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43-004 (2)
160 GREENLEAF DR BP-2019-1446 GIS 4: COMMONWEALTH OF MASSACHUSETTS Mao:Block:43-004 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category:window replaced BUILDING PERMIT Permit 4 BP-2019-1446 Proiect4 JS-2019-002338 Est.Cost:84000.00 Fee:840.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Sige(sp.fl.): 233481.60 Owner: KAZEMI HOSSEIN&MAHNAZ MAHDAVI C/O WILLIAM J HOUSE Zoning: Applicant: VALLEY HOME IMPROVEMENT INC AT. 160 GREENLEAF DR Applicant Address: Phone: Insurance: P O BOX 60627 (413)584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON:6/19/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 2 REPLACEMENT 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 p 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 Occuoancv Siensture: FeeTvpe: Date Paid: Amount: Building 6/19/20190:00:00 540.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner /N00w3 City of Northak*.r(, .- Building Pepdffnient ' — Cu { 212 M in reef Rom '40 JUN 1 8 2019 �T'�•` R Nolihamp n, A01060 phone 4l&587-1 0 NOIrTHAIdP ( 4 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH AONE OR TWO FAMILY DWELLING SECTION SITEINFORMATION 1.1 Property Address: {�= This section to.be completed byoBiee a aJ F 'xtn I(DD rQ w-o(f2f- �2lVC. &i,Q o Lot 00 Umt _ Oe a 6 Overlay Distnot ._SEyO�stnct CB District _ SECTION 2.PROPERTY OW NERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: S, v 1(00 bcYa.lu� Dhvc� Name(PMI) CuneJ1ilirj!9d s: �• Telephone ff��''11 1' Signature ' 2.2 Authorized Anent: St I Qem-irnan Rc)rer Cr— MA- otoca- Name(Print) Cunent Mailing Address; 413-584-1522 Signature- SECTION I. ignature SECTIONS•ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be O(Hciat Use Only completed by Permit applicant 1. Building (aj Building Permit Fee 2. Electrical (b)Esgmated 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 Nun=: This.Section For Official Use Only Date Building PennitNumb Issued Signature: ' Building Cp mksionemnspectpraf Brtlldings - Dale EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) I d. Section 4. ZONING All Information Must Be completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning 'tlsis<aNmu mteSBea ioq i BvadwB DcpaNvmt Lot Size Frontage Setbacks Front O O Side L:= R= L:= R:0 Rear Building Height Bldg.Square Footage O O % D O C Open Space Footage Praising) mumr bldga Paved O LJ . #ofParkingS aces Fill: volume a.ruudov17 A. Has a Special Permit/Variance/Finding ever been issu d for/on the site? NO O DONT KNOW Q Y IF YES, date issued: IF YES: Was the permit recorded at the Registry o Deeds? NO © DONT KNOW © YES IF YES: enter Book 7 Pag' and/or Document# B. Does the site contain a brook, body of wate or wetlands? NO O DONT KNOW © YES O IF YES, has a permit been or need to b obtained from the Conservation Commission? Needs to be obtained © btained © , Date Issued: L�J C. Do any signs exist on the property? ES Q NO O IF YES, describe size, type and t cation: D. Are there any proposed Chang o or additions of signs intended for the property? YES © NO O IF YES, describe size, type nd location: - E. Will the Construction activity it turb(clearing,grading,excavation,or filling)over 1 arae or is it pan of a common plan that will disturb over 1 acre? YES © NO Q W YES,then a Northamp n Storm Water Management Permit from the DPW is required. . SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replace tt ndcws Alterations) Roofing or Doors N Accessory Bldg. ❑ Demolition ❑ New Signs [0) Decks [Q Siding[0] Other[EM Brief Descripof roposed ''ll L Work: 4LG Z 4UIL, afnra(��1+✓.-w I�N+,'Se+ 1a W dJ� —NV C7((A``N92. ' 'fD Alteration of existing bedroom_YesXNo Addingnew bedroom Yes A—N r//I1N1 Attached Narafive - Renovating unfinished basement _Yes No _ if Plans Attached Roll -Sheet sa. If New house and or addition to existing housing, complete the following. 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? 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 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 7a-OWNER AUTHORIZATION-TOBE COMPLETED WHEN OWNERSAGENT-OR.CONTRACTORAPPLIES`FOR BUILDING PERMIT I. t L1UWI 44Gd$,z - as Owner of the subject property hereby authorize M to act on m behalf,i II matters relative to work authorized by this building rn' application. Signature o Date I, LAT'xMn Sr I uermon '= 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. eU V Px Print Name Signature of era Date / I SECTION 8-CONSTRUCTION SERVICES ' 8.1 Licensed Construction��``S��uosrvisor: Not Applicable ❑ Name of License Holder: C 31"E�IIL`(7 V II�12rmr'1n 017219 license Number �b mer Srx1� R ta-1'b (alai leo Address Expiration Date Slgnaturb / / lephone 9�_Reci3fe[eom' .fmo h' "Ea f&F ".h�iidi r.'v k^ja'� ij` x .. Nol Applicable ❑ V(�P.v, k�nrnr,Svnn�royemend- 10554' ComoanvN Registration Number Olo 7 tX c OlO 2 7 1-1 12-0 AddressrI Expiration Date Telephone'113-58N-752 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G L c.152,Q25C(6)1 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...... ❑ I City of Northampton {. Massachusetts' 'S� 1 =MT T OF BUILDING ZNSPECTZONS S. 212 Main Straat a Municipal auild n, y i �. Nortaampton, 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 familyhomes.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, aftereaoo,renovation,repair, modernization,conversion, improvement,removal, demolition,or construction of an addition to any pre- xiso'ng owner-occupied building containing at least One but not nave than four dwelling units....Or to structures which are adjacent to such residence or buildingJ'be done by regj§Ltred contractors. Nate.If the homeown er hat contracted with a corporation or LLC,that entity must be registered. Type of Work �/¢ Bat.Cost: Address of Work: 1 &0 6r°CCYi f &! .-L yr— Date of Permit Application: I hereby certify that: - Registration is not required for the following reasoq(s): _Work excluded by law(explain): Job under$1,000.00 _Owner obtaining own permit(explain): _Building not owner-occupied - Omer(specify): OWNERS OBTAINING THEIR OWN PERMIT ORENTERING INTO CONTRACTS WTTH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FORAPPLICABLE HOME]MPROVEMENT WORK ARENOT 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 RESPONSIBHIT'ES 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: (00�/ 1^ c igppL3 Date Contras 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 r OEPABTMENT OF BUILDING INSPECTIONS a '� \p 212 Min Street a Mnicipal Building N—ct tan, . 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 110.85.1.31 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 suchwork 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 persou(s) you hire to perform work for you under this permit. City of Northampton n� Massachusetts i( S: DEPARTHSNT OF BOILDING ZNSPFCTIONS 212 Main Strout •Municipal Building Northampton, M 01060 .�fl 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: I(DU �-�n/t2� R7 (Please print house number and street name) Is to be disposed of at: (PI a print n Te and location ofd Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) 6- /F-/' Sigillil6e9of Permit Appl c t or O r Mile - 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 Tw.rkers' Department offndustrlalAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/dim Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERWrMGAOTHORM. Applicant Information as Plee Print L.2ibly Name(Busineworga¢imtionandividual):�•^� �Oe'Z).v�t Sh C- Address: P.o.P)Ixa too,;)) t $L1b \tiIUPXS�.t�rIVG QtY/State/Zip: "VI Olbb2 Phone#: t{.13-58y�5a'a Are You an empbyerY Check the approPdate box: Type of project(required): 1.151..empmye<wm_1�empm><«(Nllmv«Pw-t®e)• 7. 0New construction 3❑I.masole pcopdemrarpanomWp nndhave m employees wodi'og fermeiv g. ®Remodeling snyt.pecity.Mo coo 'comp.mammce nquu i.j r❑lm.homeow¢amu�g.u..«km T[Nowodma-c mammce�d]' 9. ODemolition 4❑Lm.hommw¢«mdwJl be hvivg m¢tnemnmwaduct all workmmy popeny. Iwdl 10 C]Building addition come m.tellmvtRcron eiWmhaveworken'compematuv msmame«em sole I LC]Electrical repairs or additions m,ktma rhlo OO ealoyCC1. 12. Plumb' airs or additions S.rl[®.gmcelwatnma and l bavc h¢edthe sut,aumcws tismt oo to,atmdnd dnot ❑ �� Thesenab,maaacmn have cmploycu mdheve woskm'comp.ioamsore.t 13.❑Roofrepafrs 6.F]W.meac«pmafim mditaeBrm have exmasedthehrightofexempeoap«MOLc 14.00ther 152,§I(4),avdwe b.ve m empto5<es.(No wmkva'mom,ioemmce re umwll - "Avyepplicmtthate ds box 41 mustelm fill om the rectionbdow showing thev weAnn'eompem.tlo¢policy ivfomeEo¢ t1.Y =whoaa tddaafdava indiratmgtheYmdoiogea woh s¢d@m hueeWide cvahagma mart rubmita sew a�dava mdiratiog mrd. 7Conmaemn tbet chert this box mus[emrded m addidaoalshut ahowivg Le Deme aftlm mbcwtramon mdsnR whNh«or nit roosemfitiez trout emph,y:a. Bthe mbcoaeacmn Lave cmploY«a,dcYmurt tmdh mrn woakcn'<omp.policy n�mbR. Iam an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site information. /t 1 Insurance Company Name�Aib'rk, -LnaQC)ry6M42 Poky#m Self-ins.lie.# ob`c50302\5 Erpodma Dete: raj) l I2g�b y, Job Site Address: I(o0 &KIM ka t T�r(f Y( City/StateMp: U✓�fite Ma 0f0b2- 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 minimal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the farm 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 ofthe DIA for insurance coverage verification. Ido hereby cerfif/y7/uunn,r�dder thepainsand ertalNes of erj' that the informationprovided above is true and correct Sumatu ee: A 1Y'/,2I qq 1I �L12 Date ` le 1 A d - Phoneq: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License a 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 4: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for then employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hue, 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 ajoiat 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 boom 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(n)and phone mumber(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members orparmers,are not required to carry workers'compensation insurance. If anLLC er 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. Shouldym have airy questions regarding the law or if you are requiredto obtain a wod=' compensation policy,please callthe 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 bas 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 permib'licease number which will be used as a reference number. In addition,an applicant that must submit multiple pemritilicense applications in any given year,need only submit one affidavit indicating current policy information Cif necessary)and under"Job Site Address"the applicant should write"a0 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 _ 1 Congress Street,Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 est. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia 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 of written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or my two or more of the foregoing engaged in ajoint enterprise,and including the legal reprasematives of a deceased employer,or the receiver or hustee of an individual,partnership,association or other legal entity,employing employees. However,the owner of a dwelling house having not mora than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maihtenance,construction or repay work on such dwelling house or on the grounds or building appurtenant thereto shall not became 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 yourissuance company's name,address and phone number along with a certificate of insurance. Limited liability Companies(LLC)or Limited Liability Partnerships(ILP)with no employees other than the members an partners,are not required to carry workers'compensation insurance. Han LLC or LLP does have employees,a policy a 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 uflndustrial 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 he sure that the affidavit is complete and printed legibly, The Department has provided a space at the bottom of the affidavit fur 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 pemrit/licens:number which will be used as a reference number.In addition,an applicant that must submit multiple permit/license applications in any given yen,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 m permit not related many business or commercial venture(i.e.a dog license orpermit.ta 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 I Congress Street Boston,MA 02114-2017 Tel. #617-727-4900 ext 7406or 1-877-MASSAFE Fax#617-727-7749 www.mass.gov/dia ForaRevisedm-23-15 ®c Commonweahh of Massachusetts l Division of Professional Lkensure J Board of Building Regulations and Standard, Cons` h1 11-pe ,"Isor CS-077279 :> .._i EA ires:06/2112 0 2 0 STEVEN ASIIVERM- 268 FOMER SOUTHAMPTOW�tAA 01 73 0!�OBJ Commissioner Office of Consumer Affairs and Business Regulation One Ashburton Place-Suite 1301 Boston, Ma�s�sa husetts 02106 Home ImprovernIM Rtractor Registration Type: Corporation Registration: 105543 VALLEVHOME IMPROVEMENT INC _ Elrpiretion: 07/15/2020 P.O.BOX 60627 FLORENCE,MA 01062 1 d A a e/ Update Address and Return Card. O zauusar .fie tlM/AL1�6(l�0��rss RaciifdG Office of ME IN PROVEN ROr Whirs a Business Regulation HOMEIMPROPVENENr CONTRACTOR Registbefore the hatInalid for late. It found use only Rearvs<ratl.,,;ooreEm before theonsumer date. and diness to: E�lrafion Office AhConsumerer-Affairs Suits 1301 Business Regulation b . 0]/16/2020 One Ashburton Place•Sulte 1301 'ALLEYHOME -SaV�M I C Boston,MA 02108 TEVENA.SILV 10 RNERSIDE1 .� ' C� e DRTHAMPTON,MA . 2 Undersecretary Not valid without signature