24A-166 (4) 319 PROSPECT ST BP-2017-0169
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24A- 166 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit# BP-2017-0169
Project# JS-2017-000274
Est. Cost: $7040.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 105953
Lot siae(sa.ft.): 12588.84 Owner: BIXBY GEORGE W&NATALIE A
Zoning: URA(l00)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 319 PROSPECT ST
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCERI02908 ISSUED ON:8/9/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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 8/9/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only '.
_ ity of Northampton Status of Permit
RECEIVED uilding Department Curb Cut/Driveway'Permit
212 Main Street Sewer/SepticAvailability
AUG 9 2016 Room 100 waterN4ell Availability
No hampton, MA 01060 Two Sets of Structural Plans
::fir 13- 87-1240 Fax 413-587-1272 Plot/Site Plans
DEPT OF BULLIDNeI SF
eomriAMPTON MAcno60 Other Specify
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
f Ip ^ 7-. Map Lot Unit
19
(/ Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
N-M-Li E 7 :,_ 9l9 � iq�l� /'lam
Name(Pont) /� q...� Current Mailing Address. n) I 0 id&
Cf/ / • Telephone ' '
Signature
K-- / / j/�J (/� ,A, . p, /�/X\ /44 ,41
Name(Print) Current Mallin Address:
Signatu Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant^
1. Building /r�` (//Lij� (a)Building Permit Fee
2. Electrical / (b) Estimated Total Cost of
Construction from(5)
3 Plumbing Building Permit Fee
4 Mechanical(HVAC)
5. Fire Protection I/
6. Total=(1 +2+3+4+5) /7Og0• l-,y:� Check Number /7s'f ? I s 4�/
O
/// This Section For Official Use Only
Date
Building Permit Number: Issued.
Signature:
Building Commissioner/Inspector of Buildings Date
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 fined in by
Building Departrnem
Lot Size
Frontage .. _.
—
Setbacks Front
Side L':--- R
Rear ._._ -. .....
Building Heigh[ -- --
Bldg. Square Footage
Open Space Footage
(Lotareamnusbldg&Paved __.
___
parking)
ri of Parkine Spaces - ---
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES Q
IF YES: enter Book Page and/or Document 8 -
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO Q
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 Q NO Q
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 D Replacament Wjndows Alteration(s) fl Roofing E
Or Doors ISTd\
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks
��Ip Siding [O] Other[O]]
Bnef Descripfi. o P . .:-. ry// p, / S �/I T
Werk 1 . � iu JW tI/ �i�✓
Alteration of existing bedroom Yes Na Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ea. If New house and or addition to existing housing, complete the following:
a. Use of building: One Family Two Family Other
b. Number of roams 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. Enemy 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, �/l/t ' ^ y as Owner of the subject
property / I-
to
authorize /4 /
to act on my behalf, in all mat relativ o work autho ' this building permit application.
Signature of Owner r�I//ill�} ` D�attee� /�.
I, -� , ` -61) /r 2 /13 , 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. r
Signed under the •ains --• •enaltiesy f perjury. n
i—
t�r._ az.
Print Name�W� , r/A�
ill%�f�
Signatur::f Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisoor::��� �f /�//y'�/ /NotAppplilii able /£ y/�
Name of License Holder' f L.f1L1L 1�/�/ '� /.//r+- ( O;/ 9
Ir�V — l/ License Number
Address ( Expiration Date
�/�r/�/ yµ1
/ ' e e/ r U /r
Signature ( Telephone
4-jf 423 2__
9.
9.Re•istered Fipmelm•rovement Con .ctor ' -/ Not Appycable_£4g3
Company Name '^ � ' Registration Number
99,0
9 //r1 s
Address 6 r ) �jm �y�," /�.y"�y�1� �) Expiration Date
�//V"'"✓ ✓ V/"'p/�•'/oi re / lelephonei//J
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(5))
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 Att ed Yes
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 he 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
The Commonwealth of Massachusefs
Department of Industrial Accidents
^Lg
,—&a i; Office of Investigations
_"�' ly 600 Washington Street
Boston, MA 02111
,x www.mass.gov/dia
Workers' Compensation Insurance Affidavit Balers/Contractors/Electricians/Plumbers
Applicant Information Please Print Lenibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer? Check the appropriate box: Type of project (required):
I.❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
listed on the attached sheet. 7. ❑ Remodeling
2.n I am a sole proprietor or partner-
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity, employees and have workers'
[No workers' comp. insurance comp. insurance.= 9. Er Building addition
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 I1.❑ Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL
12.0 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.
tConttactors 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 subcontractors 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 DLA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
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#:
City of Northampton
-ST¢rF.
/[-
Massachusetts
DE ARTMEnTT OF BirlDTYC INOPECT IONS } ..
