38B-182 (4) 25 FORT ST BP-2019-0980
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B- 182 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Catelox� Porch Repair BUILDING PERMIT
Permit# BP-2019-0980
Protect# JS-2019-001611
Est.Cost: $4000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License:
Use Group: BENJAMIN SYLVIA 097008
Lot Size(sp.ft.), 5532.12 Owner., KIM MIA C&MICHAEL G SULLIVAN
Zoning, URB(100)/ Annlicank BENJAMIN SYLVIA
AT. 25 FORT ST
Applicant Address: Phone: Insurance:
123 MONTAGUE RD (413) 768-8393 SOLE PROPRIETOR
WENDELLMA01379 ISSUED ON:3/8/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.RESUPPORT PORCH AND SECURE FRAMING
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: 91. 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:
FeeTvpe: Date Paid: Amount:
Building 3/8/2019 0:00:00 565.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
j-6 n Department use only
City of Northamp on R E C E I UI Pe It:
•.�✓ " BuitdingDepartm nt Permit
a
212 Main Stre PdAN / tic v ilabuxy
Room 100 6eg A eb3iry
•a Northampton, MA 0 06 of S aural Plans
phone 413-587-1240 Fax 13- 7 _ i�mn (Plan
—� NOr',A�n�-on. ^
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Procerty Address: Q This section to be completed by office MaP49�_ Lot /_Unit
�a �� MA GiGbG zone O"dayDls
Ehn St.Distrkt Ca District
SECTION 2•PROPERTY OWNERSHIPIAUTHORQED ilGENT
2.1 Owner of Record: Si 11
Ml koe 5u11rJ0.�1 �S It61r�- T" �Os�^'1CL✓��on MA 81060
Name(Print) Current Mallir�gAddress:53
L4 l3—'S�d - t l•
1 Telephone
Signature
2.2 Authorized Agent:
22 :tkr�;r S.rluil 123 Mg., r,c z Tc!
Name(Prim /n7 �n Cana/nt'MeNlig Adtlrass: )
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
wm leted bv pernnit applicant
1. Building NOQO.— (a)Building Permit Fee
2. Elechical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) IA
5.Fire Protection
6. Total=(1 +2+3+4+5) (,(,7 , Check Number
This Section Fw Oficial Use Onl
Date
Building Permit Number: lssued:
Signature: 7-O -ZD lq
Building Commissioner/Inspector of Buildings Date
&-asy� r�1 I sw @y tv'10 6
�
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION S DESCRIPTION OF PROPOSED WORK fcheck all aoolicable)
New Nouse ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doo13 1
Accessory Bldg. ❑ Demolition ❑ New Storrs 101 Decks IC7 SMIng 101 Other ICI
Brief Description of Proposed
work j ..,,,�_+ Porti a• d Secel'e -Erit,n.��.�r,
Alteration of existing bedroom_Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basemen Yes No
Plans Attached Roll -Sheet
So. K New house and or addition to exlstina housing complete the foDOwina:
a. Use of building :One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is Mere a garage attached?
d. 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. Massoheck Energy Compliance form attached?
h. Typo of construction
I. Is construction within 100 fl.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_ CitySewer Private well City water Supply_
SECTION To-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, fAl Ket S IIv'/� .as Owner of the subject
property
hereby authorize TI n A&Aen 9, 13' Su I V A
to act on m If, m all matters relative to work autho ed by this building permit application.
Sidnatum of Data
I, 1�2✓A,e wit '^ Jy��(7161 ,as Owner/Authorized
Agent herob declare that tit statements and information on the foregoing application are We and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
7"eWfeCI�ZZk 3 Wil%
Slgnef w/Agent Date
Section 4. ZONING Ail 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 Depamnent
Lot Sim
Frontage
Setbacks Front
Side L: R U R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Cot area mines bldg&paved
kin
#of Parking aces
Fill:
volume&Location
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 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 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(deanng, grading,(5 or w filling)over 1 acre or is it pad of a ixrmmon plan
that will disturb over t acre? YES O NO V
IF YES,then a Northampton Stan Water Management Permit from the DPW is required.
SECTION S-CONSTRUCTION SERVICES
&7 Liowmd Corldwd lon SpuoeMaor: Not Applicable ❑
Name of Lldeme Holden lFeM✓xw�;� V�U l C S-097000
License Number
is,Al,aL� fwd s131�ac
Adlro Explr to
,�� �el� M ot�l 1
Signature Teleptwoe
w vim`A4", Vi ;
p.Rodfahrod Noma Imprw"nt Contractor: Not Applicable ❑
Ib37)�Q
Comoenv Nome Regisbaaon Number
Atldress Expir do Dale
'-.3 ��B A,� ce ��Eti ��� �� Telephone JaI&A""93` 5
SECTION 70-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MAL c.152,§25C(e))
Workers Compensation Inswanca affidavit must be completed and submitted with this application. Failure to provide this affidava will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... O No...... ❑
City of Northampton
Massachusetts F
l 'I DEPAR1MMf or aozrorac rnsnscrzoss d m
212 Main SL t • amicipal funding
\R, 9oitEagpton, MA 01060 by xy^
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 few 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 ownero cupied 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.
Nate:If the homeowner has contractedd
with a corporation or LLC,that entity must be registered.
Type of Work: (4.IM Gyle 1 fLe, I Est. Cost '1CQ--I- O
Address of Work: �S Fct S1 t ft''tidvarhpfd^
Date of Permit Application: 7 '.)-t I f T
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.SUCH OWNERS ALSO ASSUME THE RESPONSBILITES 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:
� 7 601 I u� �,;� s�l�t�� 63�aP
Date Cowtort Name I 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
' .� DaPAR2NNUT OF BErXWXNG INaPaCTIDNa 1`
212 Nein Stink • M ieipnl Building
rt North�eg+ , " 01060
Massachusetts Residential Building Code
Section 110.R5.1.2
Homeowner: Person (s)who own a parcel of land on which helshe 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
,d
Massachusetts
DWARDWIT OF aU=XM XAMECTZORa 2
.p� 112 amain 9t t 016micipal
QBoildinq cDn
Rortemptoo, 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:
No1�-�,��o{v�. na c�obo
(Please print house num and street ame)
Is to be disposed of at: f
we�lel� �rwSFCf ah ,-�e4,tjj t A 0071
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
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.
'<a"\ The Commonraralth of Massachusetts
Department of IndustriallAccidents
1 Congress Street,Suite 100
Boston,MA 02114-20177
rvww.massgov/dia
Wv orken5 Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FRED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/organintioMndividuuaal): pot t'iyLt, .-v S,/�F 1' .
Address: 1 23 ol,0
Ci /State/Zi W rMdel �`131� ��
Are Y.av employer?check it.ap iniad k boa: Type of project(required):
1.Q l em a e i laym witb`employes(fall andlor Part-time)." 7. []New conslNction
25alamasok proprpkrmparmerehiP and leve no employees workisg f«mein 8. Remodeling
any capacity.plo warkesa'comp.insumvee mquimd.)
3.Ol am abmt wnmM aU wale U. 9. ❑Demolition
ag myae Mo warkm%comp.lauancc mgwrd]r
4.❑l gin a hanawmar ad will be birmg covvackrs to conduct all work on my PraPe tY. 1 will 10 O Building addition
rnaam that all wrd ackrs tither lave workers'cm peasa m itmmmmae m arc axle 1 L[]Electrical repairs or additions
pruphot with noemployees.
12.Q Plumbing repairs or additions
5.0 I.. ad l lave Nrd the submntractms lived on the attadied sbeet 13.�Roof repairs
These ash- ratoalave employem and bave woflcm'comp.imae e.:
6.[]W, 14.QOther
152reI(4),
and we lava no employees.Mo w.kms'pomp.amamnoe ralain,d]
'Aey applicant Nat checks box#1 mum elan fill at the action below slowing du:b wadws'mmpearnon policy information.
t Homeowmors who aWmit this affidavit indicating rise,are dais all wmk end dan hire ouaide canaaclass must a taint a new affidavit iedirdting such.
=Contractors Nat check Nis box moat attached an additimal sheet sbowimg the same oftbe ab-warmmn ad mak whether m not those afifies havc
employees. If ft sub aaawtai lave employees,Ney It pmvidc their workesa'comp.policy number.
I aax ap eapioJrr flat rs providing workers'copapatsalion insawnce for my eaapla)'ees. Below is the poUey and job site
informadom
Insurance Company Name:
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compeosatiou policy declaration page(showing the policy number and expiration date).
Faihrte to secure coverage m 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 statemem may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby caWfy ander the palm and penahies of perjury flat the lnformadon provided above is nae and corre[x
Sumstlte, ' i Icui`ek,e n -r� l I,A- Date
Phone# yls -766,-P 3 1 S
OQiciai use only. Do not write In this area,to be completed by city or town of eklL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityrfown Clerk 4.Electrical Inspector 3.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers in provide workers'compensation for their employees.
Pursuant to this statute,an employ"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 otum 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 in do maintenance, construction or repair work an 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 slates that"every state or local licensing agency shag withhold the issuance or
renewal of a license or permit to operate a business or to construct bugdhW 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)annuls),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 orpartners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employces, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Aho he sure to sign and date the allidavit. The affidavit should
be returned to the city or town that the application fm 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 pemti7license number which will be used as a reference number. In addition,an applicant
that must submit multiple pemrullicense 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
I Congress Street, Suite 100
Boston, MA02114-2017
Tel. #617-727-4900 ext.7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia