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29-177 (4) 191 BROOKSIDE CIR BP-2019-0167 GIS#: COMMONWEALTH OF MASSACHUSETTS Map.Block:29- 177 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation BUILDING PERMIT Permit BP-2019-0167 Proiect# JS-2019-000283 Est. Cost:$17800.00 Fee: $116.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: KEVIN WERNER 085114 Lot Size(sq. ft.): 16901.28 Owner: JONES DALE Zoning: Applicant: KEVIN WERNER AT. 191 BROOKSIDE CIR Applicant Address: Phone: Insurance: 197 PARMENTER RD (413) 834-0488 WC BERNARDSTONMA01137 ISSUED ON:8/17/2018 0:00:00 TO PERFORM THE FOLLOWING WORK.ADD A BATH AND 3/4 BATH, RE-DO KITCHEN, ADD BEDROOM IN BASEMENT 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: FeeTvoe: Date Paid: Amount: Building 8/17/2018 0:00:00 $116.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2019-0167 APPLICANT/CONTACT PERSON KEVIN WERNER ADDRESS/PHONE 197 PARMENTER RD BERNARDSTON (413)834-0488 PROPERTY LOCATION 191 BROOKSIDE CIR MAP 29 PARCEL 177 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLO REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildima Permit Filled out Fee Paid Tvmeof Construction, ADD A BATH AND 3/4 BATH RE_D64eTCHEN,ADD BEDROOM IN BASEMENT New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Include& Owner/Statement or License 085114 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INPRMATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance' - Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Cub Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management edition Delay Si of Do.ding P i �ad Date / Note:Issuance of a mg permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. •Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. )Knlar' l 60 1464V - DepaMlem use only City of Northampton Stems of Permit ^ 1 Building Department Curb CutlDrwewey Paid A 18 212 Main Street Sewed9epuc A"IftWty Room 100 waterNVell AvailabilityN rthampton, MA 01060 Two Sets of Structural Plena 41 587-1240 Fax 413-587-1272 PWtlSko Plane D[PT O "NSP NORTHAMPTON.1dA Ot060 Gther SpKify N APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION I -SITE INFORMATION 6 P- 1.1 Proaerty Address: Is section to be completed by office AS / ,kS'ide 6rC4 Map Lot 17� Unit �l�rr f1�'7,/• r /Yl% Zone OverlayDLmat Elm SL obMet ee olmta SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Dn le t �I o vtis i l i 6Jy rem r, �hx Name Current Mallin Add. mai 1'L�f TBleplme Signature �Z '✓4./ / i - }.3� =� ? 2.2 Authorized AaeM: Name(Print) Current Mailing Addrea® Sign w. Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by2ernift applicant 1. Building i 3 Ldc> �,f (a)Building Permit Fee 2. Elecbical Sero ri.2 (b)Estimated Total Cost of Construction from 6 3. Plumbing �y0(7 _ e� Building Permit Fee 4. Mechanical(MVAC) V 5.Fire Protection r C l+ 6. Total=(1 +2+3+4+5) /j' Ate? Check Number This Section For Official Use Only Building Permit NumDate ber: Issued: Signaw Building nepecin of Bu*kga 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 This column to be filled in by Building Deparu„ent Lot Size Frontage Setbacks Front Side L: R: - L: R: Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot arw minus bldg&Pined Parking) #of Puking Spaces Fill: volume&l.ocetion A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO is DONT KNOW © YES O 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 O NO k) 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 'Q IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,gradintV 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 Storm Water Management Permit from the DPW is required. SECTION 6-DESCRIPTION OF PROPOSED WORK(check all applicable) New House E Addidon ❑ Replacement Windows Altemtion(s) ® Roofing Q Or Doom O Accessory Bldg. ❑ Demo iti n / New Signs [C2I Decks [p Siding[O) Other[� Q Brief Description of qro�p�sed /� g Work_f(.L7GY Qi 6Q.Ji.f- %y LJp -r�, /P-�o �c,�C�i-�n. CAc�o� rd2eGL2�d Alteration of existing bedroom li Yea_No Adding new bedroom ✓Yes No Attached Narrative Renovating unfinished basement _Yes No Plans Attached Roll -Sheet r2 - es.ff•" "" ""o 4KkWleritio exYtltwl Iwuelnui complete the followfrlu: a. Use of building '. OneFannill 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 stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance farm attached? In. Type of construction i. 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 COMPLETEDWHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Y as Owner of the subject property hereby authorize (.$ ✓v L✓ to act on my behalf,in all matmre relative to work authorized by this building permit application. Signature of ovmer Date I, as Owner/Authorized Agent he re that the state c and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Sign der the pains and Pe of perjury. Print Name Signature of 0wher/Agent D to SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Constmction u rvi r: Not Applicable ❑(/ Name of License Hold. 01W r License Number 141 �GrM�nY�� P� gec���Js�� Fnq "�/a7lis Add res Expiration Date Signature Telephone {^' Not Applicable ❑ e7 .A b4Mcne/wt Bu • )e✓' 139776 Cllompany Name,,v�.. R�ejgistration N nber Address Expiration Date Telephoneg3/flogs/ SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§28C(8)( 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 c 1212A i. g OF B- ..D. G .NSP&CTZGNS 212 Main Sttaet • Nun 010 Building NoaTempton, Mw 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, modemization, conversion, improvement,removal, demolition, or construction of an addition to any pre-existing owneroccupied building containing at least one but not more than four dwelling units....or to structures which am adjacent to such residence or building"be done by registered contractors. Nate:if the homeowner has contracted with a corporationkyr LLC,that entity must be registered Type of Work: N �b"� Est.Cost: Address of Work: Date of Permit Application: 1 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.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: 1 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 and Signature City of Northampton Massachusetts d DEPABTNENS OF BUILDING INSPECTIONS \\ ' 212 Nain St setNunlcipal Building p. qC N.n.a tnn, !a Massachusetts Residential Building Code Section 110.85.1.2 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 110.85.1.3.1 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. City of Northampton I Massachusetts 3s,. •�.' c�( L D6PANTNFl1T OF BOZLDZNG ZNSPSCTZONS 212 Min Street *tunicipel Building Northeepton, M 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 (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: x/14 /S IC6,(/ D 4"� (Ganpany Name and Address) q Signature of Permit Applicant or Owner at 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 oflnduslria7Aceidents I Congress Street,Suite 100 Boston,MA 02H4-2017 www.mass.gov/dia Wm,arkers'Conapensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lesibly Name(Business/OvganizatioMndividual): e V gyp.. V-312e; w r— Address:_w City/State/Zip:&S tw.cit) 5�'n Phone 91 -0 ez Are you xa employer?Cheek the appropriate bar: Type of project(required): 1.[]1 am a employer with employees(full and/or pa-time).• 7. ❑New construction I am a ale proprietor or partnership and have no employees working for me,in S. 153namodeling capacity.[No workers'pomp,assurance required_] ��� 3 an a homeowner don l work myself [No workers'compmorrace required]' 9. Demolition 4.❑1 an a homeowner and will be terms contractors to conduct all work on my property. I will 10❑Building addition crounithatall comwwrseitherhaveworkers''wmpensatwn mouranceorare sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5Q l am a general contractor and l have hired the sub-contractors listed on the stated sheet 13 ❑Roof repairs Thea sub-omorewrs have employces end have workers'camp.inswan : 6 W are a cwpestr n and its officers have exercised doer right ofewortatn per MGL c. 14.[:]Other 152,§1(4),and we have ata employees-[No workers'comp-insurance required.] •Arty applicam that checks box AI most also fill our the section below slowing their workers'compensation paltry ordeneatem. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such. :Contractors that check this box most toothed sat additional sheet showing the name of the sub-conersctors and state whether or not those entities have employees. Ifthe sub-contractors base employees,they man provide their workers'comp-policy number. I am an employer that is providing workers'compema don insurance for my employees. Below is the polity and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/zip: Attach a copy of the workers'compensation polity 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 hereby cern der thepainsa d canlfies of perJury that the information provided abov�A t/ ;and correct. S atme4'/Zi � D t 43 / Ph #� B3r-o 45W 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#: ca /,nbb lt/ svol� arms rr✓t oo�,/ x S )J 79^J'CrS'�/,�v, a.ylpP>T �5>U n '/oo(- JJ2ICjss� ' SS��,� sI Sr� 'rlo� w,•m rC�U'" f?irYJ �e vo�o r., 7�c fly'» -n��a�a.-t '✓Jto,,�,s ��r�7b"t �nc7�ra� '?� ,a PP? l £ I %t , 6/ ' wno.+f)Xj v dap;/ 1rw,rarr?SvS ;5z fpv Sty cit s5afa Nm 'onp Avo Snswa3` n (ivy^ , °f a,., `L.i •/xdn 17-p ny e a4o1d+7y l / ..ya aQ„r 7 '`r`a'A 7 Y'T�6 " u,,aos knrr„j �� nw� anoue °f rn,,,�c>, t�vn ��Suruu�-d anoic+)� IwaNJ,�r.s/ --ti zur t j� crr nz�^ nZ�z _Sf.f f!{> rotntj r`gn�{ts'dI \vet G.,v` . Rr . 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