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43-022 (4) 486 PARK HILL RD BP-2018-1339 GIs#: COMMONWEALTH OF MASSACHUSETTS MM-.Block:43-022 CITY OF NORTHAMPTON Lot -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category, Deck BUILDING PERMIT Permit# BP-2018-1339 Project# JS-2018-002378 Est.Cosi: $11451.00 Fee: $71.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use croup: Homeowner as Contractor_ Lot Size(so. R.): 90866.16 Owner: GAGNON DANIEL E&JULIET L zonin : Applicant: GAGNON DANIEL E & JULIET L AT: 486 PARK HILL RD ApplicantAddress: Phone: Insurance: 486 PARK HILL RD (413) 586-3483 O FLORENCEMA01062 ISSUED ON:6115/2018 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACEMENT OF EXISTING DECK 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 k 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 sinnamre: FeeTyoe: Date Paid: Amount: Building 6/15/2018 0:00:00 $71.00 212 Main Street,Phone(413)5874240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2018-1339 APPLICANT/CONTACT PERSON GAGNON DANIEL E&JULIET L ADDRESS/PHONE 486 PARK HILL RD FLORENCE (413)586-3483 Q PROPERTY LOCATION 486 PARK HILL RD MAP 43 PARCEL 022 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST E D REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construct om REPLACEMENT OF EXISTM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFJ�RMATION 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 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 Ambilecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management A.fB ition Delay fficial 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. 'Department use only City of Northa pion Status f Pe it: Q�7 Building Depart ant JUN 1 4 2 rbC VD . way Permit 212 Main Str et Sewer epti AvailabilityRoom 10 ppqRWater ell stabilityNorthampton, M 018b1/�TpBTMAM°io�'�nam of tructural Plans phone 413-587-1240 Fax 413- s Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION � I This section to be completed by office 1.1 Property Address: Map Lot 0 Unit �491. I G.r�� }till IZd- '� I yr11I_`T1 o I D In 2. Zone Overlay District O .hl c2 Elm St.District CS District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: E Gann on 4( wk N 1l RtI �nrence 1�A n1 Name(Print) Current m4dress dress T� Teleph Signature 2.2 Authorized Agent: %"Acl l cor6e:,i 143 tworkSt. Eo, rk MIN NI!7 4Current Meiling Address: OI O Signature Tele one SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permitapplicant 1. Building (a)Building Permit Fee 5 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee .� 4. Mechanical(HVAC) �I 5. Fire Protection 6. Total=(1 +2«3+4+5) 1 Check Number This Section For Official Use Only Date Building Permit NumberIssued: Sign re: Building C issionedlnspector of Buildings Dale V,jw1ret @ L&�wS* n' - EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed.:Permit Can Be Denied Due To Incomplete Information Existing uProposed Required by Zoning This Autumn m be filled in by Building Department Lot Size Frontage Setbacks Front Side L R: L.. R Rear Building Height Bldg. Square Footage ', % -- -- Open Space Footage tut arca minus bldg&paved erkiv ] #ofParkiu Spaces Fill: ...... (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 10 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 Q , 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 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb(cleanng grading,�ex avation,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(check all applicable) New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks Siding [Mil Other[c]] Brief Description of Proposed -I,eGlxcemig,M cls exIsAIA!A deck 1 , Alteration of existing bedroom_Yes No Adding new be om Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Rall -Sheet ea.If New house and or addition to existing housina. complete the following: a. Use of building : One Family Two Family Other It. 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 AGENT ORCONTRACTOR APPLIES FOR BUILDING PERMIT I, L )2n; / isaki on 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, r' "w,J_ .-�.1i --� — -..-.._..� ,as Owner/Authorized Agen erebl icy declare that the statements and information on the foregoing application are true and accmad,to the best of my knowledge and belief. F16 N6 rJ Print Name Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor. Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9.Realstered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(8() 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 A ® s 0212 "in S OF BUILDING al Building 2 212 Narn Street • Municipal Building i C Northampton, NA 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 perforating 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:Lf the homeowner has contracted with a corporation or LLC, that entity must be registered Type of Work Est. Cost: Address of Work: 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 of the owner Date Contractor Name HIC Registration No. OR: Notwithstanding the ab9ye notice,I hereby apply for a building permit as the owner of the above property: Dat Own Name and Si a e City of Northampton Massachusetts +- j;; DEPARTMENT OF BUILDING INSPECTIONS 212 Mein Street • Municipal Building Northampton, MA 01060 Massachusetts Residential Building Code Section I I O 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 110.85, 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 BUZI.DING INSPECTIONS 311 Main Street •Municipal Building North tm, MA 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: ysL P0.0.k H;n Ikol 0 oto f� ono (Please print house number and street name) Is to be disposed of at: I�-" /J11 n TgPiAjew 5rAJ)w OkI /(1Z l� (uwIl� R". (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) 6 �/2 SI ature of Permit pylic tt or or OOwner 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 Boston, MA 02774-2017 www.mass.gov/dia N1 urkcrs'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Orgenizetionilndividuep: Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of prof act(required): 1I am a employer with employees(fall and/or pan-time)" 7, ❑ New construction 3.❑I am a sole financier or partnership and have no employees working far me in S, ❑ Remodeling any capacity.[No workers'compinsurance required.] 3F-11 am a homwwncr Join all workmSsc IC No workers cont - d 9. Demolition 3 your, l p.insurance rcgwrc l' 4VIat a homeowner and will be hiring contractors to conduct all work on my propcny_ 1 will 10❑ Building addition Iaer that all contractors either have worker''compression insurance or aro sole 11.❑Electrical repairs or additions propdaters is all be cmpbyaa,, 12.❑Plumbing repairs or additions 571 am a general contractor and l has a heard the subwntracmr listed on the enriched sheet. 13 Roof repairs Th¢c subaonnactor he,,employees and have worker'comp.insurance. 6F We are a corporation and its officer base exercised their right of oxmnption per MGL c. 14.❑Other 152,§1(4),and we have no employees[No so-kms'comp_insurance mgaimd-] Any applicant that checks box AI must also fill out the section below showing their worker%compenaadon policy information. s Homeowners who submit this affidavit indicating thev are doing all work and then hire onside contractors must submit a new affidavit indicating such. rCurneam,that check this box most watched an addhic nal had,showing the name of the sob-eontracmr and state whether or not those entities have o nployers. It the sub-contractors have employees,they most provide their workers'comppolicy number. I am an employer that is providing workers'compensa/ion insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Setf-ins.Lie.#: Expiration Dale: Job Site Address: City/State/Zip: Attach a copy of the 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 of the DIA for insurance coverage verification. I do hereby eerily a er the pains a}nit ens/ties of perjury that the information provided above is true and correct Si nature: �14� .j Data: 6 -� -` "k Phone#; L//s —. q-I ' y6 y Oficial 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 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 ofa 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,§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 of compliance with the insurance requirements ofthis chapter have been presented to the contracting authonry." .Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-conhactons)camels),address(es)and phone number(s)along with their certificates)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 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/lieense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all 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 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 (Le.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 soother 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 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,§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 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 permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permitllicense 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 Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or I-877-MASSAFE Fax#617-727-7749 www.mass.gov/dia Form Revised 02-23-15 I I j ( 7� H 6..(47# . �a -7- I 1 AAA, �[t { p��{�S9 �+ t.:P Corbeiui Consvacdon REMODELtrta" PROPOSAL 148 Park Sheet t�orrry crarrtx i�b sW�-e�x(OMQ4 EasWmmpkwXMA01027 Tel (413)527-9288 JotDeocnrrnrtnwb real SuBowrmla iF9G p.9�l,C fi�icGA04 HNA NSA r�T//S"�l'� /t/i4• AAhPPP���PPP1tt�aa7000jjjSiJIR'fDMEpru Aleve$ DArE Ieawanaer.rsrecArA710M woes w,awrc r�ca'i�sif ,CdrT`J^' �ji3�laFil7zE6.Bc�YaG /BI rf'�. /�G'"sE .�Yllg�if".+�' �• /��'i4s�.f � r/r97lnr� dv .P�lD E y. v 'fislaalaarr.ttde3stortto.nse, � � . iNepn*m hmebytafAuUhtsada andtAwin MarsetMtepotealeeatebeasgrerire.Aasad;itr aerwrde"VdIbloobw "d-_*L am aF .1h 11�101rSEellay wliAlbwll�fQ PimQ. ,(�, W . 3 amuame.ah.am»mbeP^ea,.tm.an�e.�- reeae. otb®a I. tAofs...r wwow ftt. inbe®dr>asiaetawx. eam.enr.�c..rmbtwneaa..e.aiaaaw� Paysmer me6areaaslaMRiresWaaaaniaraa[e4seM era new..saw.epre+�tetaaoraoe+upmectieer.o• qudp�Eppe� �71�tsN,i3�'S AelafeboV=W rcwftt tes..lo.reoaarrareWWweest �'+�j{73} si,wt ane�m.wrer�eear�e�d.��� (+Ll�^'� �L.au�rme m�emratr�rctiodf�wee�atarer*m NoWthbpmpae maybevft& t bywifnot pwmeaeaq�cwa»rw�e.�q.amra.arnesd atoepled WYJ* 30 days. . aeWYtaOn. - Accepmnce of proposaL the above P&M speelcd6ons,and cmw mrs am sebbcbty and are hereby accepted_ You 8teaubwdze0to dothewakass� Payrererowibemwta as orated aabove. t