf building '. One Family Two Family Other b. Number of rooms in each family unit. Number of Bathrooms c. Is there a garage attached? J. 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 1. Is construction within 100 R. of wetlands? Yes No. Is construction within 100 yr. floodplain_Yes_No j. Depth of basement or cellar floor belay;finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer_ Pnvate well City water Supply SECTION 7a-OWNER AUTHOR17ATION TO BE COMPLETED WHEN OWNERS AGE R CONTRACTOR AP IJES FOR BUILDING PERMIT I, as Owner of the subject property hereby authorize to act on ehaIf, in all m ft relative to work authorized by this building permit application. 9 Signature of Owner Date 1, ::L(i t �N , as Owner/Authorized Agent hereby declare that the 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. "[ dea Print Nam, e Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed ConstructionpSyu�pervisorr:: Not Applicable ❑ Name of license Holder iorW/0" t�e.l� �,)`CJ/]7�G7 license Number `� gl��u MC'a�'C� D1• NND bz—� Mta 01037 a-9- ��i Address Expiration Date 5(rd�ialure Telephone S..Repidler"1//Home lrn rnvmr:erd Conlync Not — BApplicable .❑ ROUCt1) Kt1 el,pl C(Yr.TAlA.1.1oJ t /8 7 Company Nam Registration Number blkU+ h^�prJw nti. (J�,pa�� Mo. Olow Atldress ///�L, S�j Expiration Dale Telephone?/7 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(Ni c. 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 i s LDING C m12 wolnNS OF B. Municipal al building 2 213 lLan Street • Municipal Builtlinq J. JCD Northampton, EW 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"). 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 must be registered Type of Work: Est. Cost: SIO to Address of Work: r� E(D)-T S-) wd1U in M9mo- ryyp m9 mo— of Permit Application: •-�i^ �g 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.S11]]CH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUTDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of petjury: I hereby apply for a building permit as the agent of the owner: R 1- 19 PKOWOIO jQ I'ru ( -192&r 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 caner Name and Signature City of Northampton - t-tE39ECt1119Ett8OsF 212A in S ee B.I .i.G INSPECTIONS 212 Hain rthe • Manicipal Building eoxMampton, M. 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 I IO 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 110.85, 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. r City of Northampton Massachusetts c z DEPAFIT T OF BUZLDZNG ZNSPECTZONS 212 Yam Street •Municipal Building //)(C Nortbe ton, 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: C-'.QsT -,T Y50 a^ \ tJ (Please print house number and street name) Is to be disposed of at: yR I lc.h tia froY13 5-6,7-5-6,7— W"? ease panteCuc ame an cation of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) U :R- 7 IF Signature of Permit 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 of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-1017 non w.mass.gov/dia TWorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print L 'bl Name(Business/Orgmizaion/Indlviduap !�: 1`O k)&(D f(Q11 , CcaUST TIOW Address:--5 &k" ang-eILtw 1 X- City/State/Zip: W 1212 l%AQ Phone#: 13- you me n employer?Cheek me appropriate box: Type of project(required): I lama employer with��cmployees(Nil and/orpoureame).` 7. ❑New construction 2.❑lamasolepmpneororpmmershipandhavenoemployeeswodoag farmein g. E]Remodeling any capacity.[No workers'comp.insurance required.] 3❑l an ahomeawner dam,Al work myself [No worwas'emop,msume.marmot]' 9. ❑Demolition 4.❑1 ams hameowma and wdl be hhlng con ytromms to conduct all work enm (will 10 E] Building addition . ensure that at ell conttmo ars ors either have worke 'compensation Nm sance or arem sole sole 11.❑Electrical repairs or additions prop emoo with no employees_ 1T.n Plumbing repairs or additions s 1 am a general contractor and I have hired the sub-cannacmrs fisted on the anached sheen. 13. Roof repairs These sub-mno-actors love employees and have workers'comp.ina... 6 we are.e tion andas officers have eaerelsed thelrn ht of exem tion 14.❑Other ream g p per MGL c. 152,31(4),and we have no employees.[Nu workers comp.insurance required.] 'Any applicant that checks box HI mast also fill out the sectian below showing moor workers ema,vo sabon policy Inf martian. 'Homeowners whn submit tires Alamo uWicaring they are doing all work unit men hire outside cmntmcon must submit a new andava indicating such. :Co momma that check this Iwx must attached an addruxual shred showug the time of the sub-contractors and saw whether or not arose entities have employees. Ifine sub-contr cmrs employees,they mint pmvide encu workers'camp.pnlicv number. I man employer that isproviding workers'compensation insurance for my employees. Below is the policy andjob site _ formation. Insurance Com y Name: Policy r 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$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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herebyceerdly uunnder the pa�in.s/and penalties ofperjury that the information provided above u true an d correct Signature: � Date 19- /157 Phone 9t/3` dtiw 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.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 ajoint 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 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,§25CC)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-contractors)name(s),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 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 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 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-N ASSAFE 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 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 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 permiblicense number which will be used as a reference number.In addition,an applicant that must submit multiple permiNicense 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 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 F.Revised @-23-15