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13-070 28 MARIAN ST BP-2019-1113 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 13 -070 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category ROOFINGIREPLACE WINDOWS BUILDING PERMIT Permit BP-2019-1113 Project# JS-2019-001808 Est.Cost$20000.00 Fee: $80.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Goo= JOSEPH LAFRENIERE 053791 Lot size(sn.ft.): 15986.52 Owner. REVAMPIT LLC Zoning: Applicant: JOSEPH LAFRENIERE AT: 28 MARIAN ST ApplicantAddress: Phone: Insurance: 192 EAST ST (413) 244-4805�j SOUTHAMPTON MAO 1073 ISSUED ON.4/9/2019 0:00:00 TO PERFORM THE FOLLOWING WORKNEW ROOF, REPLACEMENT SLIDERS AND WINDOWS 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: 29i 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 4/9,/20190:00:00 $80.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner wvotusl Depanmemuaremry City of Northamp on Status of arm ,> Building Departm nt APR C 'y Permit 212 Main Stre R ilability Room 100 IIA tabiliry Northampton, MA 066ePT On mllrnlNra Bf etuml Plans phone 413-587-1240 Fax MPTON Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION (> P- 1.1 > P 1.1 Property Address: This section to be completed by office 57— Map �� Lot 1017Q Unit Zone Overlay District Elm SL District CS District SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: /4r1 ey5r— Sr, Sova4,t1otw /o- r9/o7 Name(Pd Current Mailin Atltlress: CwWk, o..ur) Yf. .9VY—y80S / Telephone Signatur 2 2 Authorized Anent Name(Print) Current Mailing Address'. Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by pemait applicantT 1. Building '10 Q961 (a) Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing "05? Building Permit Fee T 4. Mechanical(HVAC) 5. Fire Protection / M 6, Total=(1 +2+3+4+5) 00 Check Number This Section For Official Use Only Date Building Permit Number: Issued' p Signature: Building Commissionerllnspector of Buildings Dale iop, @ reVaynPi+P'ro5f eom EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information ExistingU 99A Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L R:- L R: Rem Building Height Bldg. Square Footage % - - OpenSpaceFootage _. % _ __.... (Lot area minus bldg&paved ri. #ofParkin Spaces -- -- Fill: memme&Lo.atmm A. Has a Sp tai Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry,of Deeds? NO 0 DONT KNOW © YES O IF YES: enter Book Page and/or Document # B. Does the site contain a brook,body of water or wetlands? NO V DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO V 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 0 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading, exc ation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aoollcable) New House ❑ Addition ❑ Replacement W' ows Alterations) EJ Roofing 0, Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O) Decks [E3 Siding[E:3) Other I[:� Brief Description of Pro sed !X r Work /I/ �Ll/ YCdOF/ /f(�(.�}O� L--xI$//bpi SLIr7E�r /1/C�nl aQE�z6}CEKfMT W/n/OOe✓Sr N/ Alteration of existing bedroom_Yes---&No Adding new bedroom Yes _�No Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roll -Sheet sa. If New house and or addition to existing housing. c m tete the follow[ a. Use of building One Family Two Family Other L Number of roams in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction Is construction within 100 ft. of wedands? 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, 12S524 IQ Fe--ei (-e c, as Owner of the subject property hereby authorize %JUpI? rGG1IGrFi to act on m ehalf, in all in ens relative to work authorized by this buildingpermit application. Y Signature'", erI /- Date 1, y/ ✓( � N b ��reN I as Owner/Authorized Ag�ereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. JB (, 6 b-,Frei, (,e� Print Naa44 4m c Y/91/19F SignaWre OwnerlAgent Date SECTION 6-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor; Not Applicable ❑ Name of License Holder: � � V IAFY'C�t I -�'-3 7? License Number I g a l 5T- 0107 ;/z6�y Atl ess p .,� i Expiration Date M uu `1f3 aYy- YdOy� Sign t re Telephone 9.14"Isten d Home Improvement Contractor: Not Applicable ❑ �evuwnl l foXol� (g�eH 'e � & 19,31 Lomoanv Name Registration Number l9� 5i i %���� Addr�egss�� 1, Expiration Date ZL"�l "^ � Telectonel-`/�3ayyy8a SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,$25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildt. building permit Signed Affidavit Attached Yes....... ✓3diNo...... ❑ t City of Northampton � Massachusetts +� ' ( Y r: DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street sai Building yv r< Northampton, MR 010 01060 hp'yj�1� AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors perforating improvements or renovations on detached one to four family homes. Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L. Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-exisflng owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building'be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC, that entity must be registered Type of Work: RzOF-, w lA/l0Ot(9$ t Su✓JQZ_ Est. Cost: .jO,000. Address of Work: 92k /+19g�-ItN ST Date of Permit Application: yC g-115F I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): _Job under$1,000.00 ✓C)'wner 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.C.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 I hereby apply for a building permit as the agent of the owner: Date Contractor Name HIC Registration No. OR: Notwithstanding the above lice,I hereby apply for a building permit as the owner of the above property: �� Date Owner Name and Signature _ City of Northampton Massachusetts U SDEPARTMENT OS BUILDING INSPECTIONS Ma212 in Stveet • Municipal BuildingN.xtha ton, MA 01060 Massachusetts Residential Building Code Section 11085.12 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 11085.1.3.1 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 persons) 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 perforin work for you under this permit. City of Northampton Massachusetts r 4 DEPARTMENT OF SDILDING INSPECTIONS 212 Main Street eNunicipel Building Northampton, MA 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: a8 ST- (Please print house number and street name) Is to�be disposed of at: (Please print name and cation of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company NameandAddress) l /FEZ � ✓" "i/16�'4.N� Sly i ture of Permit Applicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. The Commonwealth of Massachusetts Department of lndustrial Accidents 1 Congress Street,Suite 100 1 Boston,MA 02114-2017 www.mass.gov/dia R orkers'Compensation Insurance Affidavit:Builders/Contractors/Elet[ricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information / ! Please Print Le 'bl Name (Business/OryanizatioNmdividuap: I/ j'/ rNc Address: tq l— E�Ai5.r— 5T— City/State/Zip: TCity/state/Zip: Sikmt�F^^�onl, f f7107 hone#: y13 r3 yy—Y�Q� Are ypu lover?Check lheappropriale box: Type Of project(required): L ployer with I employees)full and/or part-time) T []New construction 2.❑lamasolepmpdecoro11mmershipandhavenoemployeesworking farmein $. Er�irmOdeling anycaproat, [No workers'camp.insurance required.) 3❑1 am a homeowner doing all work myself[No workers'comp.mormace required.1 q. ❑Demolition 10❑Building addition 4.❑1 an a homeowner con and will be hiring worker contractors n conduct all work ce or re sole . 1 will we that allconuacmrs eitherhwe workers compensation inaaranw or are ank I1.❑Electrical repays or additions pmprow.with no and. ees. 12.❑PI tubing repairs or additions s�I lama generalcontractorhrand I eempl veer ed fle,and workers comlisted ne me marched sheet [} Roofrepairs v These subaonuactors have employees end haw workers'comp_inswmce: 6.❑we are a corporation and its officers have extracted men right of exemption per MGL a 14.❑Other _ 152.00),and we have no employees[No worker'comp-mearmce ex,m ed] "Any applicant mat checka box%1 most also fill out the section below showing their workerscompenstem.policy information. t Homeowners who submit this affidavit thdwating they arc doing all work and then hire outside contiacmrs must submit a new,affidavit indicating such. :Cmauamors that check this box most attached an additional sheet showing the name ofthe sub contractors and store whether or not those entities have employees If the sub-co muctors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information / ,rAd Insurance Company Name: LI 147l 2 I Policy#or Self-ins.Ln.#: N/(/?-31 S "36VV j�(�fo � Expiration Date: 3110I 9(7a0 Job Site Address: �i-S roi olf-1IJQq� � l� 51 Ciry/Stale/Zip: ' IMGt Ny+ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and, 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce fy under the pains d penalties ofperjury that the information provided above is hue and correct SSii,matme: Date Y19119 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r 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,§25 C(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 insurauce requirements ofthis chapter have been presented to the contacting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone numbers)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retumed 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 ofthe 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 o 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 ofthe affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proofthat 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. # 617-727-4900 ext 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia