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11. (a)HAVE YOU BEEN REGISTERED PREVIOUSLY AS A HOME IMPROVEMENT CONTRACTOR? YES XNO
(b) IF YES,PLEASE PROVIDE THE NAME AND REGISTRATION NUMBERUNDER WHICH YOU WERE
PREVIOUSLY REGISTERED:
NAME: HIC REGISTRATION#:
12.(a) ARE YOU CURRENTLY OR HAVE YOU EVER BEEN AK OFFICER,PARTNER,OR CO-VENTURER OF
AN APPLICANT WHO PREVIOUSLY APPLIED FOR OR HELD A HOME IMPROVEIIIENT CONTRACTOR
REGISTRATION? YES Y-NO
(b) IF YES,PLEASE PROVIDE THE NAME OF THE APPLICANT/REGISTRANT AND THE REGISTRATION
NUMBER:
NAME: HIC REGISTRATION 9:
13.(a) ARE YOU CURRENTLY OR HAVE YOU PREVIOUSLY BEEN EMPLOYED BY A REGISTRANT OR
APPLICANT FOR REGISTRATION AGAINST WHICH DISCIPLINARY ACTION WAS TAKEN?
_YES/No
(b) IF YES,PLEASE PROVIDE THE NAME OF THE APPLICANT/REGISTRANT AND THE REGISTRATION
NUMBER:
NAME: HIC REGISTRATION 9:
14. (a)HAVE THERE EVER BEEN ANY FORMAL COMPLAINTS AGAINST YOU WHERE DISCIPLINARY ACTION
WAS TAKEN BY THE DEPT.OF PUBLIC SAFETY OR CONSUMER AFFAIRS,OR ANY COURT
JUDGMENTS OR ARBITRATION AWARDS ISSUED AGAINST YOU?
_YES Y NO
(b)DO YOU OWE MONEY TO THE GUARANTY FUND?
_YES YNo
IF YES TO EITHER,PLEASE IDENTIFY.BY DATE,CASE NUMBER,OR DOCKET NUMBER:
IMPORTANT FEE NOTICE: CHANGE IN LAW ABOLISHES CSL's HIC REGISTRATION FEE
EXEMPTION. As a result of a recent change in the law(Section 80 of Chapter 27 of the Acts of 2009),the holders
of Construction Supervisors Licenses are no longer exempt from the HIC Registration fee. CONSEQUENTLY,
ALL CONTRACTORS,INCLUDING CSL's WHO ARE APPLYING FOR A HIC REGISTRATION MUST
PAY A REGISTRATION FEE OF$150.00,AND A GUARANTY FUND FEE. (See below for Guaranty Fund
fee schedule.)
Guaranty Fund Fee Contribution
0—3 Employees $100.00
4-10 Employees $200.00
11—30 Employees $300.00
More than 30 Employees 1 $500.00
15. REGISTRATION FEE ENCLOSED:$ GUARANTY FUND FEE ENCLOSED:
PLEASE INCLUDE TWO(2)SEPARATE CHECKS OR MONEY ORDERS,ONE MARKED"REGISTRATION FEE"
AND ONE MAP,KED"GUAP.ANITY FUND."11AvcE CHECKS PAYABLE TO"COMMONWEA LTu OF
MASSACHUSETTS."
THE COMMONWEALTH OF MASSACHUSETTS For OCABR Use Only.
