32C-195 (6) 123 WILLIAMS ST BP-2018-1085
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:32C- 195 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit. Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:ROOF BUILDING PERMIT
Permit# BP-2018-1085
Proicct# JS-2018-001953
Est.Cost: $8000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use GomP7 STEVEN LEMPKE 047805
Lot Size(sq. ft.): 8102.16 Owner. VALLEY BUILDING COMPANY INC
zonine�URC(100 Applicant: STEVEN LEMPKE
AT. 123 WILLIAMS ST
Applicant Address: Phone: Insurance:
403F BATCHELOR ST (413) 575-9728
GRANBYMA01033 ISSUED ON:4/25/2018 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR ROOF, REMOVE ROT, FRAME AS
NEEDED FOR REPAIRS, NEW ROOF
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:
FeeTvpe: Date Paid: Amount:
Building 4/25/2018 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
R COVED
'MR 2 0 Department use only.
O City o N hampton Status of Permit
Build! g epartment Curb CuVDDveway,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 Ploi Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION &P - 17 - 1i
1.1 Property Address: This section to be Completed by office
Map �a e-" Lot Unit
123 Williams St, Northampton, MA Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Valley Building Company, Inc. 101 East Street, Hadley, MA C)j(, >S
Name(PCurrent Mailing Address: 413-584-7710
Telephone
Sig ure
2.2 Authorized Agent:
Steve Lempke Ce�.r�at,en.,✓ Steve Lempke •I6131� aS4rcw¢7-r,�F�
Name(Print) Current Mailing Address:
Steve Lempke Nr3_ ri_y �1
Signature Telephone 6 '10— rPi-i
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 8000 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee I
4. Mechanical(HVAC) iry){/ '1,1'/,",`/7
5. Fire Protection
6, Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number: Dale
Issued:
Signature:
Building Comm sionerllnspector of Buildings Date
pgelinas @ valleybuildingco.Com
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
—, This column robe fitledin by
Building Department
Lot Size -1
Frontage
Setbacks Front
Side L: R:' L �I R:� 1 -.
Rear
Building Height
Bldg.Square Footage °o
Open Space Footage % _
(Lot area minus bldg&paved
,nirking)
#ofParking Spaces
Fill:
(volume&Locmio°
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW 0 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 filing)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 applicable1
New House ❑ Addition ❑ FReDploaciement Windows Alterations) ❑ Roofing QJ
oAccessory Bldg. ❑ Demolition ❑ igns [E3] Decks IO Siding[D] Other[C1]
Brief Description of Proposed Repair roof.Remove rot,Frame as needed for repairs.New roof. n
Work:
Alteration of existing bedroom_Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes x No
Plans Attached Roll -Sheet
Be.If New house and or addition to existing housing complete the followlirl
a. Use of building: One Family Two Family X 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 Wootlstoves 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 CONTRACTOR APPLIES FOR BUILDING PERMIT
I, V,-i ,u r (/4�� y �. as Owner of the subject
property
Steve Lempke
hereby authorize !n
to act in all afters relative to work authorized by this building permit application.
)i/i `9- lb -r
Sig remOwner Data
1, srey* �MPfI'� ,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
Slgnalure ofdDwm,fq.mt ale
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Nameof License HOlder:2ME6f ji 'y � 05076; dS-
License Number
ANS dA a 's
Address Expiration ate
Signature Telephone
v» 57f�Tz�
9. Registered Home mprovement Contractor: Not Applicable ❑
/ t 7-9"3-
Name
-
Name Registration Number
Address G�Va^^>K tJ o//off Ey�WDaa
te
$AFM(J Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152,§25C(6))
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
Massachusetts
s
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building =fir••. ,,:�<
Northampton, NA 0106e
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 he registered
Type of Work: 1i��u`�'�-- ,HivS�' Est. Cost: �,OckJ-oma
Address of Work: /Z Lvi G G I ij,v j.f"
Date of Permit Application: /.Y
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:
/
271
a[ Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice, I hereby apply fora udc ing permit as the owner of the above property:
Date' Own6 amep dSignature
City of Northampton
'-' Massachusetts
s
DEPARTMENT OF BUILDING INSPECTIONS �
212 Main Street •Municipal Building y�t•. Ca
Northampton, M 01060 ss�ri „O
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:
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
ompany Name and dress)
.�i� r'it'I a
Signatur of Poirmit 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.
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
ofthe foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trust"of au 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,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence ofwmpliance 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,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
ofthe affidavit for you to fill out in the event the Office oflnecstigations 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 pennit/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 Corrmaonwealth 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
Forth Revised o2-23-15
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Name: 4 i6toOKt� GOA/gP'f�u-ri'r7m-.r i
Address: 6102 1" T_Gi.rc+r-E LaP G,p
City/State/Zip: 6-Pd/1-Ng V 04 Phonek
Are you an employer?Check the appropriate box: Business Type(required):
I l® Ia..employer with_,employees(Poll and/ 5. ❑Retail
or part-time).' 6. E]RestaumntBar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no
7. ❑Office and/or Sales Had.real estate,auto,etc.)
employees working forme 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.E]Manufacturing
no employees. [No workers' comp.insurance required]'
4.❑ We are a non-profit organization,staffed by volunteers, I L❑ Health Care
with no employees. [No workers' comp. insurance req.] 12.0 Other Gw�s�ELr�>�
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
"I Rhe em,mate officer,have cxemp¢d themselves,but the corporation has other employees,a workerscompensation policy Is required and such an
organization denied check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is tie policy information.
Insurance Company Name:
Insurer's Address:
City/State/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 a 152 can lead to the imposition of criminal penalties of
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.
1do hereby certify, under th7ains and nalries ofperjury that the information provided bove is true and correct
��/ i '
Signature; �e- /- - l� Date
Phone#:
Oficial use only. Do not write in this area,to be completed by city or town officiat
City or Town: Permit/License#
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#:
www now owdis