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16D-015
189 NORTH MAIN ST BP-2018-0976 GIS#: COMMONWEALTH OF MASSACHUSETTS Mao:Block: 16D-015 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categorv: KITCHEN& BATH RENO BUILDING PERMIT Permit BP-2018-0976 Project JS-2018-001763 Est.Cost: $21000.00 Fee, $137.00 PERMISSION IS HEREBY GRANTED TO: Const Class: Contractor: License: Use Group: BOURKE BUILDERS 055137 Lot Size(sa. H.): 11412.72 Owner: HUTCHINS KATHLEEN A zoning: URB(100)/ Applicant: BOURKE BUILDERS AT. 189 NORTH MAIN ST Applicant Address: Phone: Insurance: 77 LONG HILL RD (413)548-9214 Workers Compensation LEVERETTMA01054 ISSUED ON.41312018 0.00:00 TO PERFORM THE FOLLOWING WORK.1 ST FLOOR KITCHEN AND BATH RENO 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: FeeTvpe: Date Paid: Amount: Building 4/320180:00:00 $137.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File is BP-2018-0976 APPLICANT/CONTACT PERSON BOURKE BUILDERS ADDRESS/PHONE77 LONG HILL RD LEVERETT (413)548-9214 PROPERTY LOCATION 189 NORTH MAIN ST MAP 16D PARCEL 015 001 ZONE URB(100V THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCL QUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin. Permit Filled out Fee Paid T eof Construction: IST FLOOR KITCHEN AND BATH ENO New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 055137 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Demolition Delay , n 16 Signature of Building Official Date ' 4 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. R=CF of Northampton ding Department 12 Main Street Room 100 ampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE ON DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Property Address: •,� F K" ��fiYi£aJCe/ kAK1 O t Ohl SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Al Owner of Record: GU, :-W11 AE- A, CAr-y AIA? EC -T- olAsc) Name(Print)off t- Cumot Maigp AdNess: `�-v� Telephww sgneare 543 7102 2.2 Authorized AtteoW T7 l cwv t} n1 LL (:a4 g 9r�1AL F: Mj. f IAl4 OfG5 6 �t) CJAt3i �S� 14 Ak-& � 3c44f-c swa um Teleooae SECTION 7-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com lelsed!by penmitapplicant 1. Building l0 :co. (a)Building Permit Fee cc 2. Electrical 4 (b)Estimated Total Cost of Construction from 8 3. Plumbing 5SVIgIny Permtl Fee 1 � CGr CC 4. Mechanlwl(HVAC) toj .� #137 5.Fire Protection 8. Total=(1 +2+3+4+5) i C'01 , CO Check Number This Settlor,For OlneMt UmOnly Date Building Permtl Number, issued: SignaWte: BUMIrp CommbsbnaranNlsuYa W Bu pato VUL @ '6d�(YkP- ,(-tl LAc�y S,IJLJ,t'6d�cykP-(,Ctl LAev S.Ije- EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) �Fiyrrt,) No (f HO-6E T'O F�rpe Section4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning u n This column to be filled in by T` Buittingp ,arnnrnl Lot Sin tj �A 000 Frontage 0 0 0 Setbacks Front O O O V'A Side L=R:= L=R= Rear Building Height O O O Bldg.Square Footag Open Space FootageO O O O (Id arca minae bid I 90 icidoiti., #of Parkin S acl", 0 Fill: b (volume&fucatiov A. Has a Special Permit/Variance/Findin`g ever been issued for/on the site? NO O DONT KNOW Q/ YES O IF YES, date issued IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page= and/or Document#� B. Does the site contain a brook, body of water or wetlands? NO ® DONT 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: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO IF YES, describe size, type and location: E. Will the construction acbvity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YEF O NO (7 IF YES,then a Northampton Stonn Water Management Permit from the DPW is required. SECTION a-DESCRIPTION OF PROPOSED WORK fehsak all apogesbb) New Nouse ❑ AdditionEl Replseemenf Windows Alferatlon(s) ® Roofing Or Ocors ❑ Accessory Bldg.❑ Osmdkion ❑ I New Signs p) Decks Q Sidingl:31 Of shi Brief De tion of Pr osed 6 Work. P r6T F/ ]`A 1l - TI Hyly I E'�✓Tl-1 Ri+C'1A A r�!✓1l'�L",bi Alteration of existing bedroom_Yes_X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement _Yes ___XNo Plans Attached Roll -Sheet 6�Ikfis' i's`a�id'+crT'tiY7lRiorl�i�� i�tioulifil'i��Tdtii'c1�aiAi'fo"Ilug�nd: a. Use of building:dere Family Two Family K Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? f d. Proposed Square footage of new construction. I`- 4rl Dimensions a. Number of stories? I. Method of heating? P Fireplaces or WOadstoves 1`- Numbar of each g. Energy Conservation Compliance. r%I d* Masscheck Energy Compliance form attached? I,. Type of construction 1. -, f i. Is construction within 100 fll of wetlands?_Yes No. Is construction within 100 yr. floodplain_Yes{No I, Depth of basement or cellar floor below finished grade tr. u k. Will building conform to the Building and Zoning regulations? Y, Yes_No 1, Septi Tank_ City Sewer Private well_ City water Supply X SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, / N k-i k 4 i'�. �`T as Owner of the subject hereby authorize /1;(/ Ly-L to act on my behalf,in all matters relative to work au onzed by this builtling parmd application.' March 26, 2018 Signalureol Owner Des as OawerlAulhoriwd Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledga and belief. Signed under the pains and penalties of perjury. prim Name - n Signature rfilirreriAgert ate SECTION 8•CONSTRUCTION SERVICES 8.1 Licensed Construction SuaerAsor::In /� Not f AppIl-iicaar�bbl�e ❑iirrk� �! NamectUm"Holder: VAC (. 6k 1 oo O-Y-'- V.5 ' F `- 5 13� License dumber 77 lor,-�6 4-fu L6,4n- 1 i� g rr -al -- l Add2 / Expiiatio t Date V4,.r.,p� e�.rll�_ �(3 5AR-9ZLQ--U Signature TeleDhane A13-348 -c)AAt— G Not Applicable ❑ �iZ lxlalrlu l�evS LLL 154aSA Company Name Regisb tion Number 7� Comer if�nv��_. Ic� �rrl�tw �inaa b 18 Address �� Expinitifin Dale Telephoned. 1L W-9;14 SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152,1 25C(6)) Workers Compensation Insurance affidavit must be wmpleted 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....... A No...... ❑ City of Northampton _ Massachusetts Z2MAR2MSNT OF BUILDING ZNBPN ZONB 212 qin S"s t • Nuoicipa evilding Nnctasaptnn, M 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes.Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement,removal,demolition, or construction of an addition to any preexisting owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by reeistered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered T of Work: RUArA,�� k`�Tf�nen)d Type �� Q B�7& Est.Cost: ,2.11 G"Lb ,cY7 Address of work: M 4 N P'lM to --',-ref cr2RA�cx f UA&k 6 106 z Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): Job under$1,000.00 _Owner obtaining own permit(explain): _Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND 1x1 NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: 31jbiIA Pat. ,,-0&� �� A 8a,(,J, i59 � � Contractor Name HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-1017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHOmTY. ADDlicant Information Please Print Leeibly Business/organiza / p-.l tion Name: I)It✓F�r� Address: '77 C.O-Y2 tP, U (LOA-13 �I City/State/Zip: (AH4 R N A O/O5q Phone#: �fI3' -S��-C7 ;11Q Are you an employer?Check the appropriate box: Business Type(required): I.0 I am a employer with 2 employees(full and/ 5. ❑Retail orpart-time).' 6. ❑Restaumnt/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7, ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. ]No workers'comp.insurance required] g. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§I(4),and we have 10.r❑-I Manufacturing no employees.[No workers'comp.insurance required]" 11❑Health Care 4.❑ We are a non-profit organization,staffed by volunteers, ue with no employees. ]No workers'comp.insurance req.] 12.7 Other k7 R 'My applicant thus checksbox#1 must also fill out Ne section below showing shah workers wmpauation polity int unlit oo. —Ifthe eo xrate olTcers have exemptdthemselves but th,co„eunion hu oderenpluyees,a workem compensation polity is mluied aW such au v,,uo�m,aI should chxk box MI. I am an employer that k prodding workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: 499” ,AYIEJx 1F—IM(Y7(DYE� ia4o-2AF— Pte. Insurer's Address: F-K)LQX` City/Statc/Zip: ��lw l;t JGTpo 1 I W]l4 © 1 80 3 Policy#or Self-ins.Lic.# CG �X)—.501�.rJGQ'�1AA Expiration Date: a 1 eapiration date). Attach a copy of the workers'compensation policy declaration page(showing the policy number e d 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 cervi er the pains andpenalues ofperjury that the lnfarmanon provided above Is one and correct Sienamre: 7�JZQ �� Dale: Phone# 13—ri Official use use only. Do not write in this area,m be completed by city or town of clat City or Town: Permit/License It Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Once 6.Other Contact Person: Phone#: www.maw,Wdia 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,essoaiation,corporation or other legal entity,or any two or more of the Foregoing engaged in ajoint 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 arty 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 bases that apply to your situation and,if necessary,supply your insurance company's name,address and phone number along with a certificate of insurance. Limited Liability Companies(LLC)or Limited Liabiliti 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 submi'led 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 requ red 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 permt/license number whic3 will be used as a reference number.In addition,an applicant that must submit multiple permitAicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary). 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 c tiaeri 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston, MA 02114-2017 Tel. # 617-727-4900 ext 7406 or 1-877-NIASSAFE Fax h 617-727-7749 cow .mass.gov/dia Forth Revis 02-23-15 City of Northampton _ Massachusetts DE udKNT OF BURL NG INSP=XOrS n 212 Nein Slx t aMmiclpal auilddq Noitbup n, Ma 01060 Debris 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. The debris from construction work being performed at: 1R9 N, 7V1� a Srz <_7 , Lowvca<. nnw otc6z (Please print house number and street n me) ' Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: �PA)f Q•I6kfr5- 'r^'UJ61 Vj�o (Company Name and Address) 0157 �/�e�s/p�cr.s`re�r �ar�r��7� �r� olo3g e a4I'q Signature of Permit ApplicantacBa�Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed.