24D-088 (8) 60 NORTH ST BP-2018-1072
GIS a: COMMONWEALTH OF MASSACHUSETTS
Map,Block:24D-088 CITY OF NORTHAMPTON
Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: Siding BUILDING PERMIT
Permit« BP-2018-1072
Proiectk JS-2018-001935
Est. cost: $25000.00
Fee: 560.00 PERMISSION IS HEREBY GRANTED TO.
Const.Class. Contractor: License:
Use Grmmo MATTHEW T WILCOX 075440
Lot Size(sa. ft.): 8886.24 Owner: FREY JOBN D&JENNIFER K DIERINGER
zuntue: URC000)/ Applicant: MATTHEW T WILCOX
AT.* 60 NORTH ST
Applicant Address: Phone: Insurance:
7 PORTER ST (413) 665-8269
SOUTH DEERFIELDMA01373ISSUEDON:4/19/20180:00:00
TO PERFORM THE FOLLOWING WORK:REMOVAL OF EXISTING SIDING AND TRIM AND
INSTALLATION OF NEW HARDI PLANK CLAP SIDING
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 ft 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 Sienature:
FeeTvoe: Date Paid: Amount:
Building 4/19/2018 0:00:00 560.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
X I Department use only
ty Northampton Status of Permit:
ildi g Department Curb CWDriveway Permit_ -- Main Street SewedSeplic Availability
:I Room 100 Water/WellAvailability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 PloVShe Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION i -SITE INFORMATION 81,9- 19- 10 '7x-
1.1 Property Address: This section to be completed by once
'.
Map c'(l/ Lot 59.- Unit
60 North Street Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZMAGENT
2.1 Owner of Record:
JohnFrey 60 North Street
Name(Fri Current Mailing Address: 413-320-1265
Telephone
4-1
Si t
2.2 Authorized Agent:
Ma ewt�-leve la-Mingl7dog�rv . Nolan Gr, N Lc�field rvlk6
Name(Print) ueeM Mailing Atldress:
'-113 52,Z— I Q 9 H
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 25000.00 (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) Check Number
This Section For Official Use Only
Building Permit NumbeDate
Issued
Signatur : / 2
Building C�, linspctr&oBuildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING Ah Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This columm to 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 %
(1,u9 area minus bldg&paved
ad,im
#of Parking Spaces
Fill:
volume&Lm ation
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#
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 0
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 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 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 Wiinpows Alterations) ❑ Roofing ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [q Siding[EI) Other[m
Brief Description Of Proposed Removal of existing siding and an and installation of new Hardi Plank clap siding
Work:
Alteration of existing bedroom_Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
w. 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?
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?
In Type of construction
i. Is construction within 100 R. of wetlands? Yes No. Is construction 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-
I. Septic Tank_ CdySewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, � as Owner of the subject
property
hereby onze "^vvr/^PiG✓ "V t ( GFX
to a n my beh f 11 matters relative to work authorized by this building per a Iiwtign_
L
Sig • ,I Owner Date
1, M(.lT'f/ll��A�
W1,
`LOX as Owner/Authorized
Agen hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief
Sighed under the pains and penalties of perjury.
Pnnt N
'me
(�I /7
Signature of Ownar/Agent Date / //
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder: MatthewTWilcox
License Number
7 Nolan Circle CSFA-075440
Address Expiration Date
Hatfield, MA 01038 6/20/2019
Signature Tele hone
413-522-1894
8.Realatenad Home Im'p�rovement Contractor: Not Applicable ❑
Wil Cox [aI lrinrs l r1c
Company Name Registration Number
2 N0`6an Gr- 1'7624 (O
Address Expiration Date
�'Pr0 ' - olb�p
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§I6C(6)) 1
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...... ❑
City of Northampton
UDEPARTMENT
y\5 3/n
Idaaaachuaetts OF BDIDDINO INSPECTIONS 212 Main Street & Mwicipal auilding��\,.. 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.
Nate.Ljthe homeowner has contracted with a corporation or LLC,that entity mos(be registered
Type of Work: gic4iirI5 Est.Cost%.1�(Ogo
Address of Work: (/O N 0(-j-h $'!i�'"T,9,4ti—
Date of Permit Application:_ L1/ 7)1 a
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 RESPONSUMLITES 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:
/041 /W a4linj a) l co
Dater C actor Na ne 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
DEPAE� OF BDILDiNG INSPECTIONS
1\ 212 Main Street • M cxpal Building Ju Cm
Northampton, M 01060
Massachusetts Residential Building Code
Section I IOX5.1.2
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 110.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 F25 - °4l
DEPARI4�NT OF BUILDING INSPECTIOIPS
212 Main S=eet elWnicipal Building 22
�.n Northampton, nm 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:
&0 No(+h are-e+
(Please
re e+
(Please print house number and street name)
Is to be disposed of at:
Val,(t u
(Please int name aPfd location tif facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
� 4 00717
Signature of Permit Applicant orpvfner 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 of IndustrialAccidents
1 Congress Street, Suite 100
Boston,MA 0211 4-2 01 7
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMI'11 ING AUTHORITY.
