17C-128 (7) 55 NORTH MAPLE ST BP-2018-1046
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 128 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 PERMIT
Permit# BP-2018-1046
Proiect# JS-2018-001897
Est.Cost: $33125.00
Fee:$215.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group JAILYN GONZALEZ 97254
Lot Sizctsq.ft.): 11238.48 Owner: MELNICK LISA
zoning: URB(100)/ Applicant: JAILYN GONZALEZ
AT. 55 NORTH MAPLE ST
ApplicantAddress.- Phone. Insurance:
44_BEEBE RD (413) 455-9944 O WC
MONSONMA01057 ISSUED ON:
TO PERFORM THE FOLLOWING WORK.REMOVE AND REPLACE ROOF/WINDOWS,
COVER FRONT STAIRS WITH PT WOOD, INSTALL NEW KITCHEN CABINETS
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: OJ: 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 4/17/20180:00:00 $215.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2018-1046
APPLICANT/CONTACT PERSON IAILYN GONZALEZ
ADDRESS/PHONE 44 BEEBE RD MONSON (413)455-9944 O
PROPERTY LOCATION 55 NORTH MAPLE ST
MAP I7C PARCEL 128 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
TTypeofConstruction; REMOVE AND REPLACE-F/WINDOWS, COVER FRONT STAIRS WITH PT
WOOD, INSTALL NEW KITCHEN CABINETS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included'
Owner/Statement or License 97254
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
r
t 'e of Builth rfficial 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.
FAVR �
_l
Department use only
City of Northampton Status of PemliL
F Building Department Curb Cul/Driveway Permit
212 Main Street Sewer/Septic AvailabilFty
Room 100 Water/WeN Availability
a` Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
` --- _ Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Atltlress:
This section to be completed by office
n
55S K I-Aq)P `�A Map Lot JA Unit
lof evlf q ICr OIl1 i,. �. Zone Overlay District
a.SL District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Nam,1e(Print) �9 (1 Curren,Mailing Addriles
ei�(/y� rt•+—rii..,eK/�t-- `I1
TeleM1ane Phone -9013
Signature
2.2 Authorized A/uent:
Prin _ Current Mailing Address:
glure Teleptwne
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 33 I 1 a S Oe+ (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) 4 Check Number
This Section For Official Use Onl
Building Permit Number: Date
Issued:
7— t
Buildingissianerllnspedor of Buildings Date
\ail n tuceY� IQ4Z Ya�o . cam
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 firW in by
Brulding Deganment
Lot Size
Eldredge _
Setbacks Front
Side L R: L: R:
Rear
Building Height
Bldg.Square F.mutge
Open Space Footage
(Lor ares minis bldg&pavW
rattling)
#of Parking Spaces
Fill:
wlmne&l.ncaeon
A. Has a Special Permit/Variance/Finding ever heen issued for/on the site?
NO ® DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Regrstry 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 G 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 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 O NO
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 EJ Addition ❑ Replacement Windows Alterotion(s) EJRoofing
Or Doo s
Accessory Bldg. ❑ Demolition ❑ New Signs [0) Decks [0 Siding[0) Other[E:]
Brief Description of Propasetl
Work: ,o, r I' a. - L'c �wn.-f;x . . ltee,.' 1 +c<v_:, u, tv, �y - ti F ' ins{allnrwe�ty�r
Alteration of existing bedroom Yes_ No Adding new bedroom Yes No
Attached NarraUve Renovating unfinished basement Yes _No
Plans Attached Roll -Sheet
6a.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 Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance fame attached?
h. Type of construction
I, Is construction within 100 ft.of weflands? 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_ CM Sewer Private well City water Supply
SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
property
hereby authorize .,._ l."
to ac�tppon my behalf,
``ii-n all matters naefvgeGtol work authonzed by this building permit application
Ll 12-.11
ignature of Ovmer Date
i, �/1 (: ., as Owner/Authorized
Agent here declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print.