OFFICE OF CONSUMER AFFAIRS AND
BUSINESS REGULATION Registration No:
10 Park Plaza, Suite 5170
Boston , MA' 02116 . Effective Date:
Application for Reeistration as a Home-Improvement
Contractor or Sub-Contractor Eapiration.Date:
" (MGL c.142A; 780 CMR 110R6)
1. NAME OF APPLICANT: / &YA rl J`
(MUST BE EMBERANINDIV'IDUAL,CORPORATION,r_T y LLP,TRUST,OR OTBERLEGAL ENTM
2. NUMBER OF EMPLOYEES:
3. APPLICANT TYPE:.yINDTVIDUAL_CORPORATION_PARTNERSHIP_TRUST
(CHECK ONE—MUST BE SAME LEGAL ENTITY AS TBE ENTITY IDENTIFIED IN#1)
4. SOCIAL SECURITYNO.:N3 36 Q 3 4�2 FEDERAL TAX ID NO.:
5. APPLICANT PHONE#:113 6-",7,:r 16-60 APPLICANT EMAIL ADDRESS: WV CONS'TRUc,�AO,4 .Cp y
6. MAILING ADDRESS: U ,�L,¢���/�i1i2y e�i2 /�`OLyar�F .Cir ✓� o/o Ya
STREET CITY STATE ZIP
7. PERMANENT ADDRESS:
STREET CITY STATE ZIP
PLEASE NOTE THAT A P.O.BOX IS NOT ACCEPTABLE FOR PERMANENT ADDRESS. YOU MUST LIST A STREET ADDRESS
8. IF THE APPPLICANT IS A CORPORATION OR A PARTNERSHIP,PLEASE PROVIDE THE NAME,ADDRESS,SOCIAL
SECURITY#AND TITLE OF THE INDIVIDUAL WHO WILL BE RESPONSIBLE FOR THE CORPORATION'S THE
TRUST'S OR THE PARTNERSHIP'S WORK(Please review the Instructions before answering this question):
LAST FIRST SOCIAL SECURITY# TITLE
9. IF APPLICANT IS DOING BUSINESS UNDER A DB/A,PLEASE STATE THAT DB/A;AND ATTACH A COPY OF THE
FICTICIOUS NAME CERTIFICATE FILED WITH THE CITY OR TOWN CLERK:
DBA NAME: IA/.((C 1�Z5/�' G£?if l c!i 2G' 0j--26'y
10.LIST ALL PARTNERS,TRUSTEES,OFFICERS,DIRECTORS,AND MAJOR OWNERS(10%OR GREATER OF
OWNERSHIP)OF AN APPLICANT PARTNERSHIP OR CORPORATION,BELOW.USE ADDITIONAL PAPER IF
NECESSARY AND INCLUDE NEEDED PAPERWORK(SEE INSTRUCTIONS).PLEASE INDICATE BY AN"X"IN THE
LAST COLUMN THOSE INDIVIDUALS WHO REQUIRE AN APPLICATION FOR ADDITIONAL REGISTRATION I.D.
CARDS.USE ADDITIONAL SHEETS IF NECESSARY.
FULL NAME TITLE % OWNER ADDRESS UPP.CARD
)' R D ldld O .;Z 'l- J 0 0 /V az # Lott/ a/it
. � City of Northampton
/ T7 Massachusetts
y t DEPARTMENT OF BUILDING INSPECTIONS
` 212 Main Street • Municipal Building
Northampton, MA 01060 ss y jtt�
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which
he/she resides or intends 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 home owner."
The building department for the City of Northampton wants any person(s)who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages, which include
foundation/footings (before backfill), sonotube holes (before pour), a rough building inspection
(before work is concealed), insulation inspection (if required) and a final building inspection.
The building department requires these inspections before the work is concealed, failure to secure
these inspections can result in failure to obtain a certificate of occupancy until the work can be
inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas)the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspections are made
I, understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
t The Commonwealth of Massachusetts
Department of Industrial Accidents
u Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 'I/j_fZ_, ,1�c)/� C' D
Address: ,Io ZIr
City/State/Zip:Z 4040 �= ,[/1 Phone _/S
Are yoy an employer? Check the appropriate box: Type of project(required):
1.2 I am a employer with-- ' 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers' comp. insurance comp. insurance.1
5. ❑ We are:a corporation and its 10.❑ Electrical repairs or additions
required.]
3.El I qu a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners 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:-,(/? 7 �i2yST No 47'-1 -/l 4 —
Policy#or Self-ins. Lic.#: ILIU1 C_ -,�0 77l V!�/ Expiration Date:
Job Site Address: o� G12/;G--Uf2y City/State/Zip: //.Og n�it
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 ofperjury that the information provided above is true and correct.
r
Sign ature: f�-'' Date: —J
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#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable £
Name of License Holder
License Number
Address Expiration Date
Sign% Telephone
9.Registered.Home Improvement Contractor.:::_ _ Not Applicable £
Company Name Registration Number
Address Expiration Date
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...... £
11 `-:Home'Owner Ezemptioln
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of 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.
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.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature,
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [M Siding[❑] Other[❑]
Brief Description of Proposed
Work: eLl r,0C>/(,I
Alteration of existing bedroom Yes ` No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement —Ye s No
Plans Attached Roll -Sheet
sa. if New°house'and or add tlon Yo'`exlsfing.h`ouslng,colrnpTete tfie Mid inc
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 /-,I, ' `D � N I* CT-
to act on my behalf, i all matters relative to work authorized by this building permit application.
_ i y
Date
Signature of Owner
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.
Print Name
Date
Sign atu o Owner/Agent
. ^
Section 4. ZONING AU Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be fill4in by ^-~^
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
of Parking Spaces
A. Hasa Special Permit/Yariance/Rnchng ever been issued for/on the site?
�� ��
NO v_��� DONTKNOYY «�� YES «��
IF YES, date issued:
�
IF YES: Was the permit recorded at the Registry nfDeeds?
NO ~_'K � D � —
�
IF YES: enter 8nuk L Page and/or Document#
B. Does the site contain abrook, body nf water orwetlands? NO 0 DONTKNOY 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained ~��`� Obtained �~�~�� Date� '
C. Do any signs exist on the property? �� ��� YE5 v�� NO �~�
|F YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre orioit part ofa common plan
' that will disturb over 1acre? YESK��� NO K���
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
-
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r 587-1240 Fax 413-587-1272 I'fof/Sit�Plans�i" 4k
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE.INFORMATION
1.1 Property Address: This section to be completed by office
L 1 -1 yNr 1 �
G` ��+--c� '�Y .Map Lot r Umt
Z_�'��irvG/! It �7 Zone }' Overlay D�str►cf
i
TY 5
_3 I
_:EIm St District � - �.. 1 CB Distuct -
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
' Telephone
Signature
Ar
2.2 Authorized Acient:
/Zlq-XA0-'NIA Gl,/i��/`�/a��'>i- / �L J3�-�d�� CiYZ i Xvrr'
Name(Print) Current Mailing Address:
f i' e/ �3 s mss-i�
Signat Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS. .
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
CV CJ Ci Construction'from 6
3. Plumbing U Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) c%'cI Check Number to
This Section For OfficiM Use'Only
r�
Date
Building Permit Number: Issued: lip
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2014-0790
APPLICANT/CONTACT PERSON RAYMOND WISCHHOF
ADDRESS/PHONE 10 Blackberry Circle HOLYOKE (413)533-2520
PROPERTY LOCATION 25 GREGORY LN
MAP 29 PARCEL 526 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid Q
Building Permit Filled out
Fee Paid
TypeofConstruction: ADD BASEMENT BATHROOM
New Construction 1 "
Non Structural interior renovations TAt YY �,
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 052126
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO d ION PRESENTED:
prove
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 Permit 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 y
/—/0 -6
Signa o Building O icial 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.
25 GREGORY LN BP-2014-0790
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-526 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Plumbing BUILDING PERMIT
Permit# BP-2014-0790
Project# JS-2014-001278
Est. Cost: $6000.00
Fee: $105.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RAYMOND WISCHHOF 052126
Lot Size(sq. ft.): 5880.60 Owner: KOWITZ KARL R
Zoning: Applicant: RAYMOND WISCHHOF
AT. 25 GREGORY LN
Applicant Address: Phone: Insurance:
10 Blackberry Circle (413) 533-2520 Workers Compensation
HOLYOKEMA01040 ISSUED ON:111012014 0:00:00
TO PERFORM THE FOLLOWING WORK.-ADD BASEMENT BATHROOM - HARD WIRED
SMOKE/CO DET REQUIRED IN BASEMENT
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 Occupancy Signature:
FeeType: Date Paid: Amount:
Building 1/10/2014 0:00:00 $105.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner