18C-049 (4) 67 HATFIELD ST BP-2016-1282
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C-049 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2016-1282
Project# JS-2016-002205
Est. Cost: $9800.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DAVID WILSON 40055
Lot Size(sq. ft.): 40685.04 Owner: HEBERT LOUIS O&JOAN J
Zoning: URB(100)/ Applicant: DAVID WILSON
AT. 67 HATFIELD ST
Applicant Address: Phone: Insurance:
P O BOX 1496 (413) 773-3810 WC
GREENFIELDMA01302 ISSUED ON.5/5/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTICMALL INSULATION
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 5/5/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1282
APPLICANT/CONTACT PERSON DAVID WILSON
ADDRESS/PHONE P O BOX 1496 GREENFIELD01302(413)773-3810
PROPERTY LOCATION 67 HATFIELD ST
MAP 18C PARCEL 049 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid 7 m7e l5
Building,Permit Filled out
Fee Paid
Typeof Construction: INSTALL ATTIC/WALL INSULATION
New Construction
Non Structural interior renovations
Addition to Existing_
Accessory Structure
Building Plans Included:
Owner/Statement or License 40055
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOIjMATION 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
-DeaiWition Delay
Signa re of Buildin O ficial 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.
F
wDepartment usenly
` Cify of NarfhamptonStaBuilding DepartmentCur016 212 Main Street SeweriSept�cAvaiiabllitRoam 100 Wate,:.f:vs ortham tort, MA 01060 Two Sets of S_tructural P'ti '' 3-587-1240 Fax413-587-1272 Piot/Site PlaeON TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -,SITE INFORMATION
1.1 Property ddress: This section to be completed by office
Map Lot Unit
Zone Overlay District
Elm St.District CB District
F
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Printf) Current Mailing Address:
c✓ i ,Y LT 7 ILS, Telephone '%/-3
Signature
2.2 Autbgrized A e t:
I@t� N P,6-2 6 00 V EeOQ R ea-�' M
Name(Print) dd
Current Mailing Address:)a
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building q800' (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3, Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection r
6. Total=0 +2+3+4+5) Check Number Azw
This Section For Official Use Only
Building Permit Number. Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition ❑ Replacement Windows Alteraticn(s) Roofing ❑
Or Doors r7
Accessory Bldg. ❑ Demolition ❑ New Signs [EJ] Decks [Q Siding [p] OtherT15R
Brief Descripti posed
Work: UPC22A '- Tb m-cm4a � 1'•
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ?C 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 NT
I, &411( as Owner of the subject
property 5)qY10
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building p rmi application.
s3 r(o
Signa re of Owner Dat
as O r/Authorized
gent reby declare that the statements and information on the foregoing application are true and accurate,to the b e
elief.
Signed under the pa and penaltis of perjury.
i� �bCSC9ita
Print Name �
f supds h(o
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction SSu(X�l�� )up�e�r�vi/s�or:� ( Not Ap(p�liicaablle`£
Name of License Holder: f�J �1�
,�A�AA•� License Nu er
12 sa&iUut- S - ���t�i f�► Iv14 � Z $
Address � Expirati D to
114 ASfit� 4, •? 3. 3810
Signature Telephone
..9.Redistered Home Imrovement Contractor: Not Applicable £
Comoany Name Registr416
Number
.G.f d)clga(. r2 uFcc-cls, �:
Address Expiratio Date
Telephone:5.773•380
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 YeA... £ 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 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
i
1)Cpa7lnienT OJ 17212US77'lal_11CC1aenrS
Office of-Tizvestigariors
Yaj 600 Tf-ashingion Sri-eel
Boston, Md 0:111
-VJ7or1,ers' Compensation Insurance Afiida)rit: Build ers/Contractors/Electriczans/Plumbers
Anulicanf Inform2tion ___ Please Print Lezibb,
INTame lBusiness/Greamzauan/tndividuO): Wlw� ,s 61"—pMS
Address: t'�.Rw 14q(,,
City,State/Zip: 2*2 it gh I&. 6)J-MZ Phone #: 13.723-x-310
Are you an employer? Cbeck the-appropriate boa: Type
U of project (required):
1. I am a tocr with 2- . E �cnera
4I am a l contractor andl
p Y 6. ❑New comstmcrion
employees (full and/orpart-time).* have hired the sub-contractors
1❑ 1 azo a sole proprietor orp=CT- listed on the attached sheet # [7. ❑Remodeling
ship and have no employees These sub-contractors have .8. ❑Demolition
work== for me in any capacity. workers` comp. insi=ce. 9_ ❑Building,addition
[No workers' comp. insurance 5• ❑ Vire are a corporation and its
reguircd. ] officers have exercised their 10•❑Electrical repairs or additions
3.❑ 1 am a homzowncr doing-aD work iig;ht of excuption per MGL 11.7 Plumbingrepairs or additions,
myself. [No workers' comp. c. 152, §1(4), and we have no 12.7 Roof repairs
insurance Tbpired.] t en3p10yecs. [No workers' 13.❑ Othcr
comp.msurame Tecluired.]
*Any applieantthat checlrsboa#1 must also fill outfbe section trlow sbowimg'tbeir workers'compensation policy infmMurdon:
t Homeowners who submitthis affidavit indicating they ere doing all work and tben hilt outside contractors inust submit anew affidavit iadicatmg such
$Cantracrm that check t]us bon must auacbcd as additional sbeet showing$u name of the sutrcontt et=and 1h cir workers'omnp,policy information.
I am an er7:plover that is providing workers'compensation insurance for nu,employees. B:low-is the poli- ,and job site
information.
Insurance Company Name:_ Twmtt 2„S`` r5r�r&16
Policy#o7 Self-ins.Lic. #:_ Expiration Date: R(7,Zl(o
Job Site Address: Ut� `� ' City/State/zip: �,,, �i75 1,rrH.DltuR1
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Faihre to secure mvera e as required under Section 25A of MGL c. 152 can lead to the hnposition of c octal penalties of a
fine up to 51.500.00 and/or one-year imprisonment as well as ci1,D penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
lwtsiigations of the DLA for insurance coverage anou.
T do hereby cert , under the pains and penalties ofperjui0-tha;the information provided above is true and correct
Sismature:
D & whm,
' Date: 3
Phone t ` rs• 77 10
Official use onlY. Do not write in this area, to be completed by cirj� or town official.
Cite or Town: Permit/License#
Issuing Authority' (circle one):
1. Board of Flealth 2. Building Department 3. City/Tomm Clerk 4. Electrical Inspector 5. Plumbinc,Znspecio;
b. Cnb er V
i
Phone r:
Ivlassa:;husetls Creno;a!Laws chapter 7.52 requ .es all employers to provide workcrs' ::0 ripeu;at1aTj fo their employees.
Pursuant to this statute; an ainployee is dcfined as "...every person in the service;of another under any contract ofhire,
e-,`press Or implied, oral or written."
An employer is defined as"an individual,partnership, association; corporation 6r other legal entity; Or any two Or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trusted of an individual,partnership, association Or Other legal entity; employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein; or the occupant of the
dwelling house of another urho 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 Iicense or permit to operate a business or to construct buildings in the commonwealth for any
applicantwhohas not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(T) 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)name(s), address(es) and phone number(s)along with their cm ficate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may 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 returned 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 Town Officials
Please be sure that the affidavit is complete and printed Iegibly. The Dcpartment has provided a space at the bottom
of the affidal%t 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 permit/license number-urhicb will be used as a reference number. In addition, an applicant
that must submit multiple permitllicen.se applications in any given year,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 as prooz-chat a valid affidavit is on file for future permits or licenses. A new affidavit must"oe 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 burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Departrnent's address; telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Officeofof Investigations
.'-
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste 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.
Address of the work: 67 4vTP(w) Si
The debris will be transported by: ►yQ � ru S
The debris will be received by:
Building permit number:
Name of Permit Applicant l() [L
S1 !6 f SG,
Date Signature of Permit Applicant
City of Northampton
Massachusetts
+5 . DEPAR2WMT OF BUILDING IPSPECTIONS y
212 Main Street • Municipal Building vti Jca
Northampton, MA 01060
Property Address: EL-0 Si-. &C71 7 gyp MM. M4-
Contractor
Name: «1al �.s �j(Jt/XJ�2S
Address: �'�• (�O'( I qq
City, State:
Phone: 13 - '7 7:3 . 38 to
Property Owner `�
Name:
Address: 6-7 d4mev)
City, State: ly�����V�VV1P3b1�S YY14
1, (contractor) attest and affirm that the building I intend to
insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
' 6
Contractor signature NO Woo
Date
a