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42-052
587 WESTHAMPTON RD BP-2020-0020 GIS#: COMMONWEALTH OF MASSACHUSETTS MV.Block:42-052 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Cateeom demolition BUILDING PERMIT Permit 4 BP-2020-0020 Project# JS-2020-000029 Est.Cost$9000.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO. Const.Class: Contractor: License: Use croup: Homeowner as Contractor_ Lot Size(sa. p.): 27573.48 Owner: RAWLINGS FRANK zoninw Applicant: RAWLINGS FRANK AT: 587 WESTHAMPTON RD Applicant Address: Phone.- Insurance: 587 WESTHAMPTON RD (617) 529-94510 FLORENCE ,MA01062 ISSUED ON:7/5/20190:00:00 TO PERFORM THE FOLLOWING WORK.DEMO MASTER BATHROOM AND DEMO HALF WALL IN KITCHEN 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 7/520190:00:00 $65.00 212 Main StreeS Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only -� City of Nort m in I s of ermft Building De rtm nt Cu dveway Permit 212 Main tree JUL ' 5 2019 dS ticAvailabilityRoom 00 rAN Il AvailabiliNorthampton, AQ BUimING INSPFCSeas of Structural Plans _ phone 413-587-1240 a`I NA^It ov6ite sans Other Spedfy APPLICATION TO CONSTRUCT,ALTER REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO DWELLING wzf SECTION 1 -SITE INFORMATION 1.4t'f lf 1.1 Property Address'. This section to be completed by office 3 8 xoAo Map Lot 06a Una Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: hq X F,ehff RAwL/N65 587 womINIO)mv Raw X ;z Name CurmM M.i"'°Adtlrew:6/7-5Z.9-9vS/ Telephone Signature 2.2 Authorized Acent: Name(Pmd) Current Melling Add.. Signature Telephone SECTION f-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bpermit applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Perrot Fee 4. Mechanical(HVAC) ✓/1 5. Fire Protection 6. Total=(1 +2+3+4«5) lozago Check Number This Section For Official Use Only Building Pernik Date Number: ssueB. Signature'. Building Comml°sloneninspector of Buildings Date @ 7- S-2LO EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) VRAKL/NGS <�QGMA/L , cost Sectlor 4. ZONING Alt Information Must Be Completed. Permit Can Be Dented Due To Incomplete Information Existing Proposed Required by Zoning Thu column w be filled in by auiidme mepmmnent Lot Size Frontage Setbacks Front —_— Rear — Building Height Bldg.Square Footage ==F�l Open Space Footage (fir mo mww bid,&pied _....._. N of Parking Spaces Fill: rni,a Munn 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 DON'T KNOW O YES O IF YES: enter Book Page and/or Document A 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 t 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 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alaaration(s) 0 Roofing 0 Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs I= Docks [0 Siding[C3] Other[U Brief Description of Proposed Wm &Woll' •s 97"h H 'q- h/Vl-r k`�I L Work kiret4rW' R Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Namative Renovating unfinished basement Yes X No Plans Attached Roll -Sheet its.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 stones? L Method of heating? Fireplacesor 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 bel ow finished grade k. Will building conform to the Building and Zoning regulations? Yes_No. I. Septic Tank_ CitySewer 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 an my behalf, in all matters relative to work authorized by this building permit application. SgrwWre of owner Date FRJV K 041VLV''� 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. Signs un er Ma pains and penalties of perjury. Fp�tiK PW41N6if Prim ria �Lr S �i9 Signature of O.wler/Agint zDale SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder LlGrne Nianber Addreu E)Vaation Date Signature Telephone LBlalstered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Address Expiration Date elephcne SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152,§25C(8)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this af0davhwill result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ City of Northampton ' Massachusetts nBpa800n:rrr OF BUILDING ZNSPBCTZONS 212 Main 9trwt a Mu,icipal Built nq J' S Mor Navptoo, l 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 most be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstructlon,alteration,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owneraccup/ed building containing at least one but not more than four dwelling units....or to structures which aro 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: Eat. Cost: Address of Work: Date of Permit Application: I hereby certify that: Registration is not required fm the