23C-071 (7) 67 WILLOW ST BP-2017-0801
GIS#: COMMONWEALTH OF MASSACHUSETTS
Man:Block:23C-071 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 PERIVIIT
Permit# BP-2017-0801
Project# JS-2017-001336
Est.Cost: $21505.00
Fee:$139.75 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
UseGroupy KIM RESCIA_ 022464
Lot Size(sq. N.): 17685.36 Owner: SILVER ELIZABETH A& MARY VIRGINIA LEE BADGETT
Zonin¢: URA(I00)/WSP(100W Applicant: KIM RESCIA
AT: 67 WILLOW ST
Applicant Address: Phone: Insurance:
311 Locust St (413)320-1831 O
FLORENC EMA01062 ISSUED ON:12f20/2016 0:OO:0O
TO PERFORM THE FOLLOWING WORK:MOVE WASHER DRYER FROM BASEMENT TO
1ST FLOOR -ADD SHOWER & BATH
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Numbing 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 12/20/2016 0:00:00 $139.75
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
4
City of Northampton LiCjL(£ SYU(Yu"fiir. '"' r
Building Department tiCvde!uL a74.a .ypG.0 ""
212 Main Street ?t'.1.'Et`Md 111 GY11LIll4 ,�,, �` ,,,''
Room 100 aii•+41'kr1 Erle
Northampton, MA 01060 i,,,4 ti.�L orfg. e(p,i j0' *, xi s` "-r-
ia
phone 413-587-1240 Fax 413-587-1272 , ,��,y i-1r,At( ¢. .;�, w }x " j *JPS
,.-fertis
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
(al ufkk\ o W Si Map Lot Unit
t- Iofen ce (MA C1O2L zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
0, 2.aart , A— s Ave( (el Will c ..ii S+ rlovernce 0I36 2-
Name Print) 1 Current Mailing Address: r
(//�(s (ggg' Ct�4I�'1 (/t� I,
V Wt `.- -X,c Telephone
v
Sign ure i n7Oi t: —
g,2 Authorized Agent:
I . in 1-co, s s1
Name(Print) AirCurrent Mailing Address:
1/V !pJ f 3W - ( 8',3I
Signature / Telephone
ECTION 3- -.TIIMATE! ONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
• completed by permit applicant
1. Building / ! l OQn + O 1, (a) Building Permit Fee
2. Electricalr (b)Estimated Total Cost of
a, C}00 , CO Construction fromJ8)
3. PlumbingBuilding Permit Fee
5-S-0 S- cc Re-C„- ,f'=7
4. Mechanical(HVAC)
5. Fire Protection p
B. Total =(1 +2+3+4+5) A�s'I 0O7 Check Number yq,�- er s 4 �i3 •S
This Section For Official Use Onl 7
e Pt,, 9d
Oso aE c w
,,L..
BuildingPermit Number ,r Issued 47"2C-0714
49
✓' �rr
Signature: // f, f
Bu'.ng Corn ssioner/Inspector of Buildings Date
Section 4. ZONING Ah Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size L__ ____. I 1—._._ _-1 L___._ _.___
Frontage -- 1 -- - -
Setbacks Front 1 r 1 1 1
Side LI_-1 R:L–_1 L: R:Lit I I —II
Rear Li 1-7 �J
Building Height
Bldg. Square Footage
I —1 L_ L_±1 I 1.7. .-1
I
Open Space Footage _ Va
(Lot area minus bldg&paved 1 r J Ir1-1 ' 1 L—i
parking)
#of Parking Spaces i I--] __J
Fill: i�
(volume&Location) -- ---A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW O YES 0
IF YES: enter Book [_ 7 Page and/or Document#�
B. Does the site contain a brook, body of water or wetlands? NON-0 DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued: L
C. Do any signs exist on the property? YES O NO O
WYES, describe size, type and location: i
D. Are there any proposed changes to or additions of signs intended for the property? YES O NOt
IF YES, describe size, type and location: 1
1
E. WII the construction activity disturb(clearing. gra excavation, or filling)over 1 acre oris it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all eppifeeble)
New House in Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Dr Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [CI Decks [q Siding[ 1] Other Io]
Brief Description of Propos d /' p S
Work: 144(3 ip (Do,-,Ler /1.'YhfG-�Y'iW. n �oiticcST- iI — art" SLcAuer . ky\-tur k\
Alteration of existing bedroom Y ....N1 ,No Adding new bedroom Yes NNl �Jo
Attached Narrative Renovating unfinished basement Yes NJ No
Plans Attached Ron -Sheet
Ga.if NB1N hopse aijdbr'tddltGoq to exi§Frost hthilincvtcpmatte thettiowitut
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. Ei t2 ak,,e1L k�tc e7 , as Owner of the subject
property
hereby authorize / ♦ f
to o my behalf in all mattes relative to work authorized by this building permit application,
nj/.�t " .. .� 12. 2.0 I(i)
Signa re ofOwnerDate
I. '(/'O 1 Lb 1 re. S c i(az ,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 uKnder the pains and penalties of perjury.
