30B-121 26 LIBERTY ST BP-2018-1022
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:30B- 121 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2018-1022
Proiect4 JS-2018-001851
Est.Cost: $8000.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: TIMOTHY LUCE
Lot Size(su.ft.): 8712.00 Owner: THOMSON KRIS&DEBRA BERCUVITZ
Zoning:URB(1003/ Applicant: TIMOTHY LUCE
AT. 26 LIBERTY ST
Applicant Address: Phone. Insurance:
127 Audobonrd (413) 387-9800
LEEDSMA01053 ISSUED ON:4/11/2018 0:00.00
TO PERFORM THE FOLLOWING WORK STRI P & SH INGLE ROOF
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 4/11/20180:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
F�00 f '
- Department use only
--'�. City of NoLP
n S tus of Permit:
.✓� - BUildingD Curb Cut/Dnveway Perk
" 212 Mai --"Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
--f Other Specify
APPLICATION TO CONSTRUCT,ALTER REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION t5p-19- C 0-:2 :)-
4.1
1.1 Property Address: This section to be completed by office
Ji ll 16 r`A `-'� �' Map Lot nit
1 CS".,r C-t ' JI�I- 7 Zone Overlay District
1 li �-_
Elm SL District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT I, V
1
2.1 Owner of Record: K-(/
Kris ��c�wr,c /� L CGS _,2 c" : 3 )(J 3
Name(Pont) Current Mailing Address: d
big TelePtwne / � L V4� ..
J
2.2 Authorized Agent:
Name(Print Current Mailing Address:
Y13 367 ZEOL
Signature Teleptune
SECTION 3.ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Oficial Use Only
completed bpermit applicant
1. Building EOcc �= (a)Building Permit Fee
2. Electrical lh-�� (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Perit Fee
4. Mechanical(HVAC) �0
5. Fire Protection
6. Total=(1 +2+3-4i5) Check Number /
This Section For Official Use Only
Building Permit Numbe - IDssueB
Signa re'
BuildingC rnissionerlinspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
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 filtel in by
Bonding Degamuent
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(l ,arm minus bldg a pavN
ark'
N of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O 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 ff
B. Does the site contain a brook, body of water or wetlands? NO O 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 O
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 O
IF YES, describe size, type and location:
E- Will the canshuclion activity disturb(clearing,grading,excavation,or filling)owl acre or is it pan of a common pan
that will disturb over t acre? YES O NO O
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 ❑ Replacement Windows Altereton(s] Q Roofing 0�
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Deeks [q Siding[0] Other[O]
W =,00n� ^ 6g- a &` 4 irl & A it, W'j k txlme/
Alteration of eristing bedroom yes No 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 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 W oodstoves Number of each_
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
I. Is mnstruceon within 100 ft.of wetlands?_Yes No. Is mnsbuction within 100 yr. floodplain_Yes_No
I. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
1. Septic Tank_ Cit)(Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, �L.-P I" I /'1�'�c- 1 .as Owner of the subject
pro
hereby authorize 1`� v• k uQ—
c:on m t,in all matters five to work authorized by this building permit application.
",
of er
ch1 Date
1"y V• �LZ_ ,as Owner/Autha¢ed
Agent hereby deparm that the statements and information on the foregoing application are true and accurete,to the best of my knowledge
and belief.
Signed under the pans and penalties of perjury.
"j - L )CA -
Pdnt Name
9A /g
Signature of OwnedAgem Otte
SECTION 8-CONSTRUCTION//SERVICES
8.1 Licensed Construction Sdoervisor: Not Applicable ❑
Name of License License Holder: �— ��9(,�5
1 c ,G, I`''� 1� A -q Z)S3 License Number E
Address Expiration Data
yr3 367 )1Sa)
Telephone
9.Registered Homme Improvement Contractor: Not Applicable ❑
—IIYua7 J . �-✓CA-- /Y/ FULL
Com an Na a Re istration Number
V 66x )q IZ2- /Z
Address y Expiration Data
�5 4/�`Ayo��-3 Telephone
SECTION 18-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C)6))
Workers Compensation Insurance affidavit must be completed and submitted vrith this application.Failure to provide this affidavit volt rasu8
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No...... ❑
City of Northampton
Massachusetts ¢2s r<<
A p
OEPARThffii'f OF BUILDING INSPECTIONS i n
212 Main Street a Municipal Building
Northampton, MA 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 pre-existing 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 registered contractors.
