23D-090 (4) 172 FEDERAL ST BP-2017-0835
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23D-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:window replaced BUILDING PERMIT
Permit BP-2017-0835
Project JS-2017-001398
Est. Cost: $8000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft): 22999.68 Owner: LAZARO REYES GO PHIL COX
Zoning: URB(I00)/ Applicant: LAZARO REYES CIO PHIL COX
AT: 172 FEDERAL ST
Applicant Address: Phone: Insurance:
172 FEDERAL ST
FLORENCEMA01062 ISSUED ON:1/6/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:WEATHERIZING, ALTERING WINDOWS IN
SUNROOM
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 1/6/2017 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0835
APPLICANT/CONTACT PERSON LAZARO REYES C/O PHIL COX
ADDRESS/PHONE 172 FEDERAL ST FLORENCE
PROPERTY LOCATION 172 FEDERAL ST
MAP 23D PARCEL 090 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PER •PPLICATION CHECKLIST
NX ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT �,�.
Fee Paid !„L
Building Permit Filled out (�(/,J
Fee Paid
TypepfConstruction: WEATH_Krzt G.ALTERING WINDOWS IN $UNROOM
New Construction
Non Structural interior renovations
Addition to Existing
•ccesso St cture
Buildint Plans Incl .ed:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
4----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/ORSpecial 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
-• u onala
pen
/� ! 1-1=/7
Signature of Building Official 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.
OK -to ,�;/ 1- S./‘ c„---
ga The Commonwealth of Massachusetts
E..1) Board of Building Regulations and Standards FOR
,. Y ',d Massachusetts State Building Code,780 CMR MUNICIPALITYUSE
Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised Mar 20//
One-or Two-Faintly Dwelling
This Section For Official Use Only
p--- Permit Number:--BuildingDate Applied:
0
N _...� ..._ ....�
in Building Official(Print Name) Signature Date
I SECTION I:SITE INFORMATION
I-
i- 1.1 Property Address: ht'bh-,nf k , 1,2 Assessors Map&Parcel Numbers
f ' __ Ili FetlereA S4 M.,_ 01060
__ 1.1 a is this an accepted street?yes no Map Number Parcel Number
__—w I;4 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
13 Building Setbacks(ft)
Front Yard Side Yards Rear Yard �—
Required Provided Required Provided Required Provided
1.6 Water Sapply:(M.G.Lc.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
FlooPublic❑ Private❑ Zone: — Outside if yes
Znnt' Municipal 0 On site disposal system ❑
Chuck ifves❑
SECTION 2: PROPERTY OWNERSHIP'
-� 2.1 Owner of Record:
RE-Ii"---S � A4fc\2,r, - ioRe ,ce , /LA A OlaEZ _
Name(Print) City,State,ZIP
FR ik vFd_€: ' l_— lit3yS 14 (3V t rig2rcp (CtGAifit‘ ,ea,)
No,and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(cheek all that apply)
New Construction❑ Existing Building❑ Owner-Occupied 1r Repairs(s) El Alteration(s) II I Addition ❑
Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify:
Brief Description of Proposed Worke: G/}=.A7-tLE:'IL. '-e1 & a G ..d A titittfi &) (t—_
y1 . o,ci r -fS.
�~ SECTION 4: ESTIMATED CONSTRUCTION COSTS
A- Estimated Costs:
Item Official Use Only
(Labor and Materials)
1.Building $ b U v 6 u 1. Building Permit Fee:S Indicate how fee is determined:
2,Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cod(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $ —l-
Suppression) Total All Fees-$ ,,,,, //A`y
`�-^r� Check No.M G ' Check Amount: !Y" /Cash Amount: ,
6.Total Project Cost: $ D 6 0 O. o 0 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5,1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
i t Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(FITC)
,.,. _._ ..........._ _— HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,g 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 ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
C za r
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
Information on the Construction Supervisor License can be found at
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms ......m Number ofhal&baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open.
3. `Total Project Square Footage"may be substituted for"Total Project Cost"
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: 1t Fed-en \ 54 /jort-L ,1-0n M.\ 0106<
The debris will be transported by: Co h.Ion c
The debris will be received by: Vc,\.(?y e c yc t t /-\3-
Building
Building permit number:
Name of Permit Applicant qt. {c5 L A+A-(W
h
Date Signc4/
ure of Permit Applicant
\ The Commonwealth of Massachusetts
cr
Department of Industrial Accidents
v _
Office of Investigations
� 1
;' 1 Congress Street,Suite 100
tsb Boston,MA 02114-2017
www.mass.gov/die
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le2ibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: _ Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
L❑ 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.❑ 1 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' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.;
equired.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs
insurance required.] t c. I52, §1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
'Any applicant that checks box g must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contactors 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:
Policy#or Self-ins. Lic. #: 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 and the pains and penalties of perjury that the information provided above is true and correct.
-y]1 Sienature: Date: j01-- c do D [
Phone#: '1 3 c� (( 72i
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#:
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 trustee 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 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 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 carry 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"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 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 bum 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
Revised 7-2013 Fax #617-727-7749
www.mass.gov/dia
City of Northampton
44� ti`s
Massachusetts
I Oed 4 DEPARTMENT212S OF BUILDING• Munici al Buildings � -
��jr 212 Main Street • Municipal Building .",
Northampton. 1P 03060 \\
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/foot' _us (before backfill).sonotube holes(before noun.a rough building inspection
(before work is concealed). insulation inspection (if reauiredl 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 occuoancy 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. (f�� understand the above.
per(resident's signature requesting exemption)
I will call to chedule all required building inspections necessary for the building permit issued to me.
Dated a'^ 5 0 I 9-
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