following mason(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: Date Contractor Name HIC Registration No. OR: Notwithstandi�n above notice,I hereby apply for a building permit as the owner of the above property: Date ° Miter Name and Signature City of Northampton j Massachusetts DEPWTNr2IT OF BDILDING INSPECTIONS Sy /1 212 Iain straat • Municipal Building Norf :;ton, IN 01060 .n Massachusetts Residential Building Code Section 110.85.1.2 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 hetshe 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 DSPARTIffiiT OFBBZLDZM INSPECTIONS 313 Main Strwt •NunicipBl Building wOJ} Hor Une ton, 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 properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from construction work being performed at: .i S7 W63?W10VR7V1N RD FtoR�cE nA ©1062 (Please print house number and street name) Is to be disposed of at: U/1[.&t% RYc� iN� (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) jv/-Y s 2-0/9 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 IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02774-2017 tourist mass gov/dia WWorkers'Compensation Insurance Affidavit:Buflden/Contractors/E me icians/Plumben. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ep t, r�r� Please Print Leaibly Name(Business/Orgwuatiowindividml): 1 rA2,jpk i`AK111 C/s Address: S$ 7 WE37-W&ViWIV City/State/Zip: L4XE CC /I# N062 Phone#: Sl7—S29-9yS/ Am yon m employee Cheakthe approprhte ha:: Type of project(required): L[JIameemplo,orwim mployces(fWl mNor earl-limcl.' 7. New construction 2.E]I earn sole faapri.orparnment,rad have an ers,i workout for me in 8. Remodeling any capacity.(No workerscmc.mismance regoir al] 3gimebooaowaerdomgetlworkm If.(Now m comp.mareareerequimd.]' 9. JR.Demolitlon 4.E]I m a homeowner asst will be burns contractors in conduct all weak on my property. Iwill 10 Building addition maser unioncontractors either have workers'sompwntion thmarmc or so,mle 11. Electrical repairs or additions poprrueswithnampbyeo. 12. Plumbing repairs or additions 5.[]1 on a geaeml contractor and I leve bud she sub<xamismn luted on the aumhd Man. 13�Rlwf repairs Throe sub-covmrs cwhave employers a nd have worker comp.numare.l o 6.[]wearta cerpmadonandinomcers have exercised then light oferem rem per MGL c. 14.F]Other 153,41141.ad we have no employsa_INS worker map.insurance se mired.] *Any applicant that checks box#1 most also all out the saetion below showing then workers'comprnsarm policy mfomrrwmo t Homeowners who submit the affduvit i throb ng they are doing all work unit then hire outride eantractors must submit a new affidavit indicating such. ;Cwh ,.dot check this bus must attached an additional sheet showing the name of the sub-con nwron and state whethvT or not those entities have employ., 11 ale sub-cwaecmrs have mnpinyers,they must Pmvidv Nur —rtters comp policy nm Mi four an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site informaton. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: Citytstatezip: 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$250.00 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. /do hereby ce nder Dins ndpenahies of perjury that the information provided above is true and correct Si®azure: Date: S, 2or9 Phone#: 617' 529 ' yJr/ 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): 1.Board of Health 2.Building Department J.City/Town Clerk 4.Electrical Inspector S.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 ajoint enterprise,and including the legal representatives of a deceased employer,or the receiver or ounce of an individual,partnership,association or other legal entity,employing employees. However the owner of 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)murals),address(es)and phone number(s)along with their certificatels)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to tarty 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 rammed 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 To"Official 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 permitAicense number which will be used as a reference number. In addition,an applicant that must submit multiple permitAiccose applications in any given yew,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 m 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.mass.govldia d'oOQ N B 8 U' .v/t6cYC� i aN/ �LI � S7o Y-x-i ors 2-2 Q�(�c�a/ No1a�G�Ffh'L �rti G 8 S X11/r.1 H1396z/7,� 7Wa I Shb brS G/9 5-9N/7MHJ *'Va9 14 s 7 -7 WA n 0 � �✓o�1i�oG,c.�Q� ah�l �yl (7, ✓o/dH611-l1 5-3M ZS S X11/M /lL38f!=/'73 72-2-;, /Sfi6 &-eS G19 S�JM�7MH`j NNyal