17C-168 (3) THE COMMONWEALTH OF MASSACHUSETTS
OFFICE OF CONSUMER AFFAIRS AND
ForOCABRUseOnly.
BUSINESS REGULATION Registration No:
10 Park Plaza, Suite 5170
d
Boston , MA 0 2 1 1 6 Effective Date:
W Application for Registration as a Home Improvement
Contractor or Sub-Contractor Expiration Date:
(MGL c.142A;201 CMR 18.00)
1. NAME OF APPLICANT: PNj L L C.
(MUST BE EITHER ANmwmuAL,CORPORATION,LLC LLP,TRUST,OR OTHER LEG
2. NUMBER OF EMPLOYEES: Z
I APPLICANT TYPE: _&INDIVIDUAL "'CORPORATION _PARTNERSHIP _TRUST
(CHECK ONE--MUST BE SAME LEGAL ENTITY AS THE ENTITY IDENTIFIED IN#I)
4. SOCIAL SECURITY#: `7 FEDERAL TAX ID#: �' l Dr`?
5. APPLICANT PHONE#N 13) E APPLICANT EMAIL ADDRESS: �� cum / -Qu
6. MAILING ADDRESS: G •
STREET CITY AXTE ZIP
7. PERMANENT ADDRESS:
STREET CITY STATE
PLEASE NOTE THAT A P.O.BOX IS NOT ACCEPTABLE FOR PERMANENT ADDRESS. YOU MUST LIST A STREET ADDRESS.
S. 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 WORK(Please review/the Instructions before answering this question):
LAST FIRST SOCIAL SECURITY# TITLE
9. IF APPLICANT IS DOING BUSINESS UNDER A D/B/A,PLEASE STATE THAT D/B/A,AND ATTACH A COPY OF THE
FICTICIOUS NAB CERTIFICATE FILED WITH THE CITY OR TOWN CLERK:
DBA NAME:
10. (a)DOES THE APPLICANT OR RESPONSIBLE INDIVIDUAL HOLD ANY OTHER CONSTRUCTION-RELATED STATE,
CITY OR TOWN LICENSES OR REGISTRATIONS? YES V"'NO
(b)IF YES,PLEASE FILL IN INFORMATION BELOW.ATTACH ADDITIONAL SHEETS IF NECESSARY.
LICENSE TYPE ISSUED BY LICENSE/REG.# EXP.DATE LICENSEE NAME
No. 201244
Florence Savings Bank 53-7168(2118
85 Main St., Florence MA 01062 DATE November 29, 2012
MONEY ORDER
PAY TO THE C G�
ORDER OF (n,<v e \'S�� CSC+ �t� ��l��y $ 100.00
One Hundred and 001 100******************************************* DOLLARS
MEMO ( L �� iC � ,� NOT VALID OVER$1000.00
NON-NEGOTIABLE
Customer Copy DRAWER/REMITTER
ADDRESS
ADDRESS
Acheson Company,LLC
t
5373
s
Q►]�QlC�Saws$al1l�
85 Mam,St., Florence MA 01062
_ MONEY ORDERS
kY TO THE `°�?�lti.ti—c vv �?ort'�'t O '� S tF-� �'J $ 100.00 J
DER OF -
One Hundred and 001100*********** " �**** DOLLARS
J -\
NOT VALID OVER$1000.00
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City of Northampton
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building 1
Northampton, MA 01060
� y
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)-
will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
Y M.
The Commonwealth of Massachusetts
' Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
y www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): `�-\ � ,}✓� L
Address:
City/State/Zip: Phone#:
Are yo.4.an employer? Check the appr rate box: Type of project(required):
1.P1 am a employer with 3 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 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.1
required.] 5. ❑ We are a corporation and its 10.E] Electrical repairs or additions
3.❑ I am 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#I 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.
tContractors 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: c Uf
Policy#or Self-ins. Lic. M `V,�C S(:�;O I Expiration Date: /
Job Site Address: �2/ A6+ City/State/Zip: I C3 e—
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 agai violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the for insuranc ovF�A cation.
I do hereb ertify nder the pai d p alties of per+ that the information provided above is true and correct.