Print Name r
Signature of awn.r/Age t /// ��� Date///
/
•
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable 0
Name of License Solder'. F1 1 .�P S[ ( 45„ r s- OZ OzzVt, 7
License Number
31k
Address
t e Expratio Date
A G.^.-74 �7 z o ' / O ^J
S19 : ure Telephone
&mar fCF X l g 1. 0 Flol5
S. Rerastered ifomelm6 •vemont Contractor ,•;r} „ 'i 1 Not Applicable ❑
e �l 74,9
Company Namee Registration Number
.+
Address 11 p,,, Expir ion Date
I�
1ALA ! 01 (3 Telephone `>cO D .Y
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--%."---L0 No 0
It."./iomeAOvvnerE+zemotion
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 he,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 betshe shall be
responsible for all such work performed under the buildtnt 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 he 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 he liable for person{s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with PE State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws andState of Massachusetts General Laws Annotated.
Homeowner Signature
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, las defined by MGL c 111 , S 150A,
Address of the work: [n 7 L/, IC5 uy- S* T 10 .
The debris will be transported by: 11, p,IN\ e Sr i
The debris will be received by: rn fliie46YeemsbLiicA
Building permit number: (V\
Name of
Permit Applicant � reSc/
/ a7 76
r'oec'/
Date Sig ature of Permit Applicant
The Commonwealth of Massachusetts
t�
--r—i.= _ Department of Industrial Accidents
g '� f- ' Office of Investigations
Aa ;= I Congress Street,Suite 100
' --%.� Boston,h4A 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant InformationPlease Print Legibly
Name (Basivaes/Organizationflndividuxl): 1 t �C" et
Address: S t IC—.''' d_,,,_
A J `
..---
City/StatefZi.: +e A_ 01 c y. Phone#: ThatO
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. 0 I am a general contractor and
employees(full and/or part-time),' have hired the sub-contractors 6, New construction
2.M I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have S. 0 Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp.insurance? `} [,]Building addition
required] 5. [] We are a corporation and its 10.0 Electrical repairs or additions
3.( 1 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
120 Roof repairs
insurance required]t c. 152,§1(4),and we have no
employees. [No workers' 13.n Other
comp.insurance required]
'Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
r Homeowners who submit this affidavit indicating they are doing all work and then hire outside coanactors must submit anew affidavit indicating such.
$Contractors that cheek this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. lithe sub-caMmetors have employees,they must provide their workers'comp.policy number.
I ton an employer that is providing workers'compensation insurance for my employees. Below it 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 insurapae covetagyverifcation.
I do hereby cert un,. ' e pains a , r enalties of perjury,that the information provided above is true and correct
Si nature: 4 -_ / Date: "'t 6
Phoned: `: -jr& /'
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 d:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership, association, corporation or 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 tnrstee 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 who 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 he an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)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 certificate(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 cany workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be 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 legibly. The Department has provided a space at the bottom
of the affidavit 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 which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information (if necessary) and under"lob 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 proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be 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 Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 7-2013
www.mass.gov(dia
City of Northampton
a'
Massachusetts
6'A�/ .24
( ,,. t.�hgY DEPARTMENT OF BUILDING INSPECTIONS 2 M
212 Main Street • Municipal Building �y
Northampton, NA 01060ISV t^0C
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
th: - 'ns•ec '•ns ca re I in failur- • .btain a - ificate •foccu• .nc unt' he work -n 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
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
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