212 Main Street a Municipal Building 1
Northampton, MA 01060may, kMA'
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- F
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 bel.
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
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
City of Northampton 212 Math 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: Th) 9 ,47 // /7/17g "
The debris will be transported by: � / 7/17g//
The debris will be received by: ij�j� 7 Pr474-
Building permit number:
Name of Permit Applicant 014q/�Iff��
�
e /6
,A9-4-L7
Date Signature of Permit Applicant
Ju128 16 07:28a p.2
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
.til / Sold.Fmishal and Installed)r.
Era'irb Name:Not E,JaM Date.-y j.24 to TI{D Arlome Sav'ices.Ino.
dicta The Home Depot At-Horne Ssvieer
Branch Numher:31 903 Boston Tun.pike,Unit I.Shrewsbury,MA C1545
Toll Free 877-9033758
Fdera IDP 75295461,ME Lic n C 1)2439:RI Cum.Lag'6427
21(� �s (( CT Lit HICCUPSSj':t M�AIHrmw improvement Thmuannr1Erg.#1268592.
Installation Address: 31-L Pa,osp ec+ r51 - (V V"— Act 614 P`f�/I9
Cly State Zip
Purcbucres):, _ W rk Phone: Rome Phone: Cum Phone: }
[ 1 [
P7l x e? [ 1 I 1 I [_.-
1 11 1 1
Mame Address:
ILdiluent from Installation Mdressi City Slim Zip
Email Addresr Ito receive prejec:communications mid Home Depot updates):—
❑ I DO NOT wish in receive y_n marketing -_- - - - -
'� gemmiL from Hone Depot
Project Information: Untenignea:'CL,wrrar'),the owner of the property.created at the above installation address.'goes In buy.
and THD AI-Hama Service,,Inc.c'The Home Depot")agrecs to famish,deliver and arrange for the installation('Installation")of
all materials described on Me below and or the referenced Spec Shemin).all of which are incmpomted into ted Contract by this
reference.along with any applicable Stale Supplement rand Payment Summary attached hereto and coy Cllaaie Orders(collectively,
'Contract"):
debP 'sr P - Spec Shed(SN: Pmp]Amount
or
9b13(o L I 3766 D`tU
J�Dadbg nrs o;ma $
l
I ElP g[Biding LI Winlows 1nmWvm -. S ..
❑G C -: OP yD 0
]R r Jsag : Windom Lit . Ly 5 1//)
❑f Covers OreP a
pttm 0 _- Y
liiN %roma not tap hPIN[4dere m,4 entrerentcontract
M.v R rtM1 )m Man blh Jof W (sal A Tato comma 5 Onnl I $ �l r'1
Cuwomei agrees that.'m de:My upon
3mak k for meth Renvdu„ Cstenrill execute n Completion Cot Moue
lore for colt Product as defiw
ned Ly
lMi:idual Spec Shoe andpay any Y.lauce cue. As appliea*k.euci Customer ender Iris
Co rt agrees to b:jointly and.severally obligated and liable hermtnder.
The Herne Dotreset vex he richt to issue a Change Order or ermine Ibis Contract or any Individual Pmduct(si iclabd herein,tic
its disotlion,if The Hone Dem'or its authorized service provider deter:ines mm it cannot perform its cbliptions dlc to a savcrtrot
problem whit:he Lame,eusironmanal hazards stilt as mold.ashesms or lead point other serf ry concern.pricing errors Cr beano..;
work required to eon-plow the job wan not incic4d 2.o the Contract 6
Payment Summary: The Paynmet Summary 0_I t-2.l)L{S I inlinued as pan of this Contract sem 'crib the teal
Conran(aniounr aid payrolls required for the deposits and final payments by Pmaot las applicable).
NOTICE TO CUSTOMER
You are entitled too completely felled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate:note:
there is one Completion Certificate for midi listed Product as defined by individual Spec Sheets)before work en that Product
is complete.
In the event of termination of this Contract,Customer agrees to pay The Herne Depot the casts of materials,labor,expenses
and service provided by The Home Depot or Authorized Service Provider through the date 01 termination,plus any o16cr
amomits set rorlh ir.this Agreement or allowed under applicable lam'. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO TUE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENT'S MADE, WITHOUT
LIMITING THE IIOMF DEPOT'S OTHER REMEDIES FC14 RECOVERY OF SUCH AMOUNTS.