Si Date: t,. vi
Phone#: �7 7 �=
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{SSupervisor: Not Applicable £ /
Name of License Holder: '*-- Ow'CUMI,�AJ�^� A �,_ )�� ,Z-
Z,Jt\��� ++� M�'C` License Number
i
C.l cqk 11 1 -7
Address Expiratiod Dat
�fi r
nature 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 Exemption
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 pen-nit 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 Alterations) Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[0] Other[0]
Brief Description of Proposed
Work: i.y'rv�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa. If New house and oraddition to exlstlilq.housnq,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
as Owner of the subject
property
hereby author' e
to act on m eh , i II matters relative to work authorized this b ding permit application.
Signature of Owner
Date
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 underthe pains and penalties of,perjury.
Print Name F
Y/�-/Y
Signature of Owner gent Date
^ °
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Tliis column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg.Square Footage
Open Space Footage %
(Lot area minus bldg&payed
#of Parking Spaces
(volume&Location)
A. Has a Special Permit/Variamce/Finding ever been issued for/on the site?
»~� �—�
NO �N� DONTKNO\� «�� YES �~�
|F YES, date ioued1
IF YES: Was the permit recorded at the Registry ofDeeds?
NO K � DONTKNOYY 'ES
~~~
IF YES: enter Book Page and/or Document#
��
B. Does the site contain a brook, body of water ur*edands7 NO m�N��� DON7 KNOW �~� YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained �~� Obtained �~� Date Issued:
�-� �~� ' .
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF YES, describe size' type and location: f |
E. Will the construction activity disturb(clearing, gradin
'
vabon.or filling)over 1 ooaorio�po�nfa common plan
thu�wi||distudbover1ao,e? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
^ —
'
City of Northampton status of Permd '� �T-�I �1 f� rA i
R — 9 Building Department Ctrr)�CUt/Drlveway Perrrt�# 1 1 t
oy
:212 Main Street SeyrerlSepticAva�rablllty Pi
• S k� ,7.T.h Tlj Y1 ��4
FIE ei.,`_ .— .;
c Room 100 WaterlklC�ellAva�lafilht
r .. I ���'�
_.
,k ,Qhhampton, MA 01060 Two Sets of�Strt�ctnFal Plans ; 1''�r{' thi ia' $ ,ti
L.tl
phone
493587-1240 Fax 413-587-1272 Plof/Site Plans
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be mpleted by office
1.1 Property Address:
AT
Zone' 5. +�" Overla District
ll Elm St District CB District
SECTION 2. PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: oc 2-
Sc - U- Ste.
Name Pri Current Mailing Addr ss:
C 73
Telephone
Signature
2.2 Authorized Age /f
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
complW&d by ermit applicant
1. Building v v (a) Building Permit Feb
G
2. Electrical C) (b)Estimated Total Cost of
y Construction from 6
3. Plumbing Cj G lj Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number
This Section For Official Use'Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector'of Buildings Date
File#BP-2014-1034
APPLICANT/CONTACT PERSON R DEAN ACHESON
ADDRESS/PHONE 6 NORTH MAIN ST WILLIAMSBURG (413)268-0246
PROPERTY LOCATION 38 HIGH ST
MAP 17C PARCEL 168 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building_Permit Filled out 4
Fee Paid
Typeof Construction: CONVERT 1/2 BATH TO 3/4 BATH
New Construction
Non Structural interior renovations
Addition to Existing-
Accessory Structure
Building_Plans Included•
Owner/Statement or License 83968
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO YXIATION PRESENTED:
Approved 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
D on Del `'
C.
<�-
Si re of B ilding Officia 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.
38 HIGH ST BP-2014-1034
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 168 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2014-1034
Project# JS-2014-001785
Est. Cost: $11500.00
Fee: $69.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: R DEAN ACHESON 83968
Lot Size(sa.ft.): 8189.28 Owner: SOLA MICHAEL
Zoning: URB(100)/ Applicant: R DEAN ACHESON
AT. 38 HIGH ST
Applicant Address: Phone: Insurance:
6 NORTH MAIN ST (413) 268-0246
WILLIAMSBURGMA01096 ISSUED ON.51612014 0:00:00
TO PERFORM THE FOLLOWING WORK.CONVERT 1/2 BATH TO 3/4 BATH
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 5/6/2014 0:00:00 $69.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner