43-153 (5) 17 HAWTHORNE TER BP-2019-0920
GIs#: COMMONWEALTH OF MASSACHUSETTS
MV-.Block:43- 153 CITY OF NORTHAMPTON
La:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Categorv:Plumbing BUILDING PERMIT
Permit# BP-2019-0920
Praiect# JS-2019-001514
Est Cost:$9000.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use croup: Homeowner as Contractor_
Lot Size(sg. it): 43995.60 Owner. JANKOWSKE MARK
Z nip : Applicant. JANKOWSKE MARK
AT. 17 HAWTHORNE TER
Applicant Address: Phone. Insurance.
17 HAWTHORNE TERR (540)239-7168 ()
FLORENCEMA01062 ISSUED ON:3/412019 0:00:00
TO PERFORM THE FOLLOWING WORK:BASEMENT RENO
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 sianature:
FeeTvve: Date Paid: Amount:
Building 3/4/2019 0:00:00 $65.00
212 Main Sheet,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2019-0920
APPLICANT/CONTACT PERSON JANKOWSKE MARK
ADDRESS/PHONE 17 HAWTHORNE TERR FLORENCE (540)239-71680
PROPERTY LOCATION 17 HAWTHORNE TER
MAP 43 PARCEL 153 001 ZONE
THIS SECTION FOR OFFICIAL.USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled o t
Fee Paid
Typeof Construction: BASEMENT RENO
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOL1,0WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION PRESENTED:
Pproved_Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Pin
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:
Curb 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
Demolition Delay
r _ _ 3- 4-Wlq
Signa re of Building Official Date
Note: Issuance of a Zoning 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.
Department use only
City of Northampton Status of Permit
Building Department Cum Cut/Dmreway Permit
212 Main Street Sewer/Septic Availability
Room 100 WaterNyell Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413587-1272 Plot/Site Plans
fy
APPLICATION TO CONSTRUCT,ALTER,IREPR,REMODSH ON OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION FEB 2 5 2019
1.1 Property Address: 17 (Jit .1J d m c This s 'on o be completed try dapr7 f✓Ih /I J-k OUTOF&11LDINOINSPECTIONe
RIANOPTON,MAOIM ( �� '/�� Unit
FIo.P.t 4e , M A lO
Zona Overlay District
Elm St.District CB Dlatrict
SECTION 2-PROPERTY OWNERSHIPIAUTHORUED AGENT
2.1 Owner of Record:
moIrK 'S&Akgwske- /7Ffawit~dnt•
Name cPnnb Current Mailing Address: Sy -7168
elephone
Signature
2.2 Authorized Agent:
Name(Pent) Cunenl Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 2,000 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
T 3,00o Construction from fi
3. Plumbing I 0O0 Building Permit Fee
4. Mechanical(HVAC) N1,4 4 J
5. Fire Protection
6. Total=(1 .2.3 i 4.5) OOU 1 Check Number Mir
This Section For Official Use Only
Building Permit NumbeDater �l
Signature: 3-LI-2og
Building Commissicner/mspectur of Buildings Date
rn tri 111 k Ow SKS- AIMa; I Corvl
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Must De Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Tbiv..Lino to be filled N by
Budding Dapurmcur
Lot Sim
Frontage - - —
Setbacks Front
Side L:tt—_ . R: CR: , —
Rear
Building Height - ---
Bldg.Square Footage %
Open Space Footage % --
lta ar a nous We a paved _ .... _.
pario..)
#of Par-Ling Spaces
Fill:
inion"&LocMian
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES Q
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 Pageand/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 soolicablel
New House ❑ Addition ❑ Replacement Windows Alteration(s) Rooang ❑
0r Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [O Siding[0) Other[p]
Brief Descripgqon of Propo
Work: ICewoy�.fc aseaa.f HaK� drvk.x.\ !_j A,PI&Ls4i dr. &Kc(ose- rsteckd.ly(It'ECtmd
Alteration of existing bedroom_Yes ✓No Adding new bedroom Yes ✓ No
Attached Nanaeve [s Renovating unfinished basement L�Yes No
Plans Attached Roll -Sheet .toe cx IVAc�n✓ry
ea. If New house and or addition to existing housing- complete 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 stories?
I. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance farm attached?
h. Type of construction
I. Is construction within 100 R. of wellands?_Yes _No. Is construction within 100 yr. floodplain_Yes_No
p 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 COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Dab
I, M6,0C J C"In.4w5 k-¢- .as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and aaurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
116arK �aWkewsKe
Print Name
;I/1-71,q
Signature or 2fm End Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder'.
Uceme Number
Address Expiration Dale
Signature Telephone
9.Realstered Home Improvement Contractor: Not Applicable
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 18-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(e))
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
' r..
Massachusetts
lAPAATq.NT OF z BUILDING INSPECTIONS �t
212 Min etxwt • Mw 0Building
uvp
Naxtlten, !P 0101060 ��pT
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, rcvwvafim,repair, modernization,conversion,
improvement,removal,demolition,or construction of an addition to any pre-existing avner-occupied building containing
at least one but not more than four dwelling units....or to sbuctures which are adjacent to such residence or building"be
done by registered contractors.
Note:/f the homeowner has contracted with a corporation or LLC,that entity must be registered.
Type of Work: OOSem,,AA t'Q.rlova+ieN Est.Cost: 9i0o"
Address of Work: 1-1 Tes rq ce. F(orence� AAA 071062
Date of Permit Application: Z (2o (l0
1 hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
lob under$1,000.00
✓Owner obtaining own permit(explain): &5—w reitoy-' i.A
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:
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice, 1 hereby apply for a building permit as the owner of the above property:
21-2t, 119 etv vowsk-
Date Owner Name and Signature
City of Northampton
.>f Massachusetts
c
.'� DBPAN1SLrMr OF BUILDING INSPECTIONS 2
212 Win Str t • l icipal Building
porthn ton, W 01060 ✓--yjPo
Massachusetts Residential Building Code
Section 110.115.1.2
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.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
Massachusetts
KPAR1fffiVT OP BOIznIaG INSPIiCTIOtiS _
212 Hain Str t •ppu,iciWl e iltl n9
NnrNa ten, i 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, 554, 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:
('I I-{yi inil'�lvk -rey.,c i 7 1otf L , M4 0(06 n
(Please print house number and street name)
Is to be disposed of at:
V0"Iv eryc�,lna a�3 ( Frilly plwiiv({ } O(OCO
(PI ase print�nam d location of facilhy) _ 7
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
2(Lo( Iq
Signature of P 7
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.
�L\ The Commonwealth of Massachusetts
V-11forkers'Compensation
Department ofIndustrialAccidents
1 Congress Street,Suite 700
Boston,MA 02!14-2077
www.massgov/dia
Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information ,A� Please Print I"Ibly
Name(Business/Organizatiowindividual): mo-r-K 3al4�ot..tkC
Address: 1"1 Raw+Wrw, Terrace
City/State/Zip: RpreAcL ,AA 01062 Phone III: 540' o�3q- -11 8
Are you as amployer^clack Ne approprlmn boa:
Type of protect(required):
I,[3 lama empbyer with dtmloy e,("I audlor put-pmol' 7. ❑New construction
2 F l..sole pabandon,vamership and have no employees working for me in 8, elf odeling
y capacity.(No work.'comp.use. natural]
3.� wwur a homdoutg all work myself[No workers'e",convince m,minstl' 9. C1 Demolition
V.�a no...and will be hard, m
ing coanon m emtduct all work on my property. all I w 10❑Building addition
sere dut.d canuactors main,have workers comcemation insurance or are sole 11.❑Electrical repairs or additions
pmpriemn with rat empbym.
12.E]Plumbing repairs or additions
S{:]Ians.generalomuthave a lhave epeadave worlhacmrs l,insun Ne atvcbedshxet 13.E]Rmf repairs
Tbese subconmumn have employed and have workers'comp.imwence.
b.❑Wc aeacmpom..n .uoffershaveexmiudnnwdghtofenempfion per MGL a 14.❑Other
152,IIla),and we have we atployees.(No workers'c W.man.moored]
'Any applicant Nat checks box dl mus[also fill out the section below showing thew workers'compecasom policy infonoatim,
'Homeowners who submit Nis affidavit indicating they are doing all work and Nen hire outride nmbLcton must submit a new alTduvit indicating such.
$'onnacmrs Nat check dr,do matt m ached an addipanel sheet showing be name of be su4eonhveners and some whether or nm Nose bddmd have
emplovess If the o bcon mecum have employers,day mattprovide their workerscomp,policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below u the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/Statelzip:
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,g25A 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 hoeby certifgqy,�Junde��r fh pain//s a penddes of perjury Mat the informaaon provided above is true and correct
Sienature: OXoa f+ a^"'e' "'�� Date. Z�201/9
Phone 4: SItD-;, (�
OjjiciaJ 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):
I.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 othm 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,p25C(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),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,arc not required to carry workers compensation insurance. If m 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 permittlieense 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 Cornmonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel.#617-727-4900 ext. 7406 or I-877-MASSAFE
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 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 152,525C(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,p25C(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 your insurance company's time,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 LIT 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. Alan be sure to sign and date the dfidaviL The affidavit should be retnmed in 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 m 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 permi0mcnse number which will be used as a reference number.In addition,an applicant that
must submit multiple permit/liceme 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 m the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
mus[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.
'I he Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Deparhnent of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel.It 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
www.mass.gov/dia
Form R<viacd W-2l-IS
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