A trepran Cr and Authorization: Cm beerecs aria understands that this AIJG'nen.is Ile a eat between Guslunier
and The Home(xpat with maard to me•PnxJ nes and Instal lark'!sc and stipends a3 prior discus v ct aid up—mamas.eider
mals %mem relating to id Pt-Moen til aelairat tan.This Ayre ammo hc iissiredor nncad d_veep: by a writ ng
signed
Iry CustomeradarTheceived ANome
copy of Gl Arm- k IaLmsal lagreesFat Customer has PAM nrdert d:.vnlmorily accepts'he
Imre oFasd has m¢Ivcd n copy of-his Armee mem
In b' Submitted by: \`-4-
// ,- a1 s/aoi� _ E ( IN1 JJJJ2�J J
Ci ignewe Date Sales Csubs,: _ are Date
t-rev
Customer's S'+_numre Duro Sale-Casolcn. .sen Sc No.
CANCELLATION: CUSTOMER MAY CANCEL THIS ottoolicat st ///���
BA DELI E q( G WRIT PENALTYNOR HEOBLIGATIONO36- /^
BY DELIA}RING WRIT'ILS V0"!ICF. TO THE HOME L✓l
DEPOT BY HIDNIGHI ON THE THIRD BI SINICCE
DAY AFTER SIGNING THIS AGREEMENT. THE !
STATE SLEPT EMEATTACHED HERETO
CONTAINS A FORM S TOUSE IF ONE IS
SPECIFICALLYSPECIFICALLY PRESCRIBED BY LAW IN
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•
The Coummrnveallh fMassachusetts
I{ 3 Department of ZutlustrialAccidents
X14 E=*PS : 1 Congress Street,Suite 100
'a ' Boston, WA 02114-2017
1-.:-47..,
M1vigniass.vov/Ilia
• Winters'Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED Win!THE PERMITTING A UlTIORITP.
Applicant Information I ��}} AT
Please Print I,esibyly,+�j�` ///
Name (Busincss/Ore:mizmroMnjj/ivvijidual)::09-5i;.-7-
1-F,�r-?t 5 4-(S) ,TT 9'231— --)014 c— "---
•
Address: // A�11C�, 04 �/o1)}J7- -. ) /�/�
• Cityisteteizip:Jt17Z uX 1.� IP id#'6 'i hone'!: .`2& —162-
2- -6lW--
`. you m.employer:Check the appropriate hos: Type of project(required):
1.❑ a enwloyer with emptmees(full an:lor pm-katal` 7. 9 New construction
2.9 I am a sole proprietor urpam eiship and have no employees methane,fir e•in
8. 9 Remodeling
nay capacity_(No workers'comp iaumncc rxnuifal.j
3.❑Iamahomeowner doing all workmyself.INowoncer comm insw-ncerequlaujt 9. ❑ Demolition
49 l am a homeowner and will he hiringcontracma'm conduetan work on my property. Iwin i6❑Building addition
ensure Wet all conuectms either bweavert:cm'compensation insurance ur are role ILO Electrical repairs or additions
roptimors with nocmployccs. 12.9 Plumbing repairs or additions
a
eml contmetm end I have hired Wesub-conmctora limed on the awcleasheet i}_ Roof airs
Ilene mLLeanmaetom hove eolith/Yew end have workers comp insumpm.: ❑ repairs
d.❑wm
e ere a commotionend its omn havcacmised their right oi nemption per MGI.c. 1A.❑Other :
.52,21(4).and we have no employees.[No workers'comp insurance required.)
`Any applicant thal checkshox AI must also fill out the section below showing their wo:Rem'compnrsmion policy iNbrmslior
Hememmem who submit chis affidavit Unfeeling they arc doing all work and den hire amide cdreaetors must nbmit a newalhdavit indicating such.
:Can:aeiers the:check this box must attached au additional sloth shoving the rune of the subcontractors and sate whether or not shoe entities have
employers. II;he subtiaou anis have enplayees,they mutt provide Weir werbers romp policy number.
1 am an employer that is providing workers'compensation insurance for my employees. Bdo,V is the policy and job site
information.
insurance Company Name: , C .-40 i-h1 1-1p )1) c 2TlJ0
Policy 0 or Self-ins.Lie.#: IXJL [y. ) J ! I Expiration Date:
•
Job Site Address: City/State/Zip: •
Attach o copy at the workers/compensation policy declaration page(showing the policy number and expiration dale). -
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,560.0D
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 ofthis statement may be forwarded to the Office oflnvestigftions of The DIA for insurance
coverage verification.
I do hereby - '>ri�rl.ey ep -,.�"—ralIi- of perjury Ebonize information provided above is true and correct.
Sienolurc: / yeti , (}• ") /�,// Date;
Phone: S // - i42-KJ`J7�-
Official use only, bo not write hi this area,to be courpieteet by ckv or town reiciat
City or Town: Pennii/Licensc a
issuing Authority(circle one): ii
_
I.Board of Beslth 2.Building Department 3.City/ own Clerk 4-Electrical Inspector 5.Plumbing Inspector '
ii
• S.Other
Contact Person: Phone d: