23A-110 (5) 168 SOUTH MAIN ST BP-2019-1244
GIS a: COMMONWEALTH OF MASSACHUSETTS
MR-.Block:23A- 110 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category,Porch Repair BUILDING PERMIT
Permit k BP-2019-1244
Project# JS-2019-002008
Est.Cost:$8000.00
Fee.$65.W PERMISSION IS HEREBY GRANTED TO:
Const,Class: Contractor: License:
UseGroum: MATTHEW KOZUCH 106644
Lot Size(sa. 1L): 9757.44 Owner: EVANS SCOTT
zoning:URB(100 Applicant: MATTHEW KOZUCH
AT. 166 SOUTH MAIN ST
Applicant Address: Phone: Insurance:
6HIGH ST (413)570-3279 0
FLORENCEMA01062 ISSUED ON 516120190.00:00
TO PERFORM THE FOLLOWING WORK:REBUILD FRONT PORCH
POST THIS CARD SO 1T 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: 011..1 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:
FeeTvoe: Date Paid: Amount;
Building 5/620190:00:00 $65.00
212 Main Street,Phone(413)587.1240,Fax:(413)587.1272
Louis Hasbrouck-Building Commissioner
File k BP-2019.1244
APPLICANT/CONTACT PERSON MATTHEW KOZUCH
ADDRESSIPHONE 6 HIGH ST FLORENCE (413)370.3279 O
PROPERTY LOCATION 168 SOUTH MAIN ST
MAP 23A PARCEL 110 001 ZONE URB(IOOV
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
NCLOSED REQUIRED DATE
ZONING FORM FILLED OUT i
Fee Paid ,in
Building Permit Filled out
Fee Paid
TvoeofConstructiow REBUILD FRONT PORCH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 106644
3 sets of Piens/Plot Plan
THE FO G ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION PRESENTED:
Approved_Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance'
Received&Recorded at Registry of Deeds Proof Enclosed
_Other Permits Required:
_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 Stant Commission Permit DPW Storm Water Management
Demolition Delay
5-6101l?
Sigfiralre 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.
RECEIVED
Department use only
City of Northa pton StatLvD
Building Depa ant MAY 3 _ 2 ray Permit
212 Main St t SewailabilityRoom 100 �CP T Oc DUILDINn IN abilily
Northampton, MA O1,06NOPTHAMPTON.a NRdural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Spedfy
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to he completed by office
1,01? 5- Map Lot 11 D Unit
FIDreTi,f-e Zone Overlay District
Elm St.Distinct CB District
SECTION 2.PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.12.1 Owner of Record: np L
,0 tvn1,S �aeW �� S� y1 I�o�6 S. leta�n S r
me(Pri ^ Cum r)LMgginp
rHovhtlop`�Il'Ire
Signature
2.1
oriz tlA enK:
1 ®zV��
Name(Print) Current Mailing AM s:
�, yn�� 4f3 39! Ps93
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ap K (a)Building Permit Fee
2. Electrical U (� (b)Estimated Total Cost of
Construction frau 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) ,
S.Fire Protecbon
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Usa Only
Building Permit Numb r: Date
Issued:
Signature: 5 G- Z0�
Building Commissionerflnspeaor of Buildings Date
M\k07--Ap nA)�ool L!W,— @
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Must Be Completed,pegnit Can Be Denied bus,To Incanplete Information
Existing Proposed Required by Zoning
This column ro be Blkd in by
[, Budding Depannient
Lot SIR
Frontage t 30
Setbacks Front zO
Side L-3 9-R''y L: ,N R:A-
Rear ?1JI /V/+
Building Height 3 -
Bldg.Square Footage LO P %
Open Space Footage %
(Lot area minus Wit @paved
k of Puking Spaces Z- -
Fill:
.otwK a Larerion
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0� DONT KNOW O YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document p
B. Does the site contain a brook, body of water or wetlands? NO e 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 \J
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 e
IF YES, describe size, type and location:
E. Will the wnstruaion activity disturb(clearing,grading,ex n,or filling)over 1 acre or is it part of a common plan
that will disturb over l acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
I
SECTION S DESCRIPTION OF PROPOSED WORK Icheck all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Q
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[0] Other[U
Brief Description of Propo 1 '
Work1
pO en J
: re St.nldrf`_I. Ir
Alteration of existing bedroom_Yes No Adding new bedroom_Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ba. 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 stones?
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 R.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 Ta-OWNER AUTHORIZATION,TO BE COMPLETED=
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDI
I. 3"i 1 ' rVytp1 as Owner of the subject
property ILA
I/
hereby authorize M 0.A K0L
on my atl all matters relative to work authorized by this 4 [mpiis buildng nniI a plica
toation.
9
agnaa.e of Otle
,'wn,w I` Da
�yr
I, 1`10. 4 f'\O L.vC� as OwnerlAuthorized
Agent hereby 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 ltles nns and penaof perjury.
IY`A4 hos C�
PnM Name_ L
Signature o�Ovmer/Aged bete
4
SECTION 8•CONSTRUCTION SERVICES
8.1 Licensed Construction Su ernisor: Not Applicable (❑
Name of License Holder: AV
07.41 W— 'OIOI OTl
p License Number
zlAddress � r F�ketionilDale
-n,e-�e4t3
Signature I elephane
9.Realstered Home Improvement Contractor. Not Applicable ❑
Company Name Registration Number
I / 9/21
Address Expiration Date
\\
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(i
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this a�davit will result
in the denial of the issuance ofthe buil ' g penniL
Signed Affidavit Attached Yes....... No...... ❑
City of Northampton
/ Massachusetts
c
1 LLOF BDZLDZBO IaSuP OBa
212 MLi. 8tb Nftildng
Northmton, !A 01060
:Cl
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 most be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation,repair, modernization, conversion,
improvement,removal,demditfon,or construction of an addition to any pne existing owneroccupied building containing
at least one but not more than four awaiting 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.
TypeofWork^I\ebui�� IO<`cr� Est.Cost: Koe0
Address of Work: IIID �. I'la t A
Date of Permit Application:
1 hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
—Job under$1,000.00
_Owner obtaining own permit(explain):
_Building not owneroccupied
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 RESPONSIBD.ITES 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:
a 19119 � _t 11107,-t;� l -7`! -z-o �L
Dare 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
c
i
D212a inS OF BDZD ci ZBSPPCTZOBS i ✓e
212 Main rfr • Mun 010 auiltlinq
BorCha�Con, pA 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 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 110.85,provided that if a homeowner engages a person(s)
for hire to do such work,then such homeowner shall act as supervisor.
Such homeowner shall submit to the Building Official, on a form acceptable to the Building
Official,that he/she shall be responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to
time, during and upon completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153
(Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts
General Laws Annotated, you may be liable for person(s) you hire to perform work for you
under this permit.
City of Northampton
Massachusetts
D212 a i6N1' 0 *MnxN l BuilT ng
zlz win its •Nuricipu suiltliny J� C
NortA.mpCon. MA 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 (0� S, A4l& SI .
(Please print house number and street name)
Is to be disposed of at:
Llt `�h
(Please n t name an location facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name andJAdddress)
Signature of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-1017
www.mass.goP/dia
Worken'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
AODlicant Intorrnation Please Print Leeibly
Business/Organization NamJe: M la-L xx e
Address:
City/State/Zip: �71af e_mt 7VY4 0 Phone#:
Are you an employer?Cheek the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑Retail
art-time).• 6. ❑Restsumant/Bar/Eating Establishment
2.0 I am a sole proprietor or partnership and have no 7_ ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] S. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,¢1(4),and we have 10.❑Manufacturing
no employees.jNo workers'comp.insurance required]-
4.❑ Weare a non-profit organization,staffed by volunteers, 11.1as1r Health Care
with no employees. [No workers'comp.insurance req.] 12.LLIOther CaA$�f..a}-�.✓�
'Myappli®mthn checks has#1 muaatso fillout rhe sectim below showing lheb lity mtomstha.
"Ifthe caspotme oaken haveexempted thmmelvca,but a,e corporation has odarenmloyees,a workers'compensation policy is newinst and such an
oranse,ation should check box#1.
I am"employer that is providing workers'compensation insurance for my employees. Below is the pulley infurmurion.
Insurance Company Name:
Insurer's Address:
City/Stme/zip:
Policy#or Self-ins.Lic.# Expiration Date:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 pains and penalties of perjury that the information provided above is true and correct.
Sienature: �yl Xy..-.� Date,
Phone#: yj3 3y[ SaT�3
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Peresit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www. es,,v/din
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 smite 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 your insurance company's name,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 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 a 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 a 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/icense 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 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 Depanment's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-NIASSAFE
Fax#617-727-7749
www.mass.gov/dia
Form Revised 02-21-15
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