Sig nalure Ker/Agent Date
SECTIONS-CONSTRUCTION SERVICES
81 Licensed Comatrugfign S i C { Not Applicable ❑ ^�
Name of Lloeese Noldar; yF
License Number
Address '— � rbc
Expiration Nate
urs Telephone
I Ranalsberad Hatme lnqU2yM.tC,*aet Not Appticabte O
_mp _ }IAC �� mbet
Company Name "- Regishation Number �
Address
Extumbon Date
111�.�11y'pSn J1G'����pp CrJP _Telephon�yr�..•�i';; _ .
SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.O.L.c.132,§25C(6)) i
Workers Compensation Insurance affidavit must be completed ana submitted with this appbcation.Failure M provide this affidavit will result
in the denial of the issuance of tMs building pertnk
Signed Affidav@Attached Yes. ..._ Na._... ❑
City of Northampton
'(6 Massachusetts
DEPARTMWr OF BUILDING INSPECTIONS
212 Hain Straut • Municipal Building
V _+ NortN,m n, � 01060
Massachusetts Residential Building Code
Section I IO.R5.1.2
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 1 IO.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 person(s)
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 person(s) you hire to perform work for you
under this permit.
City of Northampton
Massachusetts
ri"A 2NI:NT OF BUILDINGINSPFCTI�S
trr Cm
313 Main aaec • NuniciPal nuildi
North,m n, IA 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, innovation,repair,modernization,conversion,
improvement,removal, demolition, or construction of an addition to any preexisting ownereccupied 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:Ifthe homeowner has contracted with a corporation or LLC,that entity must be registered.
Type ofWork: 4AylFltu.l"ldaraS jl(.i4ahe raak, t"xe. Est. Cost: 33r Ia-$ �J
Address of Work: -C-5 N K_Q0 e -Si- FIU.¢.rice , M IT
Date of permit Application: 4 118
1 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:
4 ] z 19 �CtAA . ISto 6,L
Date 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
City of Northampton
Massachusetts v?'�
OBPARTDffiA'T OF BUILDING INSPEc!rzWs
313 Ifaiv t[ •Municipal Builtlinq
9orChampton, !P 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 property licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
ti , h�tn( n ��dYe" e, MW
(Please print house number and street name)
Is to be disposed of at:
a�U FagQurpr+� � Vc' iyig 'e(j,
(PI a print name and location of facilityT
Or will be disposed of in/a�dumpster/onsite rented or leased from:
lu SnF �d Tar"`' Sq4-run
°company Name and Address)
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 of Massachusetts
Department oflndustrial Accidents
I Congress Street, 2100
Boston,MA 02114-4-20017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITI'.
ADDlicant Information Please Print Leeibly
Business/Organization Name: .jr�
Address: 'L'?f' I�'_1
City/State/Zip \1k 1;'1A, 61-', Phone#' `j1-, I 'gid Y'Y
Are you an employer?Check the appropriate box: Business Type(required):
1.0 I am a employer with employees(full and/ 5. ❑Retail
of part-lime).• 6, ❑Reslairra Bar/Ealing 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 A. 152,§I(4),and we have 10.❑Manufacturing
no employees.[No workers'comp.insurance require,11*4 11 ❑Health Care
4.❑ We are a non-profit organization,staffed by volunteers, 1�
with no employees. [No workers'comp.insurance req.] 12.®Other 1
*Any applicsnt th a checks box pl mau also fill out Ire section below showing their workers'compensation Policy inf minion.
"Itthe<oryomrcoffibave exempted Ihemsetves,bur she co�pomtiovhas oNer empWyea,aworkers'compewtion policy is required and such av
o�ganvnliun shanlJ ch-k box%1.
lam an employerthatisproviding,,�workers'compenmdoninsuranceformyemployem Belowisthepo0cyinformadom
��
Insurance Company Name: li,�W
Insurer's Address: > - ti
City/Stale/zip: }�01. 'e,, .r.A
Policy#or Self-ins Lie.# v 'J V<'.(] -zQ(;; Expiration Date: I I -I
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 a 152 can lead en 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.
1 do hereby certify,under the pains and penalties of perjury that the information providedabove,is now and correct
Sumamte. ��/r'— L J' �� La 1. C.1 Date Li'12'1
Phone#: �'lh - 4'-t-f
Official use only. Do not write in this area,to be completed by city or town ofpclat
City or Town: Permit/License#
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#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all empioyeia to provide workers'compensation for their employees.
