38C-067 3 CHARLES ST BP-2018-1142
GIs#: COMMONWEALTH OF MASSACHUSETTS
M=Block: 38C-067 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 d BP-2018-1142
Project# JS-2018-002059
Est Cost$3400.0
Fee: 540.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(su. ft.): 5009.40 Owner: DUFFUS WILLIAM C JR& PHYLLIS&MARK R DUFFUS
zonine7 URB(100)/ Applicant: DUFFUS WILLIAM C JR & PHYLLIS & MARK R DUFFUS
AT. 3 CHARLES ST
ApplicantAddress: Phone: Insurance:
3 CHARLES ST
NORTHAMPTON MA01 060 ISSUED ON.5/3/2018 0:00:00
TO PERFORM THE FOLLOWING WORK STRIP & SHINGLE ROOF - 10 SORS
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:
FeeTyoe: Date Paid: Amount:
Building 5/3/2018 0.00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
2�F
Department use only
City of N rtha npton Status of Permit:
.a} " .2B2d$ig epa Indent Curt Cut/Driveway Perm@
21 M in SI eat Sewer/Septic Availability
} R 10 WaterNVell Availability
PT.of BtlanllYON! M01060 Two Sets of Structural Plans
AMP t 413-587-1272 Plot(Sde Plans
- Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION I -SITE INFORMATION
1.1 Property Address: pThis section to be comm�pleet7ed by office
3 Ch /o'R\ [Q J Map �d Lot �lJ / Unit
-
I\)0 R I h AM /Irmo N✓ Zone Overlay District
n f o b f Elm St.District CB District
SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: 7�
ln.'g✓-w
Na PnM) Curre Yingl�d /�
1` �� Telephone
l- 70�
Signature
2.2 Authorized Agent:
Name(Pont) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (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 Number: Date
Issued.
Signature:
Building Commissionerllnapedor of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
� F1%� ,/
Section 4. ZONING7 All Information Must Be Completed. Permit Can Be D med Due To Incomplete Information'
Existing Proposed Re i -116 Zom
This wlumn to be filled m by t
Building Depa,m,ent
Lot Size
Frontage
Setbacks From
Side L R: L: R: .._....
Rear
Building Height
Bldg.Square Footage %
Open Space Footage
got aten minus bldg&paved
kin t
#of Parlung Spates
EJI:
Fill(volume So Location) 7-
A. Has a Spec/property?
it/Variance/Finding ver been issued for/on the site?
NO ODON'T KNOW YES 0
IF YES, date iss
IF YES: Was tmit recorded at he Regi::try of Deeds?
NO ODONT K W O YES O
IF YES: entBook Page and/or Document a
B. Does the site a brook body of water or wetlands? NO 0 DON'T KNOW Q YES Q
IF YES, hasit bee or need to be ohtained from the Conservation Commission?
Needs to bned O Obtained O , Date Issued:
C. Do any signs he property? YES ONOIF YES, desze, type and location:D. Arethereanyed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location:
E Wil the construction activity disturb(clearing.. grade.ng, 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 tchack all applicable1
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [[I] Decks Siding[0] Other[[:X
Brief Description of Proposed o n
Work'. A/re C✓ 1\ CQ� rt(l l' S�t i�l� �-i.� � // z/Q S/ {�i p/�/�'� 7�
Alteration of existing bedroom_Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ba. If New house and or addition to ex]sting 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?
cl 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 CONTRACTOR APPLIES FOR BUILDING PERMIT
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 pena ties of perjury.
Print Name
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDi(M.G.L.c. 152,§25C(6))
Workers Compensation Insurance affidavit must be completed anc submitted with this application. Failuretc provide this affidavitwill result
in the denial of the issuance of the building permit. _
Signed Affidavit Attached Yes....... ❑ No...... ❑
City of Northampton
:.� Ss ...
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS (ir�Jj
212 Main Street • Municipal Building F
Northampton, 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.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
0
Type of Work: / 7 G-'.'� i�j II.T 'u3` � /-J -<4 0411c,:..M<F-TBsG Cost: c1ro Z
J
Address of Work: � C h xq 1&_p,J S t
Date of Permit Application:
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 pernit (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 pernit as the agent of the owner:
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:
J���� ?/C� ✓{✓/ ///A/4k /���� �J
D'ate � Owner Mme and Signature
City of Northampton
Massachusetts ra35 5�_
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • M.nicipal Building Jr C
� ,.... N r@ Bnpton, MA 01060
Massachusetts Residential Building Code
Section 110.R5.1.2
Homeowner: Person (s) who own a parcel of I ind on which he/she resides or intends to reside,
on which there is, or is intended to be, a one o-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 bu.lding permit is required shall be exempt from
the licensing provisions of 780 CMR 11025, 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 Ofl ficial, 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.
1
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS r
212 Main Street .Municipal Building
Northampton, MA 01060 yfirh `^9m
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:
3 G hA/1LeT S /
(Please print house number and street name)
Is to b` e int e disposed of at:
(Pleas
V /� LfV,
name and 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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress.Street,Suite 100
7
Boston, AIA 1/2114-2077
., wlawomass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING ALTBORITY.
Applicant Information Please Print Legibly
Business/Organization Name:
Address:
City/State/Zip: _ Phone#:
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with_ employees(full am], 5. ❑Retail
or part-time).* 6. ❑Restaurant Bar/Eating Establishment
2.0 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 r. 152, yl'1(4),and we hse 10.❑ Manufacturing
no employees. [No workers'comp, insurance required];'°
4.❑ We are a non-profit organization,staffed by volunteers, 11.11 Health Care
with no employees. [No workers' comp,insurance req.] 12.❑Other
'Any applicant that checks box ql ansa also fill ou[tM1e seuion below showing their workers'compensation policy infonnourn
""Itlbe coRonte officers have exempted themwlos,but the eo@oation has other employees a workers compensation policy is required and such an
n'.atwit should check box#1
I am an employer that is providing workers'compensation insmance for my employees. Below is the policy information.
Insurance Company Name:
-----
Insurer's Address:
City/State/Zip:
Policy 0 or Self-ins.Lic-It 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 si c. 152 can lead to the Imposition of criminal penalties of a
fine ap to 51,500.00 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 ofthe DW for insurance coverage verification.
I do hereby certify,under the pains and penalties of perjury that the Information provided above is hue and correct
Stimulate- _. Data
Phone p'
Official use only. Do not write in this area,to be completed by city or town ofwiai
City or Town: _Permit/License H
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.CityrYwnn Clerk 4.Licensing Board 5.Selectmeds Office
6.Other
Contact Person: Phone#:
www a 's govldla
,
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
efthe foregoing engaged in ajoint enterprise,and including the legal representatives into deceased employer, or the
receiver or trustee afar 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,g25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of puhlic 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 Hart 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 Investigations has to contact you regarding the applicant.
Please be sure to fill in the perneirlicense 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 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
Fmm Revised 02-D-U