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16A-018 (7) 478 SPRING ST BP-2018-1091 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 16A-018 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Stair BUILDING PERMIT Permit BP-2018-1091 Project# JS-2018-001965 Es[ Cost$4200.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: EDWARD RICKEY 96159 Lot S;ve(sa. R.): 14549.04 Owner: BRIDGMAN JAMES E zoning: URA(100)/ Applicant: EDWARD RICKEY AT. 478 SPRING ST ApplicantAddress: Phone: Insurance: P O BOX 62 (413) 695-7059 WILLIAMSBURGMA01096 ISSUED ON.412512018 0.00:00 TO PERFORM THE FOLLOWING WORK:REPAIR TREADS, RISERS & RAILING ON INTERIOR STAIRWAY 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 4/25/2018 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2018-1091 APPLICANT/CONTACT PERSON EDWA-:D RICKEY ADDRESS/PHONE P O BOX 62 WILL]:MSBURG (413)095-7059 PROPERTY LOCATION 478 SPRING ST MAP 16A PARCEL 018 001 ZONE URA(I00F THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST NCLOSED REQUIRED DATE. ZONING FORM FILLED OUT _ Fee Paid Building Permit Filled out Fee Paid TvpeofConstruction: REPAIR TREADS RI RS& AILING ON INTERIOR STAIRWAY New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owned Statement or License 96159 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-1 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. Am 24 DeparNlent use only -- L —Ew .----- ity of Northampton status of Permit Building Department Curb CutfDriveway Permit ,I 212 Main Street Sewer/Septic Availability Room 100 WaterNYen Availability a Northampton, MA 01060 Two Sets of Structural Plans phone 413587-1240 Fax 413-587-1272Plof/Sne Plans Other specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION i -SITE INFORMATION 1.1 PJ[ro�rovertyAddress: This section to be cornpleted by office •7!O ;yP,41 J ,v Map 1(914 Lot �rdn Unn /111A, Zone Overlay District Dm St.District GB district SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: AGF8 M *N e Print) rte, 8 X iV5, I*Ts✓+L� Tdeat. Sign re 2.2 Authorized Agent, Name P [) _ •/ Curmrt Ma*irg Address: / NV Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only mm uleted by permita licant 1. Building i{ Or, (a)Building Permit Fee 2, Electncal 7 (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(I -2+3+4+5) fGC�% r•o Check Number d- This Section For Official Use Only Building Permit Number: DateIssued: Signature: Building Canmissionm/lnspector of Buildings Dd1e EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Most M Completed. Permit Can M Dermad Due To Incomplete Information Existing Proposed Required by Zoning This column in be F311W in by Building Dqp vrent Lot Size Frontage Setback, Front Side L: R: L R: Rear Building Height Bldg. Square Footage Open Space Footage (Lm area minus bldg&p.vM .kin k of Parking Spaces Fill: (wiume&Lamuon A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES NO IF YES, describe size, type and location: E Will the construction activity disturb(Gearing,grading,excavation,or filling)over 1 acre or is K part of a common plan that will disturb over 1 acre? YES NO IF YES,then a Northampton Stam Water Management Permit from the DPW is required. SECTION 8-DESCRIPTION OF PROPOSED WORK(check all aoolicablel New House Addition ReplacementWindows Alteration(s) Roofing Or Doors Accessory Bldg. Demolition New Signs I ] Decks [ 1 Siding I 1 Other[✓] Brief De ip on QLD posed n •�7 Work: , `. /Y° Alteration of epsbng bedroom_Yes V No Adding new bedroom Yes ✓ No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Sit,if New house and or addition to existing housing, complete the following a. Use of building:One Family I Two Family Other b. Number of rooms m each family unit: Number of Bathrooms a 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 attached? 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. I. Septic Tank_ City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR[[C``ONTT� ��R��ACTO//R APPLIES FOR BUILDING PERMIT p X M A ,as Owner of the subject property �� herebyaumorize �W- to act on my behalf,in all matters relativ to work authorized by this building permit application. x x Signature of Omer Date / Date I,mad 7lL.cLew j� as Owner/Authorized Agent hereby declare th the statements and information on the foregoing application am true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Eow,7 Ru Print Name Signature of ,/Agent Data SECTION 8-CONSTRUCTION SER WCES 8.1 Licensed Construction Suupemisor: Not Applicable ❑ Name of Lleer Holder:rd![!i�_�tL 016159 License Number 7M 01477[ 7 b 9 Address fie Dale 3 - 9f 7a S9 Signs Telephone 9.Repisterad Home ImpmyemeM Conbaptor: Not Applicable ❑ 1Sa9y47 Company Name Registration Number s. Lys Lz7I?� O/Oj6 S/a Address E i [ion Dale Telephone y�3.675• ' SECTION M WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.162, 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 but P ing permit. Signed Affidavit Attached Yes_ .... 16 No...... ❑ City of Northampton Massachusetts r1212 MaIinNT r e Municipal ZNS8r 1&ko, 212 aria street • aunicipal euildiry acrthaagNNan, 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.C.L. Chapter 142A requires that the"reconstruction, alteration,renovation, repair,modernization, conversion, improvement,removal,demolition,or constmction 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 WorkEst.Cost: Address of Work: y7$ a,,,, $,{ a[ 7MDate of Permit Application: �y3 •26'/T 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 ownerbecupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE NOME 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: 13 •/t oaY� Date Co ctor Na a 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 "L Massachusetts DSpANTMENf OF BUILDING rNSF=ZWS 1 212 Main Street • Municipal Bu Iaang �®J a 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 farm structures. 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 1 I O.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 UT DEPANTNENTtraaO£ BUILDINGINSPECTIONS212 Win St •Wnicipal Building01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40, S54, 1 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: Y78 Sot: t _ !� YviA (Please p nt h se number and street n me) Is to be disposed of at: rnA lease of na and location of facil� ) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signatur f Permit plicant 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 i De Industrial Accidents I Congress essss Street,Suite 700 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. AoDlicant Information Please Print Leeibly Business/Organization Name: Address: . 6" 62 City/State/Zip: 0/0', Phone#: N/3-gjgg 7jm f Are you an employer?Check the propriale box: Business Type(required): L❑ I am a employer with employees(full and/ 5. ❑Retail or part-time)` 6. E]Resmumnt/Bar/Eating Eslublishment 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] & ❑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]' I1 El Health Care 4.ElW e are a non-profit organisation,staffed by volunteers, with no employees. [No workers'comp. insurance req,] 12.❑Other 'Any applicant that checks box 91 moa also fill out rhe secoion below stowin,hev workers'oun s aminnpolicy inions .sic "'If the corporateomcershaveexempted ihcayselves,brathe do oationlasoderemployees,aworkers'Compensation policy isrequimd and suchan organization should the k box#1. 7 am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City'scue/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 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 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 ofpedury that the information provided above is tragi and correct Sidnatum Date: ',2.,t Phone#' Oficial use only. Do not write in this area,to be completed by city or town offiefal. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Citylfown Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia Information and Instructions Massachusetts General Laws chapter 152 requhes 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 a joint 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,§25 C(7)states"Neither the commonwealth nor any of its polidcal subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requiremenls 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,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 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 lnvestlgations 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 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 fit led 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. #617-7274900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 www.mass.gov/dia Pon,Revised 0223-15