ADDlicant Information I ,.1aPlease Print Leeib
W lv
Business/Organization Name: 11C`m bl la Id � �,
Address: 7 l j oiositn cr
City/State/Zip: FLA±fi W MA a Phone#/:
Are y�employer?Check the appropriate box: Business Type(required):
L I am a employer with 10 employees(Poll and/ i ❑Retail
orpart-time).' 6. ❑Restaurant 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] S. ❑ 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.❑ Manufacturing
no employees.[No workers'comp.insurance required]* 11 ❑Health Care
,LF We are a non-profit organization,staffed by volunteers, r��. l�
with no employees.[No workers' comp.insurance req.] 12.❑Other Oms "All
'Any applicant that checks box pl must also fill out the section below showing their workers compensation polies information_
"Uthe corporate oRce>s have exempted themselves,but corporation has other employee,a workers'a mpensonch policy is mlwrad and such an
organisation should check box N I.
I am an employer that is providing worker 'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: Qr'I� 4.CV r) Lmb"
Insurer's Address:_ (Qa- IM-Ple L_ lu'M t r 2 1 1(p 2
City/State/zip p� 1 ' p�
Policy#or Self ins. Lic.# XI a S 57S r��f 3r1(_)��� Expiration Date: I a 5
Attach a copy of the workers'compensation policy declaration page(showing the policy number and a piration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition ofctiminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil 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 copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under th stns kr! enal8es of perjury that the information provided above is true and correct.
Sim u>� Date'
Photic#: '�{�`—�
Oficial use only. Do not write in this area,to be completed by city or town official.
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 Office
6.Other
Contact Person: Phone#:
www.m tva— ur
acoiro® CERTIFICATE OF LIABILITY INSURANCE
Nn2/2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEN D,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT. Nthe c Mfi aie holder he an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or INS endomed.
H SUBROGATION IS WAIVED,subject to the terms and conditions of no policy,certain policks may require an endorsement A statemerd on
this cerNBcaM dons net confer rights to the cerlfRcate holder in lieu of such endorsement(s).
PRODUCER CONTACT Linda P.,S
AME:
WehherBGnnnell Ia�"ic°Nw EN. (413)586-0111 (413)58&8481
8 North King Street anNOAal�.ss: Ipowedy@AeeeemndgnRPUIl GO.
INSUREmaI AFFORDING COVERAGE SAID.
NOlthan-plon MA 01060 INSURER A: OHIO Seounty/Libedy 24082
INSURED INSURER B:
W E,ox Builders,Inc INSURER c
Alin Martin.MI. INSURER D
7 Nolan C,"D INSURER E:
Hatfield MA 01038 INSURER E:
COVERAGES CERTIFICATE NUMBER: Master Evp 11-2018 REVISION NUMBER:
THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD
INDICATED. NOIDNITHSTANDING ANY REQUIREMENT TERM OR CONDITION OFANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAV BE ISSUED OR MAY PERTAIN,THE INSURANCEAFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUW ECT TOALL THE TERMS,
EYCLUSIONSANO CONDITIONS OF SUCH FOLIOSE LIMITS SHOWN MAY HAVE BEEN RE WCED BY PAID CLAIMS.
/ [—ADDLrUBRj PO
ITR T,PED INAURaN, IMAD ANN
PRUCY NUMBER vsaTOYEFF YPoDIVyTYP
LICYOY IMITS
X COMMERCNLGENERALUABIl1 TY EACHOCCURRENCE E 1,000,800
CUIMS UNDE O OCCUR FEMISES Ea oxurreI.I $ 100.000
mE.'(A „aPH.11 $ 1,006
A BKS57534380 11/01/2017 11101/2018 PERSONALa AUVINLURY E 1 000DOC
GENLAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 3,000,000
X POLICY JE0 LOG PRODUCTS-COMPIOPAGG $ 3,000,W0
OTHER
AUTOMOBILE LIABILITY LCCMBIINIO SINGLE LIMIT $ 1,000,000
ANYAUTO B0.111.11RY(I cas. I $
A OTESPED ONLv wHEWDULED BAS576343B0 111014D17 11/01/2018 FODILVIRUPI,nema.,,) E
X AUT050n1Y X AUOTOS ONLYD LOPE. AMAGE E
Medical payments $ 5,WO
UMBRELLA WB OCCUR EACHOCCURRENCE $
CACEBBWB CIIIMSMADE
AGGREGATE
DED NTIUN E g
WORNERS COMPENSATION ER OTH-
ANDEMPLOYERS'LABILITY X STATUTE ER
A OPYIC NA MBEF EsCLUDEo.EcurrvE YO x XW557534380INYR 12/154017 1211512018 eL.EACH accmenT S 500000
tM,na.l.ry In xm EL DISEASE.FA EMPLUYES S 500000
IO...RIION OF OPERATIONS be. EL DISEASE- 500,000
POLICY LIMIT }
DESMG NWOPEMT SILOCA S/VEHICLES(ACORD 101,AEJNen.IR—MnS.MEUM.May MManl,eEr m.n yvs Is ry,nNH
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EX%RATION DATE THEREOF NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
5
AUTIORIZED--I--
0 1938-2015
EPRESEHTAIIVE®1888-3015 ACORD CORPORATION. Ali rights reserved.
ACORD 25(201611 The ACORD name and logo are regbtsr°d marks of ACORD
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 of 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 heense 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 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,net 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
most submit multiple permit/license 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 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 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-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Form Revised 02-23-15