44-010 (8) 409 ROCKY HILL RD BP-2018-1048
GIS#: COMMONWEALTH OF MASSACHUSETTS
Man:Block:44-010 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Categorv:renovation BUILDING PERMIT
Permit BP-2018-1048
Proiect# JS-2018-001899
Est Cost:$7800.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group' VITALIY PANCHENKO 111142
Lot Size(so. e.): 85377.60 Owner. JEWETT KIRA
Zoll Applicant: VITALIY PANCHENKO
AT. 409 ROCKY HILL RD
Applicant Address: Phone: Insurance:
14 BIRCH RD (413) 454-3346 SOLE PROPRIETOR
WESTFIELDMA01085 ISSUED ON.4/17/2018 0:00:00
TO PERFORM THE FOLLOWING WORK:DEMO CLOSET AND MOVE, EXTEND WALL,
REMOVE LIGHT AND ADD FAN**NOTE - SMOKE/CO DETECTORS AS REQUIRED IN AREA
BEING RENOVATED
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 4/17/2018 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File q BP-2018-1048
APPLICANT/CONTACT PERSON VITALI C PANCHENKO
ADDRESS/PHONE 14 BIRCH RD WES!FIELD (413)451-3346
PROPERTY LOCATION 409 ROCKY HIL.,RD
MAP 44 PARCEL 010 001 ZONE
THIS SEC HON FOR OFFICIA. USE ONL Y.
PERM IT APPLICA FION C6ECKLIS-'
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT _
Fee Paid
Building Permit Filled out
Fee Paid
T eofConstruction: DEMO CLOSET A O EXTEND WALE REMOVE LIGHT AND ADD FAN
ort— S+ueK b-6RCTdPS AS f D id n/�5 &-/P\7 REittovq�
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure _
Building Plans Included'
Owner/Statement or License 111142
3 sets of Plans/Plot Plan
THE toLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INATION 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
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.
f
Department use only
-"-� City of Northampton Status of Permit
Building Department Curb CuttDiveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
_ phone 413-587-1240 Fax 413-587-1272 Montle Plans
C ther Specify.
4APPLICATION TO CONSTRUCT,AL SER, EPAIR,RENOVATE O'2 DE MOLISH A ONE OR TWO FAMILY DWELLING
APR 1 3
SECTION 1 -SITE INFORMATION
Derr or aus:,ino wsa=_cnorvs This section to be completed by office
1.1 Property Address'. rvomm�u=ran,w,acroso ^
f' Map Lot nit
Zone Overlay District
F� L M/r Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
4irj'a r%2Gt� �f ye�q�OtltN /��r✓ �enceM
Name(Pnn(7 q Current Current Mallin
✓ f CQ/� 7 ' Telephone
Signature
2.2 Authorized Agent:
Name(Prion Current Mailing Aodmsss.
Signature Telephone
SECTION 3.ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed bPermit applicant
1. Building / p o (a)Building Permit Fee
2. Electrical � 700 (b)Estimated Total Cost of
Construction from 6
3, Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
Total=(1 +2+3+ + 5) tbO Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissionedlnspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
New C�liellicom
R
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column m be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage
iLut area minus bldg&paved
do 1
#of Parking Spaces —
Fill:
lrolume&I�wtiou)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Recistry of Deeds?
NO O DON'T KNOW Q YES O
IF YES: enter Book Page and/or Documentla
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES O
IF YES, has a permit been or need to be obtaiied 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 C NO O
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 l acre? YES NO O
IF YES,then a Northampton Storm Water Managemer t Permit from the DPW is required
A '
SECTION S DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding[0] Other[OJ
Brief Description of Propose
1
WorkC' /Mc P141,
add,ybri, Cir//�q7/ rl mo
Alteration of existing bedroom_Yes No Adding new bedroom Yes No /f✓y�/�yyAAJp�� f -//
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ba.If New house and Or addition to eadstina housinl 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?
J. 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
1. 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 O/R'CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 'i-et ( , 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.
Signature of Owner Date
I, ,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 under the pains and penalties of perjury.
���tGy /N/IG�t{g9�iA
Print Name
Signature of Owner/Agent Date
e
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervis
or: Not Applicable (❑1
Name of License Holder: Uf � 1 /V/W('�v_ CJ-//// ` 2—
License Number
ed Le-) 0 ylWAV
Address Expira—ia�e
yi3- y�l-.�3y6
Signature Telephone
9.Registered Home Im rov ment Contractor: Not Applicable ❑
u P Achn LGA. /gpfaY
Comoanv� Registrati n Nu ber
/Y �iiYli �c✓ Gi{® l o/ 1
Address Expiraion Data
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
Workers Compensation Insurance affidavit must be completed and s.ibmitted 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..- ❑
U; tar;y Pani &4-0
City of Northampton
" ( Massachusetts
l � . 3
I DEPARTMENT OF BUILDING INSPECTIONS a'
212 Main stceat • Nunioipai Bvildivg
Northampton, ! 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:If the homeowner has contracted with a corporation or LLC,that entity must be registered.
Type of Work:�� 9� /�{n� (,- V 17 Est. Cost:
/� /, a
Address of Work: - O9 jeady ll l/ N Ro-o�("ei /"I /1
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/f3/f �„
11, �t d� l9'0aY
Date tractor 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
R
City of Northampton
Massachusetts "®
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Huiltlinq \ {
\� Northampton, MA 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 famr st:-uctures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner.
Section I 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 11 O.RS, 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 penult.
As acting Construction Supervisor your present e 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
5
Massachusetts4 -.s
DEPARTMENT OF BUILDING INSPECTIONS 2
212 Main Street •Municipal Building
Northampton, MA 01060 "rstiptil,a
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:
L/ G��1 e.�e IwIJ
(Please print house n ber and street name)
Is to be disposed of at:
�I
(Please prinf nam nd location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
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.
t
The Commonwealth ofMassaehusetts
Department of Industrial Accidents
I Congress Street,Suite 100
s Boston.All 02114-2017
wet sv.mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERbI1TTING AUTHORITY.
Applicant Information p /+� / /' /Please Print Legibly
Business/Organization Na/me: n /C. /,��,// AM,./l'u GGYI A�h LLG .
Address: Iq /YU1 1C�Q/ WLR ,, 1�1� I7 /
City/State/Zip: W/V t e G' �'�✓ Phone 4: q,?'Y.fY'�3yb
Are you an employer?Check the appropriate box: Business Type(required):
L❑ I am a employer with employees(full and/ 5. ❑Retail
,�,/�[part-time).' 6. ❑Restaurant/BadEating Establishment
2.1e i am a sole proprietoror partnership and have no 7. ❑Office and/or Sales Qncl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] S. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, ¢'1(4),and we have 10.❑Manufacturing
no employees. [No workers' comp. insurance required *
4.❑ Wearer non-profit organization,staffed by volunteers 11.❑Health Care
with no employees.[No workers' comp,insurance req. 12.0 Other
'Anv appluvar encheeks box Bl must also fill outthe section belowshcwing their arlsrs'mmpomation policy information.
^Itthn corppnte officers haveunpmd themselves,but We emposs ion has o her ecompensation,a workers'compensation policy is required and such an
m,aazanonshouldcheck1u,sl
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/Stale/Zip:
Policy#or Self-ins.Lic.# 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 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 e vil penalties in the form of STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a cc py of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, u der thepains andpersallies ofperjmy that the informadon provided above isdruse qnd
dccorrect
Sienature- _ Date �O
Phone#: Y T-f1JY—22JV9
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: _Permit/License 4
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board S.Selectmen's Office
6.Other
Contact Person: Phone#:
cows,. s..gomdla
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 ajoint enterprise,and including the legal representatives ate deceased employer, or the
receiver or trustee of m 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, p25C(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, k25C(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 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. 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 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 o 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). A copy ofthe 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 licens'es. 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 Departments 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-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
I onn aevlsed 0223-15
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New Home Improvement
England
General Contract
Contracting ESTIMATE#: 786: 04/12/2018
,LLC
14 Birch rd
wesniela, NIA utU6D
Phone: (413)454-3346
License MA#CS-111142 [HIC and fully insured]
To:
Kira Jewett Phone Number:
Work at addrecs 409 Rnchv Hill Rd Florence. MA
JOB DESCRIPTION: Good quality work done within 2 and half weeks.
Electrical
Supplies and labor for electrical
Move hallway wall sconce for the new wall location(Electrical)
Demolition of old electrical wiring
Installation of ceiling toddle fan which includes a switch
Recess outlet into wall beam
Installation of a light
Installation of outlet if needed
complete removal or waste and debris
Construction
Supplies and Labor for Carpentry
Drywall installation:taping and mudding, sanding and adiusting
Painting with primer and paint
Fix empty flooring area in bedroom
Closing of the construction site to the ridge beam
Building of a wall for the door and the bedroom
Building a closet 3'x4' feet in the bedroom; installation of the closet door.
Demolition of previous walls in the bedroom(walk in closet)
Move the wavy wall above the door
Payment Schedule: A thud of the project cost($2,6Q0) must be received before construction starts. The
second-third of the payment will be received half way into the project; once the project is complete,the
last portion will be paid in full.
Work Costs Amount for entire job description: $7,800.00
Uncu*It
e: Late:
New England Ge al Contractor Signature: Date:
-------------
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