32A-014 (2) 15 WALNUT ST BP-2019-1249
CIS 4: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A-014 CITY OF NORTHAMPTON
Lot: 01 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Cateaorv:renovation BUILDING PERMIT
Permit# BP-2019-1249
Proiect0 JS-2019-002014
Est.Cost,$55000.00
Fee:$358 Do PERMISSION IS HEREBY GRANTED TO:
COX I Contractor: License:
Use Groun: THOMAS MALONE 055236
Lot Sizcha.ft.): 6229.08 Owner: RAINBOW PROPERTIES LLC
4Ming_VRC 1001/ Applicant: THOMAS MALONE
AT: 15 WALNUT ST
AoplicantAddres�s: Phone: Insurance:
128 RYAN RD X413) 885-9038 WC
FLORENCEMA01062 ISSUED ON.5/14/2019 0.00:00
TO PERFORM THE FOLLOWING WORK:RENO 1 ST AND 2ND FLOOR
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 I:
Final: Final;
Rough Frame:
Gas: FireFire baoartmenl Fireplacc/Chimney:
Rough: 11; Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occuoancv Signature:
Fgelyve: Date Paid: Amount:
Building 5/14120190:00:00 $358.00
212 Main Street,Phone(413)587.1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File 4 BP-2019-1249
APPLICANT/CONTACT PERSON THOMAS MALONE
ADDRESS/PHONE 128 RYAN RD FLORENCE (413)885-9038
PROPERTY LOCATION rI;WALNUT ST
MAP 32A PARCEL O14 001 ZONE URC(100)/
0
THIS SECTION FOR OFFICIAL USE ONLY: P LPA
PERMIT APPLICATION CHECKLIST
ENCLOSED D REQUIR DATE
ZONIN F FILE OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tvueof Construction: RENO 1 STAND 2ND FLOOR
New Construction
Non Structural interior renovations
Addition to Existing _
Accessory Structure
Buildinst Plans Included•
Owner/Stgtement or License 055236
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQRMATION 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:`—She Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit _ Variance'
Received&Recorded at Registry of Deeds ProofEnclosed
,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 Pernfit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
_Demolition Delay
Signature of Building Official Dates
Il
Note: Issuance of 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 MOL 40A. Contact Office of
Planning&Development for more information.
- City of Northa ton
RECEI Detachment use only
-> Building Depart ant Curb rl yPenn
212 Main SIT at TAY 6 valla"ll'� a
-� ^). Room 100 r ell it"Ity .
` Northampton, 01 0 TWo Of '.Plain
� ,F
phone 413-587-1240 Fa 418zr� "r11Q�D7 ir,l'=_ j P
Q
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Prooertv AdtlresThis section to be completed by office
a:y_
1! Wc+�nK SI�W>'1- Map Lotinl Unit
Zone Overlay District
Elm St District C8 District
SECTION 2.PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
2c et, ., Q11bf WJ < LL �as� (LZ FcrFc_ mA utnet
Name(/PriJnt)�) r Curent MaiM1ng�Atic�ress-
Telephone
Sig�re
21 Authorized Agent:
"t-FL \ —OL(A 7 .
Naie(Print)tA�noGurent MaY' Pdtlress
u�1�sS-4ul F
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by vermit applicant
1. Building (a)Building Permit Fee
2. Electrical (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) Check Number
This Section For Official Use Only
Da e
Building Permit Number: Issued:
Signature:
Building CommissioneAlnspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
1
Section 4. ZONING All Information Must Be Completed.Permi[Can Be Denied Duero lncompletelnformation
Existing Proposed Required by Zoning
" 'his column to be filled in by
loodding Depmunent
Lot Size
Frontage _..
Setbacks Front
Side L. R:._ L: R:.. _. ...
Rear
Building Height
Bldg. Square Footage
Open Space Footage ov
(LM arca ni n o bldg&pavN _..
reirkni
#oniParking Spaces -" - --
(volume&Locadon)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW O YES O
IF YES,date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(.) Roofing E:]irpoos O
Accessory Bldg. ❑ Demolition ❑ New Signs [0) Decks [E] Sidini Other[ED]
Brief Description of Proppsed
Work, RE J FC- 4 Tl
Alteration of crusting bedroom ✓Yes_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Sheet
Ga.if New house and or addition to exisdno housing.complete the following.
a. Use of building '. One Family Two Family Other
b. Number of rooms in each family unit. Number of Bathrooms
-
a 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
L Is construction within 100 ft.of wetlands?_Yes _Nois 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
L 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
` KV cxv .r-S (y(�,c�f/�— as Owner of the subject
property
hereby authorize \'4RY " ly\ Y`yc
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, � ,y, 'N�.S �c.J"� as Owner/Authorized
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 and penalties of perjury.
` �NS-j P1�AlrP�
Print Name
Signature of er/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: NotApplicable ❑
Name of License Holder
License Number
Address Expiration Dale
lab (��4. ft 1, F tt crr�CM�Ft h Wk
SignaWre
Telephone
IA
C
RU�
9.Reois0emd Homelmprp nt Contractor Not Applicable ❑
�.S
Company Name Reg`thkti umbe�J r
10
Address Expiration Date
TelephcnekkN)i SA dA
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§28C(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 permit.
Signed Affidavit Attached Yes....... ❑ No...... Er
r _ City of Northampton
Massachusetts
;( DEPARTMENT OF BUILDING INSPECTIONS
212 Nein Btreat a Municipal Building
Nortiu motan, . 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 pre-existing owneroccupied 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: \ ti2.rL p'Ur rt,-4 q�kc^ Est. Cost: 55. 000
Address of Work:
Date of Permit Application:
I hereby certify that:
Registration is not required for the fallowing 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:
_ 5-� —\h '�4.w�s (,(\a\u-,-- l 6"t SIRS
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
s --
" Massachusetts
" DEPART T OF BUILDING INSPECTIONS
212 Nein StreetMunicipal --Id-,
Narthan�[on, !W 01060
Massachusetts Residential Building Code
Section I IO.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 I IO.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 1 I O.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
s" Massachusetts
( DEFARTNENT OF BUILDING INSPECTIONS Z
i
212 Main Sliest 9M Icipnl Building
Nortb—,ton, MA 01060 rYgr'- 1
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 house number and street name)
Is to be disposed of at:
V U,%'�"b
(Please pdntname and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Permit Applicant or Owner Date
If,for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The Commonwealth ofhfassachusetts
Department of Industrial Accidents
I Congress Street,Shope 100
Boston,AIA 02114-2017
wwr+.mass goders/
kIzIlWorkera,compensation Insurance Affidavit:Builders'Contractors/Electrioians/Plumbers.
To HE FILED WITH THE PERHITTING ADTHOBITY.
Applicant ifn m tinName �t� �...�.
Cityi State/Zip: yir(/ty+vr"" 0 Ob Z. Phone#:_ ._.......—
Are tray an employer^check me ammai ralebox: Type of project(required):
Lp l oma enio.ya with_ �Iaployeas(full moNn,im-time) 7. C]N cim trucbon
❑Iamnsnlc l»'eprieturor paMcros'hip anJ bdve no employeey working triennia S. rXR-rinodcling
any capacity-(No worm romp.iosm ove required.] 9_ Q Demolition
;�tamuMmcownenSoviy Inti wick mradf(Nowo,ters'vonpmo mmenorievi
10 Q Building addition
a, an a not will be hiring omactorg to eoW uet ell work on toy propvry. [will
e swe thtt alt ccntranrrs eirluK have weske,s mttwenmvo»msmanc-amare uvk I1.❑Electrical repairs or additions
pn<mrs w0 oa employee.+. 12.❑Plumbing repairs or additions
Saa;;enemi mmxvor a>dthuvehirtttthe aM.cano-aawslaeA nn the atueh�sbcet- 73.❑RoaPlrpaivs
Z, haveenpbyees and have workersromp.innmancei
14.[]Other
of]We ueawnxtrntion end its o07ev:have exercBed then right oracmpdov per MGL -
152,R I(a),Inner. we heve no employees-form wnmkers comp,normal"re rmore)
"Ant,applicant tha[ehcek box hl must also fill out the section below shewing tltcirworkern"oompertsation poling INntmWimre
'Homrnwnerx who o on.this allidavn month,they arc doing ell wod,and then hireouaide wnr[actnn nUlfx suMnn a mew anidavit izuix'vcing svxh.
k7marram-s that cherk is,box mus anach d a»Mdltion:J sheet showing nm none mf the sub-motrxctors and state whither or not those entities have
employees. It 01 sub-enmrnmors have e, plmyees,they over provide the. workers'comp.isheY mints?.
I am an employer that isproviding workers'compensation insurance for my employees. Beloit,is the policy andjob site
information.
Insurance Company Nanw: ... ,
Policy N ar Seif--ins.Cie d:�.. Expiration Datc:
Job Site.Address:_, ) � w \,A- Sk� —C'irylStateiZiP: r- ___('} Ql0(g(�
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Mt"iL c. 152,§'25A isa criminal violation punishable by a tine up to$1,50080
and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a tine 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 pains/andpenaldes ofperjury that the information provided above is true and correct
Dqt
phone Ikt� —iip�(� � ._. ._...�
Official nor only. Do not write in this area,to be compl ted by city or town official,
City or Town: L8.11ding,
...._...�_Pexmit/LiceaseIssuing Authority(cir1.Board of Health 2. artment 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person- Phone ffi
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 142,,¢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, g25C(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 subeontractor(s)turrets),address(es)and phone number(s)along with their cerat ficate(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
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 permi llicense 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'9ob 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 he filled out each
year. Where a home owneror 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 Departments 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-MASSAFF
Fax#617-727-7749
Revised 02-23-15 wwWmass.gov/dia