17A-023 25 HASTINGS HGTS BP-2018-1341
GIs a: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-023 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
CategoryROOF BUILDING PERMIT
Permit 4 BP-2018-1341
Project# JS-2016-002383
Est.Cost:$10950.00
Fee:$40 00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: CYRUS NEWMAN 064690
Lot size(sq. ft): 12458.16 Owner. ALEXANDER MARGO
zoning? RI(100)NRA IOO)/ Applicant. CYRUS NEWMAN
AT: 25 HASTINGS HGTS
Applicant Address: Phone: Insurance:
697 Bridge Road (413) 586-1093 Workers Compensation
NORTHAMPTONMA01060 ISSUED ON.611812018 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP EXISTING 3 LAYERS/INSTALL ASPHALT
SHINGLESNENTING
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 N 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 6/18/20180:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
RE g-" F
Department use only
CJif Northampton Status of Permit:
KMTg1[&p *en Curb C.uNOnveway,Permit
7, M 212 Main Street Sewer/Septic Availability
r !l Waterl Well Availability
DEPT FBDILqM�C�,.Iyy��P� T�p�g�
NDt�atpBBN M/At�WbU Twc Sets of Structural Plans
\�-•r phone 413-587-1240 ax 4 - 87-1212 Plot/Site Plans
.._ Other Speedfy
APPLICATION TO CONSTRUCT,ALTER REPAIR RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 6 P- f f-3 (11
7.1/IProoeM/Arddress: This section to be completed by office
Map t74 Lol a,3 2> Unit
Zone Overlay District
Elm St.District CB District
SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: AL
��AA
'MNeIn Rlfa4Nt�f� aS d' 7inq) ALL& �Riw f !lM UQ67
Name(Print) Current Mailing Atltlmss:
TelepbH/3 ' 3r1 c9�2y
Signature
2.2 Authorized Agent:
C� al 64"I�Adda
Name(Pdn Current Mailing Address 01060
Signature Telephone
SECTION 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) Ff LID
5. Fire Protection
6. Total= (1 +2+3+4+5) Q co Check Number �Q
This Section For Official Use Only
Date
Building Permit Number: Issuetl:
Sig01
n re:
�Bfldngo stoner/Insp�afBwldhg�� Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Must Be Completed.Permit Can Be Domed Doofid Vt complete Information
Existing Proposed Required by Zoning
This column to be rilW in by
BuildinE Department
Lot Size
Frontage
Setbacks Front
Side L R L' R'_.
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot arca minus bldg&pav'cd
#offiarking Spaces --
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW f YES O
IF YES,date issued:
IF YES: Was the permit recorded at the Re ' try of Deeds?
NO Q DONT KNOW YES O
IF YES: enter Book Page and/or Document#
S. Does the site contain a brook, body of water or wettands? NO O DONT KNOW 0 YES 0
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 Q NO w
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 N
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,exc vation,or filing)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,
SECTION 5-DESCRIPTION OF PROPOSED WORK(check 11 applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ RooHng
Or DoorsID
Accessory Bldg. ❑ Demolition ❑ New Signs [OI Decks [O Siding[Ell Other l[:I]
Brief Description of Proposed I r
Work 5n ixr ,'49 136/`J sh ft/-4i
i
Alteration of existing bedroom_Was_No Adding new bedroom s No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Sa. If New house and or addition to existing housina. 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 attached?
h. Type of construction
1. 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 rAGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, I L.t_N j�jYl as Owner of the subject
fir perty
`
hereby authorize
to act on my behalf in all orthers relative to work authorized by this building permit application.
Signature of Owner Data
as Owner/Authorized
Agent hereby dbclare that the statements and mformation on the foregoing application are true and accurate,to the best of my knowledge
and belief. /
Signed unlQ'er the pains and penalties of perjury.
Print Nime e
6 �o
Signature of er/Agent ate
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: CV �EliM CS - a6H6YG
7 I License Number
c�r7 p 21�e LAS1
Add&. Expire n ate
- L —
Sig Telephone
8.Registered Home Improvement Contractor. Not Applicable ❑
111 \
NEilM N5 ST2UG f\W /yc?&
Company r, Registration Number
64 t YC
Address/� T Exp_prillaatica ate
(j Telephonei—/O
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
' DEPABTNENT OF BDILDZNG SNBPECSZONS -°
212 Main Street • Municipal Building
\ NozCLav¢[on, 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 addlion to anypre-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 reeistered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: i n Est. Cost:__
Address of Work ��i d/STi Nis hl't�TS 11 pt ct1p/ .L1
Date of Permit Application:
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 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 the owner://
lkli.p 4M
on Contractor Name HICRegtstrahon No.
OR:
Notwithstanding the above notice.I hereby apply for a building permit as the owner of the above property:
Dace Owner Name and Signature
City of Northampton
+' Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Munica 010 Bu¢lding
MA 010
NozUhen,ton, 60
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 I O 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
DEPARTMENT OF BUILDING INSPECTIONS
f
a
5
014 Main Street •Municipal 9uilaing T
. " Nox[tampton, MA 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, 554, 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 �I debris from construction work being performed at:
X47 /.7?tn�oi k9 fAa✓ttnCt-
(Please print house num V
nd s V et name)
Is to 1bee disposed of at:
YRr. Iv 71cv JL
(Please not name a location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
-40-05 Z np-F:,
(Company Name and Address)
B
Signatueo Pe mit 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
I I Congress Street,Suite 100
Boston,MA 02114-2017
wivmmass.gov/dia
K orker t'Compensation Insurance Affidavit:Builders/Contractors/Eimtricians/Plumbers.
TO BE FILED WITH THE PERMITTING.AUTHORITY.
Applicant Information I Please Print Legible
Name (Business!Organ,'¢afi^oonindividual): w/✓( �(JS
Address: 697 1 , 2i DCL �r�. 64A.. .visap�vL�
Cary/stat e/Zip: �{� O Of Phonea: /3 ` Y6 -/04
Are yon an employer?Check the appropriate box:
Type of project(required):
I []lamacmploycrwhn employees(fnlland/orpantome)1 7. []New construction
2 lemasolc pmprinor er partnership antl M1nve no employee working
premium 8. Remodeling
/gaithyrolve,t, [Neworker,'comp.insurance requited]
3.❑lam a homeowner doing all work mywh.[No earkcvicomp-insurancerequircll` 9. Demolition
4F I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑ Building addition
asame that all ecnoacmrs either have workers compensation nearges or aresole Il.❑Electrical repairs or additions
pro'n'e....with we sind'ca
12.❑Plumbing repairs or additions
5.❑I am a general covtmcar and I have hind the sub-contractors listed on the nuached sheet. 13.[]Roof repairs
These rvb-.onmacm¢have emplOYers and have workers'comp_insurenceo
6.❑We .cmimeadm and its officershave c..r sed floomolu ofe,wedooe per NIGL e. 14.❑0ther
152,§I(4),and we have no employees.[No workers'comp_insurance required_]
`Aug applicant that theds box 41 most also fill out tho section below showing their workers compensation policy information.
'Homeowners who submit this iffide,o indicating they ate doing all work and then hire Outside conammrs most submit a new affidavit indicating suclh.
tC.m.mts that check this box must amaohW an additional sheet showing the name ofthe sub commetwo and stare whether or not those entities have
employees H the sub,thimorors have employees.they must provide their workers comp_policy number.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy ofthe workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations ofthe DIA for insurance
coverage verification.
I do hereby certify under t pains and penalties ofperjury that the information provided above is true and correct.
tSi nature: Det
Phone#: / D
Official 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.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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 airy 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."
NGL chapter 152,§25C(6)also states that"even 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 151§25C(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 sub-contractors)morels),address(es)and phone numbers)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Pmmerships(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 eonfimation 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 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 curer
policy information(if necessary)and under`Job Site Address"the applicant should write"ab locations in_(city or
town)."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 Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax,#617-727-7749
Revised 02-23-15 www.mass.gov/dia
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,orthe 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 ofsuch 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,MCL 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 ofcomplianee 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. Ifan LLC or LLP docs 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 full out in the event the Office offs vestigations has to contact you regarding the applicant.
Please be sure to fill in the perma/license number which will be used as a reference number.In addition,an applicant that
must submit multiple perrnit/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 m town
may be provided to the applicant as proofthat 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
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
Forth Revised n2-23-15
leu Iald—G
NEWMAN'S CONSTRUCTION
rim Bridge Rd.
12441244
NIg a sss10
PROPOSiL&IDMIryEDTo I oda DALE
8
6TPEET Aa NAME
t -200 F
C(!Y,SrATE pMZIPCDDE xsi tOcAroN
APG.EC! DATE DE fMANS JDB PIgNF
yJe hereMy aubnaspeafiwdaa eid estlmetes br.
RanF�: f Qx.wtoui.g�I-t �-- 1 _ z ..........-.
T'...1 . 1L
�irlStr�lf-_ q�Y�S�iN.-1S�b--ArlcO.i�yl�+sttC_6n—YtINl#4_�li2^`��1.�1 .. 'u�S . -... _.
"Z—,kA_..
or pravan _hereby to furnish material and labor—ccin accordance with above specifications,for the sum of:
1 '. Ud dollars($ a ).
Payment b be matle esMows:
AAi
An mam
lenal Is guaab ead Ire ll worm be mm
as speaAad.At pbted in a wakmanNiw Authorized ,
manner according to sbnLad aa9bea,Any intension or diNliton hum aEcve spaefi a4om Signature
inva+ing awe wsb wA be estions any upon wrXlan oNam,aM oval becmla en etla
cbaes over end ebwa IM1e es Mnela.NI i,ft.ema do d ca upon Mkef. awiMMs
a tlNaye bayaW ow contra.Owrer to my Me,twredo ane oNer rea..aaw'maureixe. Notw Thk p ay In
Corvghers are fuYy wretetl CY wonu�ls^§Lwnparaalien Ireura�w. wiNtlfawn by us H rwt wlthdaya.
Arrepfaure of proposal—Th.Etsov d=es smsclri=aaons � �
and cwiions are satisfactory and are hereby accepted. You are authorized Signidii _L
aq do
W do the work as specified.ggp'yyai/y/(ill be made as outlined above.
Dale of Acceptance: `'K �� Signature