Loading...
31A-090 (2) 1 O U)M rnrn i VJ M r— J O g J i J 1 p r) O J / i U 1 Z w i � w 0 F- i ■ Y = Y ■ Z \ rm Z _ m Er m Ir cn LD N a0 co LB Z N ru Z N ru Ir Ir w \ u, LO wZ 2 Lo LO s V1 a • LL 7Z) � I LL LJ h ■ J 1 O N 6 r■ V _ 2 r Y� 63 co cc cc d N Fao __^^ �: NY�H pay _n LD v LO 1 � I r'� cc co Z W rte W © ru CD CD LLI 04 � z c �' Zoo ' y. mLL O amLL O boa ' O moo~ S O Zai = Zai 3 ._ ~ m m Co z p z " c!3:L N off W J V j co x LL Q!, i LL p a H F- 0 o J > o � "' o' Q w Y D CL i i I hereby swear, under the pains and penalties of perjury, that all information set forth on this application and submitted in support hereof is true and accurate to the best of my knowledge. Further,I certify under G.L. c 62C, §49A, that I am in compliance with all laws of the Co zonwp4,1h relating to taxes, reporting of employees and contractors, and withholding re i o chi supp¢4 tore JAkoi#t If a corporation or partnership,position held. D�e INSTRUCTIONS FOR COMPLETION OF APPLICATION FOR REGISTRATION AS A HOME IMPRO1,Eb4ENT CONTRACTOR OR SUBCONTRACTOR Please refer to the following instructions for assistance ui completing the Application for Registration as a Home Improvement Contractor or Subcontractor. NOTE:NOT ALL ITEMS ARE LISTED AS THEY ARE SELF-EXPLANATORY. ITEM#: I. Name:The name on the application must be the legal name of the applicant,not a DBA of other fictitious name under which you are doing business.If you are renewing a previous registration,the name cannot be a different name than used for the previous registration.If you wish to register using a different name you must file a new registration application and pay the initial registration fee as well as pay the required Guaranty Fund amount. 2. Number of Employees: The number of employees must include all construction-related employees who worked 20+ hours or more on the payroll in the weekly pay period prior to the filing of this renewal form Businesses that are renewing a registration and have increased the number of employees since the previous registration may need to pay an additional amount into the Guaranty Fund pursuant to M_G.L.c. 142A, § 11. 3. Applicant type: For all applicants doing business under a name other than their legal name, a copy of the fictitious name certificate filed with the city or town clerk must be included with your application. 4. Federal Tax ID: Applicant partnerships and corporations must submit a Federal Tax I.D.number.Even if the applicant is an individual,he or she must submit a Federal Tax I.D.number if they have employees in addition to the owner. 8. Responsible individual:If the Applicant is a corporation or partnership,M.G.L.c. 142A,§9(c)requires an individual to be designated as the person who will be responsible for the corporation's or partnership's work. The identifying information applicable to that designated person must be entered here. 9. Company name: An applicant doing business under a name other than the applicant's legal name must submit a business certificate issued by the city or town. 10. Corporate and Partnership Information: Corporations or partnerships listing partners, owners,etc.must provide an official document that lists the information entered here.The document may be any one of the following:pertinent sections of the Articles of Organization,a current annual report,or registration with the Secretary of State as a foreign corporation.(Information on these documents can be found on www.sec.state.ma.us.)Organizations other than corporations must submit copies of a business certificate filed in the city or town where the business is located,pursuant to M.G.L.c. 110, §5. 12. Prior Affiliations: Applicants must provide the name(s)of any businesses registered pursuant to M.G.L.chapter 142A and 780 CMR R6 in which the applicant was an officer,partner,or co-venturer.Attach additional sheets as necessary. 