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38B-002 (37) 15- 17 PAQUETTE AVE BP-2019-1020 GIS 4: COMMONWEALTH OF MASSACHUSETTS Man:Bloc : 38B-002 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Perm t: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit BP-2019-1020 Proiect 4 JS-2019-001673 Est Cost$6000.00 Fee_ $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group JEREMY SAWYER 106836 Lot Sin(sa R.): 95962 68 Owner: SAFE JOURNEY LLC Zodnw URC(100)/WP(14)/ Applicant, JEREMY SAWYER AT. 15 - 17 PAQUETTE AVE Applicant Address: Phone: Insurance: 121 WEST STATE STREET (413) 478-1536 WC GRANBYMA01033 ISSUED ON:3/19/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE ROOF - 1500 SF 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 4 Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: 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 3/19/2019 0:00:00 540.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner FFS�C ` rL �r / City of No amlit EEC L- bre" Permit ! _ - Building De art n Perms 1 : i' t9. I 212 .in tre t MAH 1 y 20'9 ,l I��A '_ 'l Room 00 W Aver% 1� Northampton, A 0 060 Swr irRlplans t`: phone 413-587-1240 ax ro iHam..;, c+ rtr APPLICATION TO CONSTRUCT, ALTER REPAIR RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLINGSECTION 1 -SITE INFORMATION 16/7n^(0 1.1 Property Address: This section to be completed by office /5-77 Psv;r Ht duL Map Lot COO— Una Zone Overlay District Elm SL District CB District SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: S Air �og r�rcS ��. 3 ydg 1/ern, , S-f- N=-t Name(Pnm) ' Current Mailing Address: T Telephone Signature 2.2 Authorized Agent: SC /d / cJ S ft f e S (rc. 41 oio_r Name(Print)se Current Meiling Atldress'. re Telephone SECTION 3.ESTIMATED CONSTRUCTION COSTS Item Estimated Cast(Dollars)to be Official Use Only cam letedb emnit applicant 1. Building ! mc::) (a)Building Permit Fee 2. Electrical b (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) ic, 000 Check Number „Z2 t This Section For Official Use Only Date Building Permit Number. Issued: Signature: Builtling Commissioner/InspeRor of Buildings 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 fil1M m by Buildmg Deparmsent Lot Size Frontage Setbacks Front -- -- —' Side L_R:— L:=R= Rear Building Height Bldg.Square Footage - % -'-- Open Space Footage % _ --- (Lot area minus bldg& xved arose #of Parking Spaces ----- ---- — Fill: (volume&Lvcvtiovl A. Has a Special Permit/Variance/Finding ever been ssued for/on the site? NO O DONT KNOW © YES O IF YES,date issued: IF YES: Was the permit recorded at the Regist of Deeds? NO O DONT KNOW O YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of wa or wetlands? NO Q DONT KNOW © YES IF YES, has a permit been or need to a obtained from the Conservation Commission? Needs to be obtained Q Obtained O , Date Issued: C. Do any signs exist on the propert . YES O NO IF YES, describe size, type a location: D. Are there any proposed ch ges to or additions of signs intended for the property? YES O NO O IF YES, describe size, pe and location: E. Will the construction a vity disturb(clearing, grading,excavation, or filling)over 1 acre or is it part of a common plan that will disturb over acre? YES O NO O IF YES,then a N ampton Stand Water Management Permit from the DPW is required. SECTION S-DESCRIPTION OF PROPOSED WORK(check all aoolleable) New House ❑ Addition ❑ Replacement Windows I Alteretionls) Roofing 01 Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [O Siding[0] Other[cf] Brief DeWriplion of Proposed ,'S�(q S g - Work: CSP o e_z sf -� aA /o Q„1- 5- Q p/ r - �/, 4e, GfIF S41-, Ir 01m AlterabOn of existing bedroom_Yes X No Adding new bedroom Yes X No Attached Nanabve Renovating unfinished basement _Yes >— Plans Attached Roll -Sheet 6&If New house and or addition toexisting housin eo tete 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? n o 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 form attached? h. Type of construction i. Is construction within 100 fl. of wetlands?_Yes _No. Is construction within 100 yr. Floodplain_Yes_No j. 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 Privatewed_ 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 TT // Date I, Si'rr -p as Owner/Authorized Agent hereby tled re that the s Cements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. 7 Signed under the pains and penalties of perjury. f all; Print Name re of Owner/Agent Date SECTION 6-CONSTRUCTION SERVICES 6.1 Licensed Constructions SSuoemisor: Not Applicable ❑ Name of License Holder'. ....]TCG++„ Sc,✓s e /0 6 00 3 6 License Number Address Expvahon Date � ature Telephone B.Registered Hi lmprovenrent Conbraclor. Not Applicable Cl F// z XX, ,O ,-r / 7Y fd Fr Company Name Registration Number /a / 4✓ S fc S-/- G » s . ,-9 ao3 aLs/a/ Address Expiration Date Telephone `i 7E/S3 6 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152,§25C(6)) 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 t. �ilding permi Signed Affidavit Attached Yes_..._Ak No...... ❑ City of Northampton S , - Massachusetts 3Y ➢EPANTHENT of BOILDING INSPECTIONS f 212 Mein a Nuoicipal Building V` M Northcthm�ien, !A 01e60 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 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 hascontractedwith a corporation or LLC,that entity must be registered Type of Work: Qoo��T77 n,. Est.Cost: Address of Work: IS--/7 tr'c cr rz e v L Date of Permit Application:— /S' —/ 5i 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 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: Date Owner Name and Signature City of Northampton Massachusetts A3' S- s`sr DEPARTMENT OF BOILDZNG INSPECTIONS 212 Main BtreeiMu icipal Building NoiNampton, `.W 01060 �jl'16 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 110.85.1.3.1 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 persons) you hire to perform work for you under this permit. i City of Northampton Massachusetts 1 DEPARTI6A`T OF BDZLDZNG ZKS CTZONS p 212 Main Strut a Municipal Building V<, dra Northampton, 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 and street name) Is to be disposed of at: /UD ry IS G (Plefeprn � pand /ation u en Sf -S�frnS -F/r/✓ /hfJ O/i Dom/ of facility) Or will be disposed of in a dumpster onsite rented or leased from: nlm �fA"/� / n, s�B��� (Company Name and dress) Sig�Applicant o-r-aw—ner 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 Will-orkers' Department ofIndustrialAccidents l Congress Street,Suite 700 Boston,MA 01114-1017 www.mass.gov/dia Compensation Insurance Affidavit:Builders/Contraaors/Electricians/Plumbers. TO BE FILED WITH THE PERMFfITNG AUTHORITY. Applicant Information Please Print Lenlbly Name(Business/OrgmizatiowIndividual): e < t Address: J -ife, City/State/Zip: rRn /" oto77 Phone#:_ �71] /S36 Are you an employer?Check the appropriate box: Type of project(required): La am a employer with employees(full and/or parttime)! 7. E]New construction 2 I am a sole proprietor or pxrmerswp and have no employees working for me m S. ❑Remodeling my capacity_Mo workers•wmp,assurance require] 3.❑I am a homeowner doing all work myself [No worker tempmoureaee required.] 9. El Demolition 4.❑I am a homeowner and will be,living rechristens to conduct all work on my Pe YI wan pro 10[-]Building addition . car othat all contractors ower have wotkera'rompevsannn lummce or Me sole Il.❑Electrical repairs or additions proprietors waw no employees. 12.[:]Plumbing repairs or additions s I am a gemml anther er and I have Each the sob-cononemrs Istel on the Muched all 13.'�AOOf repairs These tanve vacmrs have employee and have workerscomp.Insurance. 6 W are acorppmdou and its offcm have exercised the.nght ofexempron per MGL r. t4.00ther 152,§p4),and we have no employees[No workers'comp.msmsnce mgvved] .,any applicant rest chinks box 41 must also fill out the section below showing they workers'compemadon policv Morocco— 'Homeowners who submit teas affidavit indicating they are arms all work and wen have o reme contractors most submit a new affidavit entreating such. TC..m chat check this box must attached an addwonal sheet ahowing the mane ofmo sub-covtrnaors aad tote whether or not those no.have employees. Ifthe subconnacers have employees,they must provide then workers'wmppolicy number I am an employer that is providing workers'compensation insurance far my employees. Below is me policy and job site btformufion. // t Insurance Company Name: TAt P., l "7 o f pe Policy#or Self-ins.Lia#: (r SFO D 13 dF/a6 /d -e / ;6- Expiration Date: y�6 h 5 Job Site Address:js-7) City/State/Zip:Ar��� pn .Mf1 Attach a copy of the worker compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL a 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 certify under the pa an penpldes of perjury that the information provided above is nue and correct Signature' Date: $-/$ -/`/ Phone#: y7 � fs3� 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.Cityrfown 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 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 sub-contractor(s)morels),address(es)and phone numbers)along with their cenificate(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 most submit multiple permMicense 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 burn 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. #617-7274900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia JEREASA-01 Nicol CERTIFICATE OF LIABILITY INSURANCE UB111 THIS CERTMKATE IB ISSUED AS A MATTER OF INFORMATION OWY AND CONFERS NO RIGHTS UPON THE GERTNIGiE HOLDER.THIS CERTIFICATE DOES MOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTIUrE A CONTRACT BEITNEFR THE MUMS INSURER(e),AUTHORR2ED REPRESEITATNE OR PRODUCER,AND THE CERT54CATE HOLDER. IMPORTANT: MOm OerUff b otderban ADDffh) LLMSURFA,1Mpo8cy(b )must Mva ADDnMNALNSUR prMWNerMmda . N SUBROGATION M WANED. subied m tlm bmla and COrl®Bons dllre po11T,4rb61pWkb amY reOfrbs an antlomlrMrlt Aabtamantan Urb eartleaats mw not cblbr hb b tM rertlglas nalder N Mau damn w.a pRgpApr Nlmbe hey Phillipa baurarWa Aaeney,No. RM 419 5946980 X, .(413)582414M 97 canbr S~ Nede®phABpaLAwmnce.com U cans. YA01013 ARQaWf.COY6NOE NNCa w:Weetam Wm1G hMumfee CO. abaRm e:SelecBve IOM Cc of South Caro Jeremy A Samyar Ona aaMm E:The Hartford AN E,cteriora 121 Waat Stab Snort moo' Granby,MA 01033 NNIMa E: aaaaaal COVERAGES CERTIFICATE NUMBER: R VHRON NUMBER: THIS IS M CERTIFY THAT THE POUCHES OF INSURANCE USTEII BELOW NAVE BEEN ISSUED TO THE INSURED NRAEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWTHSTANDNG ANY REWLRSWIENT, TERM OR COMImON OF ANY CONTRACT aR OTHER OOCI94�(TVATH RE9PECTTO WHICH THIS CERTFXi1TE NAY BE ISSUED OR MAY PERTAIN, TLIE NSt1RPNCE AFPORDED BY TIE POLICIES DESCRIBED HERENISSUBJ TOALLTHETERNS. E%CLUBIONB AIIDCONDDIONS OF SUCH POLICIES.UMTTS SHOWN MAY HAVEBEEN Rk7J000ED BY PAD CIANs. limn TYIEOFNmMMICE Pa1lCYalalt?ER eff POkY URa A X cnrramwLoemewLuaeam F N 1.000.000 CWNaMPDE OX PP832894t 06103/2018 oemomm019 oFAIN'E1oPE0f® s 100,000 w®Elw t 5.000 PFAEDWIa ADV NuuRY E 7.000.000 CExLAamEwTe LaR WPUFS Paz oINIgo�oriE t 2.000.000 �1Y❑P� ❑Lac oAowcrs-��� 1,000,000 oma: 8 AuroMmlEUAmm m�raew®RHot6twr f 1.000.000 ANY wOTO 9105120 04/1812018 001812019 amLvnUum MmIT09 CflY X IU109 BWLYINAAO E X AMb Y UaaR UWA MMREAC ocuw FACE N ELVa AGGflEGATE DEO rR/F s C c wATpmI, X "ER X Y/a WUI12Et2N2-8-1e w1mots Wte g EL uc.,rccmm.r t.0oo.000 �Ea'CDmm1 o a,A F1.01¢A`E.FAE 1.000.008 r m�OF ELOISFAg-POI.ICf—ar 6 1,000.000 eIaGTI1OX W MGAIpNa/LOCATpNa/WIIILL®p.R'aalm.MltlpallmMrEtlwm4,a9'b matJlMtlnanrp�u 4ngbtl) CERT11FICATE HOLDFR CANCELLATION 8HWLOANY OF THE wBOYE MBCIBBtD POMGIE88E CANCELL®BEFORE THE E RARON DATE THEREOF, 00110E POLI. SE DEINEREO N ACCOMANCE WRII TIff POMY PROWSONS. AOmpo AWrE9FMATWE �✓Y yjl, h.y ACORO 25(201003) C 198&2015 ACORD CORPORATOR. AU dghb raaerved. The ACORD name and logo are registered marks of ACORD CavlonwsaAh of Moss Usens u / Division of Pmiessional Licensure Boardof BuNing RegWmm.and StaMtsrds Construction SaWmisor HOME IMPROVEMENT CONTRACTOR CS-106536 Flukes:0612St2020 JEREMYSAWYER 121 W STATE ST JEREMY SAWYER ,�:: GRANBY,MA 01033-9614 # UI WESTSTATESTREET GRABBY MA 07033 _ L�.IREG r -�kPi1TE3--. 1IIC.0636067 12/01/2017 11/30/2018 Commissioner - ..----^- .,., gMaof E impRo Amew COMTR CTOR en MpME MPw EMEdMdJW RACTOR TYPE:IYi9dExa 10 i9 TEKYSAWYEA p AALI EXrSFf AEREMYSAWYER 121 WEST STATE ST GRANBY,MA 01033 Undsr$0CretWY All Exteriors aofing, Flat Roofing, Siding, Windows, Repairs, Snow Plowing 121 W State St Granby, MA 01033 MAH.LCRegk atkM#17462# CTH.LCReghtrzdon#MM67 MACorttruction Supervaomi-kenm#106636 Thomas McCarthy 8/3/2018 3 Broderick St Easthampton MA 01027 Paquette Ave Northampton Roofs 1) Remove the existing roof down to the deck and dispose of the debris in a proper landfill. 2) Inspect the decking and replace any bad sheets for$55 per sheet of plywood used. 3) Provide and Install 6'of new Ice&water barrier on the eaves. 4) Provide and install new felt paper on the remainder of the roof deck. 5) Provide and install new white F8 aluminum drip edge on the eaves and rake edges. 6) Provide and install new starter strips on the eaves. 7) Provide and install new GAF Timberline HD(lifetime warranty)architectural shingles to the manufacturers'specs in the color chosen by owner.Color: 8) Provide and install new GAF ridge vent and cap shingles on the ridges. Provide Owners with a 10 yr workmanship warranty on the work completed. 16-18: Contract Total:$6,800.00 Down Payment:$2,267.00 Balance Due Upon Completion:$4,533.00 21=23: Comb-act TotaF.$8,000.00 Down Payment.$2,667.00 Balance Due Upon Completion:$5,333.00 15-17 Contract Total:$6,000.00 Down Payment$2,000.00 Balance Due Upon Completion:$4,000.00 All 3 Buildings Done Together. Contract Total:$19,000.00 Down .$6.333.00 lance Due Upas Completion:$12,667.00 q bu116 Estimates are honored for 60 days from the e. 1 # L L 1 Acceptance Of Proposal: The above prices,specdications,and conditions are satisfactory and are hereby accepted. You are authorized to complete the work as specified. Payments will be 1/3 down at the contract signing and the balance the day of the job completion. Estimated start date:10/1/2018 Estimated completion date:I2/1/2018 Date: Owners Signature: 7' Date: Estimators'Signature: (413)478-1536 X17 at, -��_S,. ._ g, . ��j°�® °'` m � �' + 16- 18 PAQUETTE AVE BP-2019-1019 GIS#: COMMONWEALTH OF MASSACHUSETTS May,Block: 3813-002 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 ft BP-2019-1019 Proiect4 JS-2019-001672 Est Cost:$6800.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JEREMY SAWYER 106836 Lot Size(sp. ft.): 95962.68 Owner: SAFE JOURNEY LLC zoning: URC(100)/WP(14)/ Applicant. JEREMY SAWYER AT: 16 - 18 PAQUETTE AVE Applicant Address: Phone: Insurance: 121 WEST STATE STREET (413) 478-1536 WC GRANBYMA01033 ISSUED ON:3/19/2019 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF - 1600 SF 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 3/19/20190:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner r EIV -I 60 t= Department use p* City of Northa pton Pe It Building Depart ent MAN y ZGwbC I,. yPan. 4 Ir 212 Main Sir t to vel » Room 100 rr it �,,�i, Wo§f ellA f Northampton, MA 10BC€PNoamAs i0 of San bural Plan- 4 lan- _. phone 413-587-1240 Fax - 2 Plofteba Plans Other Sperafy APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION ,16 10/ 1.1 Property Address: This section to be completed by offim / 6,i4 09 n'peflc A✓L Map 3q6 Lot 00-�- Und Zone Overlay District Elm St District CB District SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Ss-ff JTe (r 1< 5 /A'& 3Vt/no, S4 Ner1�.Win {-, mN. Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent, r .... SG, c e 6ia� l9/f 6/o7 Name(Print) Current Mailing Atltlress'. v� s-is ter_ TelophOne SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com ieted by permitapplicant 1. Building �OO (a)Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from fi 3. Plumbing Building Permit Fee 4. Mechanical(HWVAC) ! 0 5, Fire Protection 6, Total=(1 +2+3+4+5) 6 P'o0 Check Number t This Section For Official Use Only Building Permit Number: DateIssued: Signature: 3- Iq. zo19 Building Commissionedlnspectar of Buildings 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 m be fiI1M in by Building Dcroon,nt Lot Size Frontage Setbacks Front Side L R U R. . Rear Building Height --- Bldg.Square Footage Open Space Footage % - (Lot area minus bldg&paved rkm #of Parkin Spaces Fill: (.olnme&Locmina A. Has a Special Permit/Variance/Finding ever been ssued for/on the site? NO O DON'T KNOW Q YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW 0 YES O IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of wa r or wetlands? NO O DONT KNOW O YES IF YES, has a permit been or need to a obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the propert . YES O NO O IF YES, describe size, type a location: D. Are there any proposed ch ges to or additions of signs intended for the property? YES O NO O IF YES, describe size, pe and location: E. Will the construction a Idly disturb(clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan that will disturb over acre' YES O NO O IF YES,then a N hampton Storm Water Management Permit from the DPW is required. SECTION S DESCRIPTION OF PROPOSED WORK(check all aoolicablel New House ❑ Addition ❑ Replacement Windows Alterations) Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [Di Decks [O Siding [0] Other[0] Brief DeWiption of Prop"" C D�o/P<'�' {'f Work: LCP O L CX S�' A 3+ Q `Y Q f �� �A!< S.t•elf Alteration of existing bedroom_Yes X No Adding new bedroom Yes S No Attached Narrative Renovating unfinished basement Yes >C- No Plans Attached Roll -Sheet 6a.M New house and or addition to existin housin Com late the followin : a. Use of building: One Family Two Family Other b. Number of roams in each family unit: Number of Bathrooms c. Is there a garage attached? fl o 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 form attached? h. Type of construction Is construction within 100 ft. of wetlands? Yes _No. Is construction within 100 yr. floodplain_Yes_No j� 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 Date 1 J f i / O 819 A// as Owner/Authorized Agent hereby decl re that the s Cements antl information on the foregoing application are true and accurate,to the best of my knowledge 7 and belief. Signed under the pains and penalties of perjury. Sc Print Name 3 / 14 re of OwmerlAgent Dale SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor; Not Applicable ❑ Name of License Holtle ') ig 6 rF 3 License Number c> e s G t, 6 ,o s/a6 /ao Atltlress Expira[on Date � ature Telephone 9.Replatered Home Impravemnnt Contractor: Not Applicable ❑ /i// Zx,c, r,o r_r- / 751 b= Company Name Registration Number /a / t✓ S <c S7 G, s m 9 o. ov3 a/2s/a/ Address Expiration Date Telephone '1,2,1 G SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.O.L.c. M §25C(6)) 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 pennit. Signed Affidavit Attached Yes.......AV No._... ❑ City of Northampton Massachusetts ( ' ) : �., DXs8f O BUILDING INSPECTIO 212 NS 7 . 232 Hein te • Maicipal auilQing xy b NartTampeon, MA Oleee 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, atterchan,renovation, repair, modernization, conversion, improvement,removal, demolition, or construction of an addition to any pre-existing owneooccupied building containing at least one but not more than floor dwelling units....or to structures which are adjacent to such residence or budding"be done by registered contractors. Note:Lf the homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work: UGoo Est Cost: Address of Work: 4-'e' C_xtt, q_ vL Date of Permit Application: / 2— I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain):_____ Sob under$1,000.00 _Owner obtaining own permit(explain): _Building not ownevoccupied _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: Date Owner Name and Signature City of Northampton Massachusetts 1� G s 212A xnS OF BoI nlaG INSPECTIONS 232 Main Street • Municipal Bniltling v � • NavNamp[en, Ma 01060 Massachusetts Residential Building Code Section 11025.1.2 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 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 persons) you hire to perform work for you under this permit. City of Northampton r� ,s M899dChll9eii9 G x D212N LnS OF BUrLDING Municipal INSPECTIONS Z j^ 212 Mein Street nn, n ipel Building No[Mampton, !A 01060 bpr'yjP 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: 16-rte �ty �� f/c ff, -� (Please print se number and street name) Is to be disposed of at: /UOfl!