38B-121 (7) 160 SOUTH ST BP-2019-1450
GIs B: COMMONWEALTH OF MASSACHUSETTS
Map:Bloc :38B- 121 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:Smir BUILDING PERMIT
Permit# BP-2019-1450
Project N JS-2019-002354
Est.Cost:$1500.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License:
Use croup: Homeowner as Contractor_
Lot Size(sa.fl.): 8276.40 Owner: SHEARER DAVID W&ALICE M
Zoning:URB(100 Applicant SHEARER DAVID W&ALICE M
AT: 160 SOUTH ST
Applicant Address: Phone: Insurance:
160 SOUTH ST (413)584-9554 O
NORTHAMPTONMA01060 ISSUED ON:6/1012019 0.00.00
TO PERFORM THE FOLLOWING WORK REPLACE STAIRS AND LANDING IN EXISTING
FOOT PRINT
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: 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 signature:
FeeTvpe: Date Paid: Amount:
Building 6/20/20190:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck-Building Commissioner
• Department use only
City of Northam ton Status Pe it:
Building Depart ent JUA t g C n way Pe and
r212 Main Sir t Sam,/ aptic vailability
Room 100 r ell A ilabiliry
1 QEp T oc BUILDING Ila of ructural Plans
Northampton, MA 106V No9THAMPTON,M
phone 413-587-1240 Fax 413- -
ONer Spedry
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONESo OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION P q-
1.1
l~v
1.1 Property Address: This section to be completed by office
-S/f{TF/S � se
T. Map�= Lot ("1`4 Unit
e'1 O 1 O!If/O Zone Overlay District
/"KJ r,Ort/4 '7 Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORUED AGENT
2.1 Owner of Reeord:
Name(PtlM) Cu M Melling Atldress:
Telephone j
SignaNe J
flM
2.2 Authorized Apert:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
cpm letedb emlitapplicant
1. Building Q(7 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Q Check Number
is Seed"For Official Use Onl
Building Permit Num DateIssued.
Signature: 19 - ZD(9
Building Commissionedlnspector of Buildings / Osla
_�rOill �g @ adllil . /st1sY1
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING7 All Information Must Be Completed.Permit Can Be Denied Due To Incurnplete Inforrnation ,
Existing 'Proposed Required by Zoning
This column m be filled in by
Building l Wnmeni
Lot Size
Frontage
Setbacks Front
Side L R: L R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(Io[ema minus bMg&puvN
N
of Puking Spaces
Fill:
volume&Locmbn)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT 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 k
B. Does the site contain a brook, body of water or wetlands? NO O 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 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 i acre or is it pan 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 1applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding[O] Other[a
Brief De tion of Pro sed f-AA(Li N (s
Work ' pfy!{)* �° SrAuVS ! /��AI - EOINtg Ek tsr,�{o 4(2� . 8IB'4/t/ K
Alteration of emsfing bedroom_Yes_�No Adding new bedroom Yes ✓No
Attached Naro five Renovating unfinished basement Yes -LZNo CJ
Plans Attached Roll -Sheet
se. N 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 stories?
L Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
If. Type of construction
i. 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. Sepfic 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, as Owner of the subject
property
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signatureof Owner ,�./) Dale
I, �r���?��1L as Owner/Authorized
Agent hereby declare that the sta ments and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under me ins and penalties of perjury.
Print Name
XSignature olsOwner/Alijent Date
1
SECTION S-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of Lioense Holder
license Number
Address Expiration Date
Signature Telephone '
9.Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 16 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(Ill c.152,S25C(S))
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....... O No...... ❑
City of Northampton
Massachusetts
1 nCPaala�il' Or B0111,1mi zNSPECTIOmi
312 Main etr«t • annIcipal eulld n,
Narthnwt n, NA 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, modamization, conversion,
improvement,removal, demolition,or construction of an addition to any pre-ezistlng owneroccupied building containing
at least one but not more than four dwelling units....ur 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: Est.Cost:
Address of Work:
Date of Permit Application:
I hereby certify that:
Registration is not required for the following remon(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 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 a building permit as the agent of the owner:
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice, 1 hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
Massachusetts
X
� [RPAR18aIlT OF BOZZOSNG INSPECTIONS
�. 212 /Lin Beni[ • N ieiFal Building �- Y
NerfA ton, N 01060 to
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 110.115.1.3.1
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.
City of Northampton
Massachusetts t
cla?" NENT OF HULLOING INSPECTIONS
212 Nein etrost •Municipal Building ?
NOrthm ten, M 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 property licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris frroo`m construction work being performed at:
90
4am Sr
(Please print house number and street name)
Is to be disposed of at:
/Ahl �ASrf/NrtPrOPI
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
SignaW of Permil plicant 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
W11corkers'
Department oflindustrialAccidents
7 Congress Street,Suite 700
Boston,MA 01714-2077
www.massgov/dia Compensation Insurance Affidavit:Builders/Controcmn/Eleetrieians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leoibly
Name(BusinessrOrganizanorelfalmdua0:
Address:
City/State/Zip: Phone#:
Am ma an employer?cheep We"in'slate nor: Type of project(required):
IQ I moa emplo ,ywin emplones(son arWorm
P -tormlu
' 7. New constrlach.on
2.01 em a sole pmpdemror permership and Mve no employees wokng forme in S. ❑Remodeling
any capacity.INo workm'comp insurance requhed.l
301 oma Mme.own,dom ml work myself[No scmks'compbamanm m,.d.]' 9. ❑Demolition
414 ren l o ncowna and will be hvwg wnuanms m emMud all wok on my repent. I will 10❑Building addition
thu all cantmemn eilh,have workers'wmpenamion ars.or am sole 11.0 Electrical repairs or additions
pmpdcmm win an employee`' 12.0 Plumbing repairs or additions
5.rl 1 am a gemrd connowwr sort 1 hove hired the anh-conmemm lined on the mmched sheee 13.OROof repairs
new sub<onoactors have employan and have wokers'camirss
p. urecam
6.0 w'c are a corporation and is oflm,s have exereisW then right ofexempdon pm MGL c. 14.❑Other
153.71(4),avd we have an empinyew.INo wokers camp.naumrce requimd.j
'Any applicant dmr checks box#I most also nu ore the section below snowing their workers'comiscroa on policy thforamal
I Hommwners who submit this andevit indicating they are doing all work and nen him outside Constrictors must submit a new affidavit maicatng such.
:C—tracmrs than check Nis box must mmched an addommal sheet showing the name of the sub-conoocmns and smm when,or nor nose entities save
empleycc5. If the subconsocmn have employees,they muse pmvidc mea workers'con, policy ounber.
7 am an employer that is providing workers'compensation insurancefor my employees Below is the policy andjob site
information
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
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 of a STOP WORK ORDER and a fine of up to$250.01 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 and penalties of perjury that the information provided above is true and correct
K
Simulate, DaleGfist h
Phone#: 1,571,57Y!/s
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):
L 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 on provide workers compensation for their employees.
Pursuant to this statute,an eacployee 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 trinam 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 on 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 numbers)along with their cenificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or patters,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
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/lic nese 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"lob 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
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.mms.gov/dia