Pursuant m this statute,an employee is defined as"...ever fiction in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,associat on,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)that legal entity,employing employees. However,the
owner of a dwelling house having not more than three spun.,us and who resides therein,or the occupant of the
dwelling house of another who employs persons to do meinlentrce,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 at 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 un61 acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the counts ting authority."
Applicants
Please fill 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 Parmmships(LLP)with no employees other than the members
or partners,at not required to carry workers'compensation in sumnce. Iran 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 sore to sign and date the affidavit. The affidavit should be rearmed 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 comoanirs should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sme that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
ofthe affidavit for you to fill out in the event the Office oflnves6gations has to contact you regarding the applicant.
Please be sure to fill in the permitllicense number which will ba used as a reference number.In addition,an applicant that
must submit multiple pernit/license applications in any given vear,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
most 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 bearri lea,es 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
I Congress Street
Boston, MA 021142017
Tet#617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-"27-7749
www.mass.gov/dia
Massachusetts Oepadment of Pubiic Safety
�- Board of Building Regulations and Standards
License:CS-097254
Construction Supervisor
JALYN GONZALEZ
44 BEEBE RD A&
MONSON MA 810ST
M H D_ Expiration:
Commissioner 0 412 9/2 018
Ot6<e of Coaswaer,Affairs&8asineu Bcgubtioa License or registration valid for indiridual use only
* HOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to:
:a Registration: 151682 Typo: OBice of CoosumeY Affairs and Business Regulation
_ Expiration: 6121=18 DBA ifl ParhP)ara-Strife 5170
Bosios,MA 02116
JR CONSTRUCTION COMPANY
JAILYN ROSARIO
W BEEBE RD _
MONSON,101057 Undersecretary _ Not valid without signature
WORKERS,'_COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
= _ InTOrMatlOn Page : __WC 00 0o 01
Atlantic Charter Insurance Company VDAC
NCCI Cu. No 292Y1 Policy Number WCVC1181603
1. INSURED: Prior Policy Nomper WCV0118160;
Jetlyn Gonzalez Produce,
JR Construction RG Neylon Insurance Agency. Inc
44 Beebe Road PO Box 1220
Monson MA 01057 Granby MA 01033
Federal IU Number 20505771:3
Business l e' Soe Pro ne!or Risk Id Number
yp p SIC 9999- NONCLASSIPABLF ESTABLISHMENTS
Other Named Insured. See WCE106 Oiler Work Places See WCE107
2. POLICY PERIOD: The Policy Penod Is From 08,0',2017 To 08/01/2018 12C1 A M. Standard Time
at Tne Insured Marling Address
3. COVERAGES:
A Worrers Compensation Insurance Part One of the policy applies to the Workers Compensation Law if the states
I5ted here MA
B Employers Liability Insurance Part Two of the policy applies to work m each state listed r :tem 3A Toe limits Of our
Iabi'nty undar Part Two are Beoiiy Injury by Accoent S 100 000 each acoaert
Bodily Injury by Disease S 500 00C poacy mL
Bodily Injury by Disease S 100 000 each employae
C Other States Insured. Part Tnree of the policy apples to the satesif any ':stee -ere
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B
D Tms poLcy includes these endorsements and schedules
See WCE'05
4. COVERAGES: The premium forints policy 6P8 be determined by our Manual of Rdres Olasstficanpns. Rates&
Rating Plans All information required below is subject to vevBcabon and change by arida
Code Premium Basis Total Rate Per Estimated
Classifications No Estimated Annual $100 of Annual
Remuneration Remuneration Premium
See WC 00 X 01
Minimum Premium Deposit Pre-mum
S500 56 114
Total Estimated Premme S5 809
Interim Aujustmen! Annualy Surc^argets) 305
Servicing Office Total Premium and Surcielge,$) $6 114
25 New Chardon Street
Boston MA 02114A72^
tro ( 4-
Issoe Date 07/2C/2017 Countersigned By: Date