14. Prior Disciplinary Action: Applicants must provide the name(s)of any businesses against which disciplinary action was taken by the Department of Public Safety or the Office of Consumer Affairs and Business Regulation that the applicant is currently or was once employed by. Attach additional sheets as necessary. 15. Fees: CHANGE IN LAW ABOLISHED CSL'S HIC REGISTRATION EXEMPTION. ALL CONTRACTORS APPLYING FOR A HIC REGISTRATION MUST PAY A REGISTRATION FEE OF$150.00. Enclose a certified check or money order for the Registration Fee and a separate certified check or money order for the Guaranty Fund Fee in the amounts indicated below. Make checks and money orders payable to the"Commonwealth of Massachusetts." Registration Fee: $150.00 — Valid for two(2)years from date of issuance. Guaranty Fund Fee:Applicants must pay the amount that corresponds with the number of their employees: Zero to three(3)employees: $100.00 Four(4)to ten(10)employees: $200.00 Eleven(11)to thirty(3 0)employees: $300.00 More than thirty(30)employees: $500.00 Completed applications, Registration Fees, and Guaranty Fund payments should be mailed to: OCABR--Home Improvement Registration Program 10 Park Plaza, Suite 5170 Boston,MA 02116 Rev, 11/2009 11. (a)HAVE YOU BEEN REGISTERED PREVIOUSLY AS A HOME IMPROVEMENT CONTRACTOR? YES. NO (b) IF YES,PLEASE PROVIDE THE NAME AND REGISTRATION NUMBER UNDER WHICH YOU WERE PREVIOUSLY RE GIS TERED: NAME: HIC REGISTRATION#: 12.(a) ARE YOU CURRENTLY OR HAVE YOU EVER BEEN AN.OFFICER,PARTNER,OR CO-VENTURER OF AN APPLICANT WHO PREVIOUSLY APPLIED FOR OR HELD A HOME Ill[PROVEMENT CONTRACTOR REGISTRATION? YES/< NO (b) IF YES,PLEASE PROVIDE THE NAME OF THE APPLICANTIREGISTRANT AND THE REGISTRATION NUMBER: NAVID: HIC REGISTRATION#: 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#: 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 4 No (b)DO YOU OWE MONEY TO THE GUARANTY FUND? YES No 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. Asa 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$150.009 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 $500.00 /(' �' 15. REGISTRATION FEE ENCLOSED:$ V GUARANTY FUND FEE ENCLOSED: / L� U PLEASE INCLUDE TWO(2)SEPARATE CHECKS OR MONEY ORDERS.ONE MARKED"REGISTRATION FEE" AND ONE MARKED"GUARANTY FUND."MAKE CHECKS PAYABLE TO"COMMONWEALTH 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 Registration as a Home Improvement Contractor or Sub-Contractor Expiration.Date: (MGL c.142A; 780 CMR 110R6) 1. NAME OF APPLICANT: 0 w�t J ja�cdlzmc5kl' gauss BE EnmERA,-imrVIDUAI,CORPORATION,LLC,LLpi LST,OR OTHERLEGA .E VT M 2. NUMBER OF EMPLOYEES: 3. APPLICANT TYPE:4nDIVIDUAL_CORPORATION_PARTNERSHIP_TRUST (CHECK ONE—MUST BE SAAIE LEGAL ENTITY AS THE ENTrrY IDENTIFIED IN 41) 4. SOCIAL SEC[JRTIYNO.:n I a 4, 7,//c/ FEDERAL TAX ID NO.: 5. APPLICANT PHONE#:­D3—210-1160 APPLICANT EMAIL ADDRESS: G�SJ U 4cl- 6. MAILING ADDRESS: 20 (5 r 6GG, STREET CITY / STATE ZIP 7. PERMANENT ADDRESS: /�,�j I��/ f .j�,� q, 1 l a�i 1�l /-t et �(G �c- - 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 ORA 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 9 TITLE 9. IF APPLICANT IS DOING BUSINESS UNDER A RWA,PLEASE STATE THAT DB/A,AND ATTACH A COPY OF THE FICTICIOUS NAME CERTIFICATE FILED WITH THE CITY OR TOWN CLERK: DBA NAME: 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 SUPP.CARD J J n rs' "3 �J o� l� 1 2. N� City of Northampton 7 7s11 Massachusetts wS, 1" i�r1t ► 4 y DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building 7 j Northampton, MA 01060 ssW .y�th 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/footinqs (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 1, 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 The Commonwealth of Massachusetts Department of Industrial Accidents 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): i3U,/G!l yt`7 f Address: , 0 !.3'x 70q a City/State/Zip: 7 _l4 , &Ije6 Phone#: l 3-2JO 0 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ 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 2.21 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.❑ 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#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: Policy#or Self-ins. Lie. #: 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 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 n er the pa* and penal 'es of perjury that the information provided above ' true and correct. Signat ure: Date: 4/1, / 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#: ti SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not/Applicable ,c£ Name of License Holder: G i L10 K�LL/�7 Jl (�c? ' �LJIp��lilc-i ff '' License Number "� Addres Expira on to gnature Telephone 6 Ri gistered Home I6pFovem6 o* ii6tor 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...... F- 'L 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 buildine 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. c - SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks Siding[❑] Other[❑] Brief DescnpW9 of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement No Plans Attached Roll -Sheet 6a:if New house and or'add'ition 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 �l d, l��� ���� as Owner of the subject property hereby authorize 0 d f gnatt on my behalf, i all matters relative t rk authorized by this building permit application. ure 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 under the pains and penalties of perjury. Print Name Signature of Owner/Agent 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 0/ Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Location) A. Has a Special Permit/Yariance/Fimding ever been issued for/on the site? «~~/ x�� �~ � NO DONTKNO\0 YES x�� IF YES, date issued:! IF YES: Was the permit recorded at the Registry ofDeeds? N0 DONTKNOYY 0 YES / IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water orwetlands? NO yQ�,j DONT KNOW 0 YES IF YES, has permit been or need to be obtained from the Conservation Commission? Needs tobeobtained _��~\ x_�Obtained »,� Date Issued: � ' C. Du any signs exist on the property? YES �~� 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 type | | ' ' E. Will the construction activity disturb(clearing,gradinexcavation,or filling)over 1 acre oriuit part ofa common plan . that will disturb over 1 acre? YES NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. 4 � 1.... � �3epartrpent use only x City of Northampton Iff.Rermtt; r I Building Department It 6 CutlCJrl(te�tiiay EM MAY 19 2014 212 Main Street Sewer[SepticAvairabllriy E ' Room 100 Water/UlfellAvailabtldy '$ ' orthampton, MA 01060 Two 5efs ot5#ructural Plans '� inspection Electric. Plumrir'9&Gas µ r o MA° s 3-587-1240 Fax 413-587-1272 P[of/5ite Plans k APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This secfiort to be completed by office Z .f ^ �, Map Lot Unp: � SD Zone Overlay D�stnct Vl� , C ;;Elm St District CB District ,- SECTION 2. PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: f �vLy iesly I� P N me(Print) Current Ma yi ng Addres l ..jv7- 5 3z� Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only om leted by ermit applicant 1. Building G3t� (a)Building Permit Fee (3500, 2. Electrical (b)Estimated Total Cost of Construction from 6 ' 3. Plumbing 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: or .- Signature: Building Commissioner/Inspector of Buildings Date 27 VERNON ST BP-2014-1212 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 3 1 A-090 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-2014-1212 Project# JS-2014-002049 Est.Cost: $3500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DAVID JAGODZINSKI 106068 Lot Size(sq. 1): 25003.44 Owner: LEVEY-WESTON HERMINE Zoning: URB(100)/WP(11)/ Applicant. DAVID JAGODZINSKI AT. 27 VERNON ST Applicant Address: Phone: Insurance: P O BOX 204 (413) 230-9160 NORTH HATFIELDMA01066 ISSUED ON:511912014 0:00:00 TO PERFORM THE FOLLOWING WORK.-RENO FRONT PORCH (POSTS & RAILINGS) 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 5/19/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner