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23B-081 (4) 54 SOUTH MAIN ST BP-2018-1193 GIS#: COMMONWEALTH OF MASSACHUSETTS MamBlock:238-081 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category:ROOF BUILDING PERMIT Pe mit# BP-2018-1193 Project ft JS-2018-002138 Est Cost:$6200.00 Fee: S40.oD PERMISSION IS HEREBY GRANTED TO. const. Class: Contractor: License: Use Group: AARON PUNSKA 105542 Lot Size(sp.ft.): 7492.32 Owner: TESCHNER ANNE F zoning:URB(1011)/ Applicant. AARON PUNSKA AT. 54 SOUTH MAIN ST ApplicantAddress: Phone: Insurance: 111 KINGS HIGHWAY (413) 626-6033 Q WESTHAMPTONMA01027 ISSUED ON.5/16/2018 0:00:00 TO PERFORM THE FOLLOWING WORK:REPAIR DAMAGED ROOF - 9 SQUARES 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: FeeTvoe: Date Paid: Amount: Building 5/16/20180:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only Q'r� RE eVcEhE Ipton Status of Permit en Curb CWDnveway Permit 212 Main Str et Sewer/Sap[teavailabilityMy 142b� i0Northampton, M 010 0 Two Sets of Structural Plans 1ph 413 587-1272 PloUSite Plans DEPT RTBULLDINN,MA0C NOnTHAMPTON,MA01080 Other Speolly APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE ORTWO F,AAMILY DWELLING SECTION 1 -SITE INFORMATION G/-/ '" ���3 7.1 Property Address'. This section to beeomRle/ted by office Map Lot 6DOJ/ / Unit 54 S. t4w� SE_ �lteatlL Zone Overlay District Elm Sl.Maui CB District SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: A"", �v dnnaf5 mru /{ Flxe�.c w1 ot1�,1 Name(Print) ^ Current Mailing Atldress:" /`/ Telephone Signature 2.2 Authorii etl A enl: ant uwl(y We+Ch 6n Mh oloz� Nemo(Pont) Curent Mallin Adtlre6 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cast(Dollars)to be Official Use Only completed by permit applicant 1. Building / ,L� IA2 (a) Building Permit Fee 2. Electrical b (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) 4J Check Number 11-no This Section For Official Use Only Date Building Permit Numb Issued: Signa S �� Building missionerllmpectar of Buildings Date Qroo, @ lKi C h EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING An Information Must Be Completed. Permit 4n Be Utllle",ar"11 lnadnplete lifdrmatioh Existing Prop sed Required by Zoning tme4 N by e �nilYind De nm Lot Size Frontage -'— Setbacks Front Side L ..... R: L R: Rear Building Height - Bldg.Square Footage Open Space Footage °o (Lot urea miaus bldg&pevcJ pankin _. __.... F ofParking Spaces fFil: ..... . . . . _ . i.lLe&Location] A. Has aSpeci l Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW O YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DON'T KNOW O YES IF YES: enter Book Page and/or Document N B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW O YES 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 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 (D- IF 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 Stone Water Management Permit from the DPW is required. SECTION S.DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition E] Replacement Windows Alteragon(s) Q Roofing ff Or Doors ED Accessory Bldg. ❑ Demolition ❑ New Signs 101 Decks In Siding[01 Other 107 Brief Description of Proposed , Work. Vf Fix, vwt- Alteration of existing bedroom___-Yes /No Adding new bedroom Yes / No Attached Narrative Renovating unfinished basement _Yes --�No Plans Attached Roll -Sheet Be,If New house and or addition to eAstina housing, complete the following: a. Use of building: One Farmli 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? L Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? In. Type of construction L Is construction within 100 ft. of wetlands?_Yes No. Is construction within 100 yr. floodplain_Yes_No T 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, Fes' It S(N hG✓ as Owner of the subject property L�,� hereby authorize /fk�J") ✓VlS^^I to act on my beh all matters rela ive to work authorized by this building permit application. �� Signature of Owner Date If I, Ilh^lh Vyh ^1 y^ , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing applicaron are rue and accurate, to me best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name m 17, 1J Signature of gent Date SECTION 8-CONSTRUCTION SERVICES BA Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: A I1 a, 'MS'L4 (5- 1 2 License Number tU kna ( i it (9 Addresses Fxgratine Signature Telephone 9.Reoiatered HomeImprovement Contractor: Not Applicable 11nPwn (11992 Company Name Registration Number ytt "VI l'�M/ WPxI `N (d IpL7 8 Atldress Expiration Date Telephone 62� Gb33 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(1 152,§25C(6)) Workers Compensation Insurance affitlavit must be completed and submitted with this application. Failure to provide this af5davit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... M-ngNo...... ❑ ' City of Northampton Massachusetts J � c DEPARTMENT OFBUILDING INSPECTIONS T 212 Main Sta lWnicipal Building Northee ampian, 6N 01060 SrhW-.yj\J 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 beregistered Type of Work:_ w! rc f(AW5rrtt Est. Cast: h r7wo Address of Work: fit S' ^lutn i7r Date of Permit Application: M1 lZ)l$ I hereby certify that: 0 Registration is not required for the following reason(s): _Work excluded by law(explain): _Job under S 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: ItI 17 1alY I�rSHtt 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 DEPABTHENT OF BUILDING INSPECTIONS i 212 Main Btieet • Municipal Building �y/J1C Northam,ton, MA 01060 ssbyr -:y;:pS` Massachusetts Residential Building Code Section 110.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 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 I h I DEPARTMENT OF BDILDING INSPECTIONS T 212 Msin Street eNunicipal Building a Jo• Northampton, ev. 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: �1 5, MNK St. (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: dill„ 5 PJ1 o FF (Company Name and Address) / 01,4 l2 7JI� Signature of P rmit Applicant or Owner ate f 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 ofMassaehusetts Department of Industrial Accidents I Congress Street, 700 Boston,MA 02174-204-20 17 wwwmass.go eldia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY, ADDlicant Information f�1] yPlease Print Leeibly Business/Organization Name: Akra vt �tirt hun5�ryt_�_�Wl'e"1r Address: III VI y 4�w✓ City/State/Zip: r w —� M On Z-1 Phone#: 1 U -6033 Are you an employer?Check tilie appropriate box: Business Type(required): L❑ 1 am a employer with employees(full and/ 5. ❑Retail I �r parttime).- 6. F]Restaurant/Bar/Eating Establishment 2. 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. E]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 10.❑Manufacturing no employees. [No workers'comp. insurance required]* 11 Q Health Care 4.C1 We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑Other "/vappllcaatthatehcls boy#Ionto,ulsonll oatrheseetion below showing WeGworkers'compensation policy infommtion. " Ifrhecorpo,aw oRic—have recenal themselves,but lhecnToratlan has mberemploycc,aworkan compensation policyo required andsich an ¢anon should check box#l. I am an employer that is providing workers'compensation insurance for my employees Below R the policy information. Insurance Company Name. Insurer's Address: City/State/Zip: Policy#or Self-ins.Etc.# 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 e. 152 can lead to the imposition of criminal penalties of o 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 ofthe DIA for insurance coverage verification. I do hereby certify,under thepains and penahies of perjury that the information provided above is nue and correct Si nature: Date: Z 12- Official ZOficial use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# 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 is: —'anis ,Id,. 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 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, p25C(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,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 peritr'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 proofthat 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 peril 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 I Congress Street Boston, MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 www.mass.gov/dia Fom Revised 02-23-15