32A-014 (3) 17 WALNUT$.T BP-2019.1248
GIS#• COMMONWEALTH OF MASSACHUSETTS
Man&Wk: 32A-014 CITY OF NORTHAMPTON
Lot 001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Pertniy Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Categ,Qrv:renovation BUILDING PERMIT
Emit ft BP-2019-1948
Pmiect# -„ISS-2019.007013
Fst Cost:$6300000
Fee, $423 OD PERMISSION IS HEREBY GRANTED TO:
Const Class Contraetarr, License:
Um Geoggi_ THOMAS MALONE 055236
Lot stra(sa ft.): 6229.0 Owner- RAINBOW PROPERTlE5 UC
zoning:URCt100m/ Applicant: THOMAS MALONE
AT., 17 WALNUT ST
ADplicanlAddress: Phone: Insurance:
128 RYAN RD (413)885-9038 WC
FLORENCEMA01062 ISSUED ON:5/14/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.RENO 1 ST AND 2ND FLOOR
PAST THIS CA"Q IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Roughs House# Foundation:
Driveway Final:
Final: Flaall
Rough Frames
Gas: t Firoplaee/Chkmncy:
Rough: Insulation:
Fivall §mglkcs Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Qeltifloate of Oosucam signature
EeLiz g: Djte Paid: Amount:
Building 5/14/20140:00:00 $423.00
212 Main Street,Phone(413)587.1240,Fan;(413)587.1292
Louis Hasbrouck—Building Commissioner
P�dn�
File k BP-2019-1248
APPLICANT/CONTACT PERSON THOMAS MALONE O(G
ADDRESS/PHONE 128 RYAN RD FLORENCE (413)885-9038 P .
PROPERTY LOCATION 17 WALNUT ST
MAP 32A PARCEL 014 001 ZONE URC(IO 1
THIS SECTION FOR OFFICIAL USE ONLY
PERMIT APPLICATION CHECKLIST
ENCLO D REQUIRED DATE
ZONING FOR FILLED OUT
Fee Paid
B.ildina Permit Filled out
Fee Pai
ofC nstruction: RENO1 TAND 2N F OR
New Constmc ion
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included -
Owner/Statement or License 055236
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOMATION 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 Permi[ __ Variance*
Received&Recorded at Registry of Deeds Proof Enclosed _
—Other Permits Required:
_Curb Cut from DPW Water Availability ,Sewer Availability
_Septic Approval Board of Health __Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
—Demolition Delay
{ _
lt- _ S 1/y I ct
Signature of Building Official Date
Now: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.
f
Department use only
City of North 01mit
Building Dep rtm ECEIV YPemat
212 Main tree E- A
cnvalWtdBy
Room 1 0 AveilatrSly'
A 0 O6�AY 6 2019 Structural Plans,--
Northampton,
phone 413-587-1240 ax 13-587-1272 itsps
DEPT OF nILLMNr iNSPEcAPPLICATION TO CONSTRUCT,ALTER, n�ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address'. This section to be completed by office
Map Lot Unit
Zone Oxeday District
Elm SL District CB Distinct
SECTION 2.PROPERTY OWNERSHIPIAUTHORIZED AGEtyT
2.1 Owner of Record:
c �jW �a� a
Name(Print) Curr t Melll A�ress
Telephone
Signature
2.2 Authorized Agent:
rrv'Wv
Name(Print) Current Mailing Address:
ignaNre Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Off Gal Use Only
completed by Pe"it applicant
1. Building (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3, Plumbing Building Permit Fee
4. Mechamital(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commisslonepinspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section4. ZONING All Information MustBeCompletetl.Perm¢Can Be Oenietl Due TO Incomplete ldamnation
Existing Proposed Required by Zoning
This column m be filled in by
Building Department
Lot Size
Frontage _.._ ...._...
Setbacks Front
Side L . R: _. U R' ..
Rear
Building Height
Bldg. Square Footage %
Open Space Footage _ % _
n of area minus bldg&paved
vrkla 1
#of Parkin Spaces --
Fill:
volume&Location
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
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 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it pan 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.
0
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacemeni Windows Alteration(.) Roofing ❑
Or Doors
Accessary Bldg. ❑ Demolition ❑ New Signs [01 Deeks [0 Siding [0] Other[I71
Bnef Description of Proposed
Work, %' sV /Zr-L
Alteration of existing bedroom ✓ Yes,No Adding new bedroom Yes ✓No
Attached Narrative Renovating unfinished basement Yes � No
Plans Attached Roll -Sheet
ea. If New house and or addlUon to existing housing, complete the followina'.
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?
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?
In. Type of construction
L 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 \ Y�4.M,t.� 1(�C `�- as Owner of the subject
property rr
hereby authorize "S MC\Wf
to act on my behalf, in all matters relative to work authorized by this building permit application.
5-b-\�
Signatures of Owner Data
I, �styryyc, I(1(�er''NL� 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.
Pnnt Nam
Signature of OwnerlAgent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: 1 5— 0
License Number
lWxv s s mztwc I—\€ —?S0
Address Expiration Date
\cLr� (1 Glivi,vc l(N� olo� L
Signature Telephone
9.Repistenrd Home tmpreyemNlt Contractor: Not Applicable ❑
Comoanv Name Registration Number
1a� fL, � RL PttnnKylocL � R-E,�
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.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 pemut.
Signed Affidavit Attached Yes....... ❑ No..— �
e._ City of Northampton
" Massachusetts
h d )®( s
DEPARTMENT OF BUILDING INSPECTIONS
212 nein Street • Municipal Building 5v� CD
Northampton, MA 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 clan addieon to anypre-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:pf the homeowner has contracted with a corporation or LLC,that entity must he registered
Type of Work: b���JvV11 Est. Cost: 1i SoW"r O
Address of Work: S�4'C!t
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 RESPONSIBH.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 building permit as the agent of the owner:
5__6_k5 CYwe .s V`hnVnn C_ \ b-I Sty
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
QiMassachusetts s
DEPARTMENT OF BIL G INSPECTIONS t
314 Hain Street .Municipal Huildinq
North3han, I�ton, NA 01060
Massachusetts Residential Building Code
Section I I O 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.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.
1
City of Northampton
Massachusetts
11 DEPARTMENT OF B➢SLDING INSPECTIONS �
212 Nein Street •MunIcipal Building c.
,.� 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:
\-? U IA" k
(Please print house number and street name)
Is to be disposed of at:
/n Pleas (Ue � .�clw�
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
s-Vk-
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.
41
The Commonwealth ofMassaehusetts
Department of Industrial Accidents
I Congress Street, Suite700
Boston,MA 02174-4-I0I7
www.mass.gov/dia
Workers'Compensation Insurance AH chisit:Builders/Contracters/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information �p Please Print L o bl
Name (Business/OrgarmatioNlndividual): MaVt'—
Address:
City/State/Zip: er �` OIO L Z Phone#:
Are you an employer."Check the appropriate boa: Type of project(required):
1.❑1man aemployer with employees(Nlland orpan-bore) 7 ❑N constructionw
2Mlam sole pmpnemrnrparramepand have w employees working forme m 8. Remodeling
capacity.[No workers rompinsurance required.l
]01 em a homeowner doing all work myself[Nu workers'comp.insurance rcyuirc9. EJ Demolitiond]'
4.Q 1 am a homeowner and will be hiring convectors to conduct all work on my pod" twill 10 Building addition
ce um net all contractors either have workers'compensatominsuance or arc sole IL❑Electrical repairs or additions
cognitions with ao employer
12.❑Plumbing repairs or additions
S nese- -carrommtthavear n le,tavewe an lose worsemmonsltstco on the atmAetl theet 13. Roof repairs
Thex cob-conhaaturn have employees and have workers'comp.insurance: ❑ Pa
6FWe arc a co tion and lie officers have exemsedflnu tent ofe.em tion 14.❑Other
rpnm re per MCI.c.
152,§I(4),and we have no employees_[No workers wrap-insurance required
"My applicant Nat checks box#1 must also fill out the section below showing their workers cumperuation policy nomination
'Hom who submit this aRidavit indicating they are doing all work and men hire outside contractor;most submit a new atHdavit indicating such.
:Cmunce.that check this box must stitched an additional sheet showing me name of the sub-cmmusc om and state whether or not those entities have
employees. Ifthe sub-conmacmrs have employees,they must provide their workers'comp policy number.
1 am an employer that is providing workers'cmnpensa8ose insurance for my employees Bdow is the policy and job site
injormatiom
Insurance Company Name:
Policy#or Self-ins.Lic.#'. Expiration Date:
Job Site Address: V7 Vrak- ay JH LFiT City/State/Zip: N, 4 .Q{sa ry�O��60
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/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine of up to$250.00a
day against the violator.A copy of this statement maybe forwarded to the Office of Investigations of the DLA for insurance
coverage verification.
I do hereby certify)under rhe pains and penalties of perjury that the information provided above is nue and correct
Sim late: D t '
Phone#: � �"XOlpG
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/Licame#
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,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 niche 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)name(s),address(es)and phone councils)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 en 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 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 bum 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
I 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 www.mass.gov/dia