$ f� / �,spes¢/ALL -A� Sf --52(, 5 �ir/0 177e 011041 (Please print na and location of fadlity) Or will be disposed of in^^a dumpster onsite rented or leased from: (Company Name and dress) Sign -0 Permit Applicant or caner 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 Industrial Accidents I Congress Street,Suite 100 WNI-orkers'Compensation Boston,MA 02114-1017www.massgov/dia Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): _ -CCe^x, 66/9 All k�h /zfr e r P Address: / J I CJ J fG 11 If , 5-�-� City/State/Zip: K9rnnJ6f, /"0 oto37 Phone Are you an employer"Check the appropriate box: Type of project(required): Lal am a employer with employees(fulland/m part-thane)? 7, []New constmetion 2.❑lam sole MMemrorpmtnershipandhavenoempinree[working rormem 8. E]Remodeling any capacity.INo workup'comp.insurance required I J.❑lamahomeowncr doing all wode myself[Noworkerscomp.cetrranccregaired.l' 9. ❑Demolition I0❑ Building addition 4.❑lama homeowner and winbehaving Conti rs'c r cnndadall work on mi em le twill me that au contraemrs diner have workers wmpensntion inmmnceor vin sole 11.❑Electrical repays or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5r 1 am a general contractor and I have lived the sab-conuactors listed on the attached shed. 13. oof re alts noworb-vonuadom have employees and have workers comp.msucce-t IL4' p 6.❑We ere a corporation and its officer;have exewised their right of exemption per MGL c. 14.❑Other 152,611x),=it we have no employees-[Ne workers'comp_insurance required) *Any applicant that checks box#1 must also fill out the semiun below showing their workers cum enation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside cnmmctors..at submit a new affidavit indicating such. tCmandic ors mal check this bux must attached nn additional sheet showing the time of the sub-coneractom and state whether or not those entities have employeesif the sub-contractorshave employees,they must provide they workeo'comp.policy number. I am an employer that is providing workers'compensation insurance jar my employees. Below is the policy and job site information. l7,l t r'�t p / Insurance Company Name: �/f{ o/ pC Policy#or Self ins.Lic. #: / S(,p Ll6 d61a6 /a 'f/S— Expiration Date: y//�/6 Z/ $ Job Site Address: �s .—,W "ZF e City,'State/Zip:/{Isr7�(1„_A� MF1 Attach a copy of the worker compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL a 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 certify under thepaks an penalties of perjury that the information provided above is true and correct Sienature: Date' $—/$ '//i Phone> : 7 r 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,cost 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, constrection 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 sub-contractors)name(s),addresses)and phone number(,)along with their certificatc(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. Citv 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Departments address,telephone and fax number: The Cornmonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia 21-23 PAQUETTE AVE BP-2019-1018 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:38B-002 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-2019-1016 Project# JS-2019-001671 Est. Cost:$8000.00 Fee:$40.00 PERMISSIONIS HEREBY GRANTED TO: Const Class: Contractor: License: UseGrmm: JEREMY SAWYER 106836 Lot Size(sg.ft.): 95962.68 Owner: SAFE JOURNEY LLC Zoning: URC(100)/WP(14)/ Applicant- JEREMY SAWYER AT: 21-23 PAQUETTE AVE Applicant Address: Phone: Insurance: 121 WEST STATE STREET (413)478-1536 GRANBYMA01033 ISSUED ON:3/19/2019 0.00:00 TO PERFORM THE FOLLOWING WORIGSTRIP & SHINGLE ROOF - 2000 SQ FT 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: Housed 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 Occupant Signature: FeeTVDe: Date Paid: Amount: Building 3/19/20190:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner City of North mpt 4 (RECEIV f 5 O ( `° ` ti i Building Dep rtm t " Permd H r: 212 Main S reef MAA 1 9 201 Room 1 0 RP" Northampton, M 01 60 els phone 413-587-1240 F x4 _ r r.lm=n " p x 4/#i'� N09TY 41Jil^Oh 'At u "fYY,v'% " APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION I -SITE INFORMATION &P-t- lG( 1.1 Property Address: This section to be completed by office Map 3 �� Lot oQ D Unit Zone Overlay District Ehn St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: / S4'r �ec torts JA4 V-r"nc' . -+ Ner-F/. n/-o-+ mN. Name(Print) o Gunerd Mailing Address: Telephone Signature 2.2 Authorized Agent: e oro Name(Pring Cument Mailing Address'. y17-54 raffi Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Oficial Use Only completed by peoil applicant 1. Building e060 (a) Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee Wqy,UU 4. Mechanical(HVAC) 5. Fire Protection 6. Total 2(1 +2+3+4+5) 000 Check Number a t This Section For Official Use Only Building Permit Num [ Date Issued: Signature: Building Commissionetllmpector of Buildings r� Date V 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 rearam to be filled an by Building Oepvrtmem Lot Size Frontage --- -- — — --- Setbacks Front --- ---- Side L R:_ L: R .-- _—. Rear Building Height '- ' -- _-- Bldg.Square Footage ___.... % Open Space Footage % --.-.-- _ (Lot area minus bldg&paved adtiv k ofPm-king Spaces -- ------ Fill. ��---- (vvlume&Locanav7 A. Has a Special Permit/Variance/Finding ever been ssued for/on the site? NO O DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Regist 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 wa r or wetlands? NO O DONT KNOW O YES O IF YES, has a permit been or need to a obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: _.. . _..... C. Do any signs exist on the propert . YES O NO O IF YES, describe size, type a location: D. Are there any proposed ch ges to or additions of signs intended for theproperty? YES 0 NO O IF YES, describe size, a and location: E. Wit the construction a vity disturb(clearing grading,excavahon, or filling)over 1 acre or Is It part of a common plan that will disturb over acre? YES O NO O IF YES,then a N hampton Sic"Water Management Permit from the DPW is required. SECTION S.DESCRIPTION OF PROPOSED WORK(check all applicablel New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing RF Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs Iol Decks [I] Siding jOj Other(OI Brief Des�nption of Proposed a 000 s� 4V / Work. UFloviL e_x,s f..,3 _s ti ..,3/e 0m..fi r Q>o/«c r.� .'Y/� U ne.— 6 s..�Ir Goa Alteration of existing bedroom_Yes No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement _Yes >— Plans Attached Roll -Sheet Be.If New house and or addition to existing housin CO iete the follow n 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? rl o J, 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 form attached? It, Type of construction 1. Is construction within 100 ff.of wetlands? Yes No. Is construction within 100 yr. floodplain_Yes_No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No, 1. 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 // Date o ]"Trio'-p as Owner/Authorized Agent hereby tled re that the s Cements and information on the foregoing application are true antl accurate,to the best of my knowledge and belief. Signed under the pains and penathes of perjury. Sc PtlM Name re of Owner/Agent Data SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder'. �trC.+.a _�c.✓os e /0 6 if 3 6 License Number t s olo TS�a6 /ao Atltlress Expeahon Date � /S 3 ,A49flature Telephone 9.Registered Home Improvement Contractor. Not Applicable ❑ Company Name Registration Number /a / Address Expiratipn Date Telephone °i 7o�/S'3 6 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted wbh this application. Failure to provitle this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes.......p- No...... ❑ City of Northampton a.-..s, f Massachusetts c z DEPAItTNENT OF aDILDING INSPECTIONS 2 :x 212 Msin Stieet • Itu ipel Building Nonthe ton. . 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 corporation or LLC,that entity must be registered. Type of Work: (.2wno- 4� t Est.Cost: Address of Work:?r" bacd G a e Yr7�� v L Date of Permit Application: 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 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: Date Owner Name and Signature City of Northampton co Massachusetts � c DEPARTMENT OF BUILDING6MnicINSPECTIONS 212 Mein Sthw a lWn 010 Building xug 'C6T NartFemptoq !p 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 fano 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 / MESSECYlY9f:tt8 fr' ; l DEFARTNENT OF BNILDING INSPECTIONS 5 212 Mein Stceet •Municipal Building Northampton, D 01060 gj�g0 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: a) a3 �s� �� t/C- i4,. (Please print se number and street name) Is to be disposed of at: NO �is.Oe S</ (Please print na a and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: Ajo fAs < . n �B��/ (Company Name(Company Name a Ld% ress) Sign of Permit Applicant or caner 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 Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/dia W-w.rkers'Compensation Insurance Affidavit:Builders/ContrasCors/Electriciaus/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aonlicaat Information Please Print L bl N=e (Business/0rmaationgndividual): Address: / J / 6') City/State/Zip: rg n S 1" oro 3J Phone#: cf 7 fir/5-3 6 Are you an employer'Check the appropriate have: Type of project(required): I'a am a employer with__C�®ployees(hill anNor pmt2fine)-' 7. ❑New construction 2.❑laoasoleptoprlerororpar mWpmdhavenoemployeesworkmg formein K [—]Remodeling my capacity [No workers comp.Insmevce required] 3. l am a homeowner doing all work msac ] 9. El Demolition ❑ g myself[No watkvs'comp.ins a required. � 10❑Building addition 4.❑I am a homeowner and will tehiring cmoacwrstocovdmtall work e r salary. Iwill ttre that an comm�nrs either have workers nnmpevsaYon ivsuavice or-sale 11.[]Electrical repairs or additions pmprielors with no employees. 5❑laws I ennhaotor and l have hired the sub-cm 12.❑PWmbing repairs or additions gevere tr.,sou sled on the attached shat. 13.�q oof repairs These subcovtacmrs have employee end have workers comp.ivswmce. IG�� p 6.❑We arc a corporations and its officers have exeaised their right of exempnon per MGL c. I<:]Other 152,§1(4),and we have no employees.[No workers'comp.insurance requited] .Any applicant that checks box#1 must also fill out the section below showing theh workers'compensation policy Nfotoanon. t Homeowners who school this affidavit indirepng they,are doing all work and then hire outside contactors must submit a new,affidavit indicating such. TCuntactors that check this box must attached m additional sheet showing the note of the subcovtraclors and sla.whether m not Nose entities have employees. Ifthe sub-contractors have employees,they must provide theh worker comp.policy number. Iran an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site mforenatmA //// t Insurance Company Name: Th! /7c e-4-r o f Policy#or Self-ins.Lic.4:_ 6 160 OQ db7ja6 /,x 'C/ Expiration Date: y//6 Z/ i Job Site Address'Q121 City/State/Zip:As<7/,r.D_nn MA Attach a copy of the worker compensatiao 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 venfication. I do hereby certify under fhepo anpenalties of perjury that the information provided above is nue and correct Signature: D [ � n—/S '/`/ Phone#: 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.CityITown 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 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 appointment 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 sub-contractors)parcels),address(es)and phone numbers)along with their certificatt(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 most submit multiple pernit/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 fuss number: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE ' Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia