24A-148 367 PROSPECT ST BP-2018-1100
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:24A- 148 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category Star BUILDING PERMIT
Permit N BP-2018-1100
Project JS-2018-001980
Est.Cost: $8000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO.
Const.Class: Contractor: License:
Use Grouo� ERIC PAYNE 086442
Lot Sim(sg ft.), 8973.36 Owner: HERZOG LAURIE E.&LAURA F ARBEITMAN
zoning:URA000)/ Applicant: ERIC PAYNE
AT. 367 PROSPECT ST
Applicant Address: Phone: Insurance:
32 BURTS PIT RD (413) 218-4276 n
NORTHAMPTON MAO 1060 ISSUED ON:4/26/2018 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE FRONT ENTRY STAIRS - NO CHANGE
TO FOOT PRINT
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 k 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:
Budding 4/26/20t80:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2018-1100
APPLICANT/CONTACT PERSON ERIC PAYNE
ADDRESS/PHONE 32 HURTS PIT RD NORTHAMPTON (413)218-4276 O
PROPERTY LOCATION 367 PROSPECT ST
MAP 24A PARCEL 148 001 ZONE URA(I OOF
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
LOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildine Permit Filled out
Fee Paid
TypeofC tructim REPLACE FRONT ENTRY -NO CHANGE TO FOOT PRINT
New Construction
Non Structural interior renovations
Addition to Existing -
Accessory Structure
Building Plans Included
Owner/Statement or License 086442
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
gn,One of m g Official Dat
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.
Department use only
City of Northampton Status of Permit
Building Department Curb CWDriveway Permit
212 Main Street Sewer/Septic Availability
Room 100 VlaterANell Availability '
Northampton, MA 01060 Two Sets of Structural Plana
phone 413-587-1240 Fax 413-587-1272 PlotlSite Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address
yThis section to be completed by office
m/ d�te
Map -2 1 Lot y Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OW NERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Addre _
� 1.3 or L-
Telephone
Siglur
2.2 Authorized
f= �\G A� !✓� '3Z � USL T'
Name(Print) Current Mailing Address:
/-t t3 Z t 8 ::k
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed bpermit applicant
1. Building � OOO (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) co
�
5. Fire Protection
6, Total=(1 +2+3+4+5) 000 Check Number S
This Section For Official Use Only
Building Permit Number'. Date
Issued.
Signature.
Buildi Commissionerllnspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Must Be ComFlate,l. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled u,by
Building DeWmnrnt
Lot Size
Frontage
Setbacks Front
Side U R L R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lor area minus bldg&Pavcd
rking)
4ofParking Spaces
Fill:lum
Ivae&Lorztionl
A. Has a Special Permit/Variance/Finding ever Seen issued for/on the site?
NO O DON'T KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registp,of Deeds?
NO O DONT KNOW ® YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or vetlands? NO (P DON'T KNOW O YES O
IF YES, has a permit been or need to be ootai)ed from the Conservation Commission?
Needs to be obtained Obtained O , Date Issued:
C. Do any signs exist on the property? YES C) 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 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
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
J
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 13
Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks Siding [D] Other[Z1
Brief Description of Proposed ``� c�
Work: rZg acs- V
?- �r-O`�� Q,V1"{ �'� O 0.x f (' —NO C/f wn� 1-0
Alteration of existing bedroom_Yes � No Adding new bedroom Yes _No , far:n'f
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existinn 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 form allached?
h. Type of construction
i. 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.
L Septic Tank_ City Sewer Private well_ City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR SUIIILLOING PERMIT
L
I, L " f - A.- � & as Owner of the subject
property
hereby authorize
to act on my behalf, in all m - a relative to wok authorized by this building permit application
Signature Date
y i
I_ `ALO ` 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
Print Name
l-_
Signature of OwnerlAgent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Num er
Address Expiration Da[
>t -7 _
Slgnalure Telephone
9.Registered Home Improvement Contractor,
,r Not Applicable ❑
;EE
Company Name ReftraoThm
r
3Z 8� v�� 5 P \ T e1 _ 3
Address 2 'l Expir tion ate
Telephrne 24, TZ l�
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidavit must be completed and scbmitted 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
Massachusetts
( DEPARTMENT OF BUILDING INSPECTIONS
212 Hain Street • .....pet Building
.. Northampton, r 01060 fy p
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: eOII'�� ) O~� Est.Cost�Apg z3C>0
—ataAddress of Work: a
qT
Date of Permit Application: 1 12-y
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 RESPONSIBRITES 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
,4JzidIg 17 9q
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 �a3'
DEPARTMENT OFBUILDING INSPECTIONS I
212 Mein Strout • Municipal Bviltling �fSM1
Northampton, ew 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 swo 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 consider:d a homeowner.
Section 110.R5.1.3.1
Any homeowner performing work for which a ruilding permit is required shall be exempt from
the licensing provisions of 780 CMR 110.R5, pi ovided that if a homeowner engages a person(s)
for hire to do such work, then such homeowner ;hall 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 eueh work performed under the building permit.
As acting Construction Supervisor your presents 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 injark s not resulting in Death) of the Massachusetts
General Laws Annotated, you may be liable :for aerson(s) you hire to perform work for you
under this permit.
City of Northampton
-" Massachusetts
f A
1 DEPAATHENT OF BUILDING INSPECTIONS
212 Hain Stzaet •Honimipal Building p^�
Northampton, H 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:
L-7 3 16 s %C,--C4 sI
(Please print house number and street name)
Is to be disposed of at:
(Please phrit name and loc tion of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Per t 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 Common wealth of Massachusetts
Department ofladustrialAccidents
I Congress Street,Suite 100
y Boston,M4 02114-2017
wwsumassgov/dia
Workers'Compensation Insurance Affidavit General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information _ Please Print Legibly
Business/Organization Name: Z;21 L � Atil
7
Address. SZ ii
_a.
City/State/Zip: __ Phone#:
Are you an employer?Check the appropriate box: Business Type(required).
1.❑ i am a employer with employees(Poll and/ 5. ❑Retail
or part-time).- 6. ❑Resmurant/Bar/Eating Establishment
2.Z I am a sole proprietor or partnership and have no 9 ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me In any capacity.
[No workers' comp. insurance required] 8- ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right ofexemption per c. 152,§1(4),and we have 101]Manufacturing
no employees. [No workers' comp, insurance requ,red'
4.❑ Weare a non-profit organization,staffed by volurneers, 11.❑ Health Care
with no employees. [No workers' comp. insurance rep.l 12.0 Other
*Any applicantatmchecksbox Al munalso till out the section below sh<wmg theirwotkers ompeneationpolicvinfonnaton
"1fthe co,vare officers have exempted tlremselves,btu the eoe aration has e her employees,a wodmrs compensation policy is nequimd and such an
organaatinn should check hnx#1.
I am an employer that is providing workers'comperwation insurance far my employees. Below is the policy information
Insurance Company Name:_
Insurer's Address:
CityiStatebip:
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 o: M(iL 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 c vil penalties in the form ofa 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 cert,under the pains and penalties of perjury that the information proviid�ed above i or and correct
Signature: �i _ Date' —I Z
Phone#: !1' 13 2 I yi 4-i-1 �h
Oficial use only. Do not write in this area,to he completed 5y city or town official.
City or Town: Asmit/Liceuse#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Tawn Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
,rowruns,-gov'dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workerscompensation 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 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 manother 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 tomorrow ealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 152,g25 Q7)states"Neither the commonwealth nor any of its political subdivistons 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 centfieate 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 resumed 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 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 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 611 out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permart license number which will be used as a reference number. In addition,an applicant that
must submit multiple perrnit/licens'e 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
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 Q.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
Foam Rcnsca @-23-15