Note:L(the homeowner has contracted with a corporation or LLC,that entity must be registered.
Type of Work: R.,� // JI � C !! Est.Cost:
Address of Work: V..¢ I tOr'/`H'/ SP•
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 DO 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:
y—f-13 �nre. 7: py92J1
Date Comptictor 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
City of Northampton
Massachusetts Fas1j�c�c
DFPAAT T OF BUILDING INSPECTIONS 2
212 !lain Street • Municipal Building F C°
� MorNan,ampton, MA 01060
Massachusetts Residential Building Code
Section 110.85.12
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.
Section I I O R5.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a persons)
for hire to do such work, then such homeowner shall act as supervisor.
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 persons) you hire to perform work for you
under this permit.
City of Northampton
Massachusetts Fy=s C c
3
( DN OF BUILDING INSPECTIONS
212Nein
S 2
212 Street a di
ipal Builng y
� Nazthamptan,on, 101 01060 'rsYpi: �`bCn
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:
ZG 4r" S F.
(Please print house n ber and street name)
Is to be disposed of at:
vs�i &V4 �U�i ti - /V4
lease p M t na and location of facility
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
j; k
Signature of Permit Applicant or Owner 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.
The Commonwealth ofMassachuselts
—Q6 Department oflndustrialAccidents
1 Congress Street,Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE PILED WITH THE PERMITTING AUTHORITY.
ADDlicant Information TT Please Print Legibly
Business/Organization Name: 1: _1. Lc.; c-<—
Address:� �ok
City/State/Zip: U d S Phone#: �Kn 3
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑Retail
OL
-lime).* 6. E]Restaurant/Bar/Eating Establishment
2. 1 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 R ❑Entertainment
their right of exemption per c. 152,§1(4),and we have ME] Manufacturing
no employees. [No workers'comp.insurance required]*
4.❑ We are a non-profit organization,staffed by volunteers, I L❑ Heart Care
with no employees. [No workers' comp. insurance req.] 12. Other
'Any applicant that checks box#1 wor por aa[ion policy rawrivairr.
'althe corporate officers lure exempted themselves,but the coweatlon has tuber employee,a workea'compereanon policy is quired and such an
orgaviWicn,hoard ehwk box 41.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:_
Policy#or Self-ins. Lia# Expiration Date:
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 e. 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, under the pains and penalties oirperjury that the information proviidded above is true and correct.
Signature: j;17642
Date:
Phone#' YI� 377
Official use only. Do not write in this area,to he completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.CityfFown Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass-grchh.
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 lure,
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 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 any of as political subdivisions shalt
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 contacting authority."
Applicants
Please till out the workers'compensation affidavit completely,by checking the boxes 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 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 oflndustrial Accidents. Should you
have any questions regarding the law or ifyou 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 m 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 permitAicense number which will be used as a reference number.In addition,an applicant that
most submit mulfiplc peri iuliccnse 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 he provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be tilled 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 Department's address,telephone and has number
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street
Boston,MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
www.mass.gov/dia
Form Revised 02-23-15
Massachusetts Department at Public Safety
Board of Building Regulations and Standards
License. CS400515 a {`OMMONW
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TIMOTHY JLUCE a �` 1
PO BOX 14 SHEET ME TAIL W
ORKEft
LEEDS MA 3w63 ISSUES THE rQUOINING LICENSEAS A
'.. MASfER•UNFIESTRICTED
TJMOT}IY J LUCE
M EXpirabon: *SDI(14 1
Commissioner 87116R018 LEEDS,MA 0t053.00i4..
13335 67n8rtolS
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QrrHOMConsumerAMENT CONTRACTOR
HOMEIMPROVEMENTRACTOn beoretton ssWridrm atel tlual IT t(oind only
TYPE Inenin11 Offora fConsurnernffair andundntumte:
Iia O100e 01 Consumer 51" and Business ReOuletion
149283 12/14/2m9 t0 Park Pleza•Suiie 5Y70
TIMOTHY J LUCE Boston,MA 02116
DMOTHYJIUCE !!?C .�Z--- ' 1
122 A005ON RD. :�
I EEOS,MA 01053 Undersecretary Not valid without signature