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46-048 109 ISLAND RD BP-2020-0466 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:46-048 CITY.OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:chimney rebuild BUILDING PERMIT Permit# BP-2020-0466 Proiect# JS-2020-000793 Est.Cost: $4200.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: PAUL KORPITA 25671 Lot Size(sa.ft.): 3746.16 Owner: DAVID S TISCHLER Zoning: Applicant: PAUL KORPITA AT. 109 ISLAND RD Applicant Address: Phone: Insurance: P O BOX 263 413 774-4640 Workers Compensation DEERFIELDMA01342 ISSUED ON:10/11/2019 0:00:00 TO PERFORM THE F LLOWING WORK.-DEMO - BUILD 16X16 BRICK CHIMNEY POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. 1wilding Inspector Underground: Service: Meter: Footings: Rough: Rough. House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas. Fire Department Fireplace/Chimney. Rough: Oil: Insulation: Final: Smok : Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy signature: FeeTvne: Date Paid: Amount: Building 10/1 /2019 0:00:00 $65.00 12 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2020-0466 APPLICANT/CONTACT PERSON PAUL KORPITA ADDRESS/PHONE P O BOX 263 DEERFIELD (413)774-4640 PROPERTY LOCATION 109 I�LAND RD MAP 46 PARCEL 048 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: DEMO- 3UILD 16X 16 BRI EY New Construction Non Structural interior re iovations Addition to Existin Accesso Structure Building Plans Included: Owner/Statement or License 25671 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD P RMIT 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 PE MIT REQUIRED UNDER: § Finding Special Permit Variance* Received&R corded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from PW 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 134y I T"e I D iI 1 Sig ture of LBuilding Official U 0 Date Note: 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. i i VSNOKL� Department use only :riarJ City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 - EDY APPLICATION TO CONSTRUCT,ALTER, REPA , REFOVATE OR DEMOLISH 4 ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION OCj 10 2019 o r � 1.1 Property Address ion t be completed by office DEPT.Or BUILDING INSPECTIONS NOM�lyi PTpN,M. A-.01060 Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 1 �� t-V t SG e2 l o _�.� - Name(Prinij Current Mailing Address: Telephone O Signature 2.2 Authorized A ent: P'X%j t V, fSo k- Name(P i ) Current Mailing Address: A AAA�k Signatur Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS —7 Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building © (a)Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee D 4. Mechanical (HVAC) o 5. Fire Protection 6. Total=0 +2+3 +4+5) Check Number V This Section For Official Use Only Building Permit Number: Date Issued: Signature: V Building Commissioner/Inspector of Buildings Date P 6OrPkf c1 @ (�,fy\,Oktl � EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front _._ "�. Side L: R: L.`_,.. . R a Rear .,. t Building Height j Bldg. Square Footage % -~ Open Space Footage (Lot area minus bldg&paved parking) .. #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO ® DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW Q YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW ® YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: s D. Are there any proposed changes to or additions of signs intended for the property ? YES ® 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 part of a common plan that will disturb over 1 acre? YES 0 NO 0 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 Alteration(s) Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[0] Othet[ Brief Des ' tion of Proposed � � Work: &A40 ',f— Alteration Alteration of existing bedroom Yes No Adding new bedroom Yes o Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If 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? 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 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, , 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. Signature of Owner Date I, , as Owner/Authorized Agent hereby declare that th statemes and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed u der the pains and penalties of perjury. Print Name 0 10 Signature of ner gent V Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su ervisor: Not Applicable( Cl Name of License Holder License um r Addres Exp atio ate b -7 ---� Si ature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ ) N690 Company Name Registration Number 7/)s a Address Expiration D to Telephone SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 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 permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ f _ City of Northampton Massachusetts ��� j. DEPARTMENT OF BUILDING INSPECTIONS y, e4 212 Main Street • Municipal Building y ` 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 of an addition to any pre-existing owner-occupied 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: Est. Cost: quo Q Address of Work: 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 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: to( f Date I 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 t City of Northampton ` Massachusetts + DEPARTMENT OF BUILDING INSPECTIONS � 212 Main Street • Municipal Buildings Northampton, MA 01060 ss -- ��� 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.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. r_ City of Northampton Massachusettsw� - 'r t DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building - 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: 1—1 (Please print house number� and street name)— Is to be disposed of at: (Please print name and locatiorP of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Si ature of ermit Ap ant or dwner 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 oflndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl Name (Business/Organization/Individual): Address: C (, (� City/State/Zip: Phone#: Q Are ytrna mployer?Check the appropriate box: 0 t 3C�L Type of project(required): 1. mployer with employees(full and/or part-time).* 7. ❑New construction 2. I am a sole proprietor or partnership and have no employees working for me in ❑ 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.a 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]i 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 [:]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.F]Plumbing repairs or additions 5.r7 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: p 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: N.An (, A AjV hof(1 tjit_ Policy#or Self-ins.Lic.#:__ty�'r� � 5 Expiration Date: Job Site Address: Cil _L II 11 L City/State/Zip: Attach a copy of the worker ' compensation policy declaration page(showing the policy number an exp ation 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. I do hereby eerti u der the pains n penalti of perjury that the information provided abo a is a/and correct Signature: J Date: 0 6 Phone#: 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 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: tX/W Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Individual PAUL KORPITA p Registration: 104540 D/B/A KORPITA MASONRY , Expiration: 07/13/2020 P.O. BOX 263 DEERFIELD, MA 01342 ^ Y h SCA 1 d ZOM-0 7 4 Update Address and Return Card. Commonwealth of Massachusetts Division of Professional Licensure Hoisting Engineer HE-083434 Expires: IOM11=1 PAUL KORPITA,JR PO BOX 2631PINENOOK ROAD DEERFIELD MA 01342 Commissioner �/�-- Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards CWW upervisor CS-025671 Expires: 10/01/2021 PAUL KORPITA, JR • PO BOX 263/PINENOOK ROAD DEERFIELD MA 01342 1 �4 Mr* Commissioner �rrrMF�M This card acknowledges that the recipient has successfully completed a 10-hour Occupational Safety and Health TraininlCourse in Construction Safety and Health PAUL KORPITA Michael Millsap 7/6/2010 _.. (Trainer name--'p'rint or type) (Course end date) Rim W'*) v1;0.;is i�4:�OtJCi l•tt+=-E!iV r.• l.xy....:-� f9!2'rt '':f :0t % .•9?VN i .. ..• �'":;'ln'`i.•�� 3t j1S!S".i�!it'x•;ty^t.Gf ir'1�::KNk�s"'�J -ETD WX 114; 401 -. -----^.••.-."'.'_.._......,.....,.._ _...,...... �(}(i:9fft:.^"fit 4>? .f Vit',"���. M1l,r•. • JT r 6 Lot;arir7+C:t;du�;�b�t:�a�t. IY �aa.�,n� pelt.=Es!3 Kctz�si�±�uz �u°a ?:vuRnlsy:• E�,S/:3"t41t1 0. jyl":,t.121t3i.1^f ,''k:ti•f!1!'l5 " rrr,4a,!;!E:tllN+il9ku ni'}•..�73C[!!'F:e.a�' ^,!.�til�2!(i i3tiL .'�Ew+i{':i; rt�•.ru.,..-•-_.. ''FES:tf`t3 WIC .... �r,�a,,� j!f t �"r: p "_'��Sf!!ti.si'� �Y'f1 't04..>•,r"• ' lepoa i Udsoc.Gt. lr ri. - =;:.i:�..-!'>IC:':U! �f1.1;!!l.'itti �C.Nilt.: '•sl �"SI}%t• Ji t+y•12agrt;tt267.�. rte;"a=.rr .a��:as.,a t�'•;nr.v�-v•:+ 1i'•L. Er;[.'I�i'`{N,,'}lei°:>.;`� .. �y�,` iJ�43. •,� %.�si.�•.stw . .. . �,,.tt.• ....11 ,y�G,�+<::.:l itll 1. il'•:=,h•, E-�,!�A.l f y.l�/;.•lIE!„-:f J{.i�e'i ff�,tn�a%j�7`v¢YL - f'^ '., . X13 ��:e t1i33E3t V41, `�..:'.xXj ' /�• l':\'4a1'1��i�4�i�'tiE;.�,C�``��� ��y `.� '�a����a1.L.����'Yh���a 1 RE: 109 Island Rd NorthamptonMA 01060 October, 7.2019 To WhOM it irr coficern'. I, David Tischiet , of 109 Island R40, Northampton, Ma authorize Paw Korpda to request a building permit for masonry/chimney work to be peelorred at said proDWV. Thank You, David T*Chkr I & J L (413)310.6W Vis, QV WORKERS COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY—INFORMATION PAGE INSURER: POLICY NO: WCP1753F NGM INSURANCE COMPANY 4601 TOUCHTON ROAD EAST RENEWAL OF: WCP1753F SUITE 3400 NCCICom an No: 16322 JACKSONVILLE, FL 32245-6000 Company Account No: CACP1753F ITEM 1.NAMED INSURED AND MAILING ADDRESS: AGENCY NAME AND ADDRESS: PAUL KORPITADBA KORPITA ENCHARTER INSURANCE LLC (SEE NAMED INSURED ENDT) PO BOX 263 25 UNIVERSITY DRIVE DEERFIELD MA 01342-0263 AMHERST, MA 01002 AGENCY PHONE NO.: (413) 549-4971 AGENCY NO.: 201506 LEGAL ENTITY: INDIVIDUAL OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Location Schedule) ITEM 2 POLICY PERIOD: From: 12-31-2018 To: 12-31-2019 Effective 12:01 A.M. Standard Time at the Insured's mailing address. ITEM 3. COVERAGE: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident: $ 100, 000 each accident Bodily Injury by Disease: $ 500, 000 policy limit Bodily Injury by Disease: $ 100, 000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: all states except: ND, OH, WA, WY and states designated in ITEM 3A of the information page. D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. ITEM 4, PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verification and change by audit. Please see Classification Schedule. Total Estimated Minimum Premium: $ 500 Annual Premium: $ 8, 609 Audit Period: ANNUAL Date: 10-26-2018 Countersigned by WC 00 00 01 A Copyright 1987 National Council on Compensation Insmrice IMR ED cow a K(A$4P r A KASUNRV -r�- 640 y, 40N�'d �d CAA G z€a,� SWR i