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29-042 (4) 49 PIONEER KNLS BP-2018-1363 GIS#: COMMONWEALTH OF MASSACHUSETTS Map.Block: 29-042 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-2018-1363 Proiect4 JS-2018-002095 Est Cost: $4500.00 Fee:$65.00 PERMISSIONIS HEREBY GRANTED TO: Const Class: Contractor: License: Use GroUV7 Homeowner as Contractor_ Lot Size/so. It): 80150.40 Owner: CAREY DENNIS P&JOANNE L Zoning, Applicant: CAREY DENNIS P & JOANNE L AT. 49 PIONEER KNLS Applicant Address: Phone: Insurance: 49 PIONEER KNOLLS (413) 584-8100 0 FLORENCEMA01062 ISSUED ON:6120/2018 0:00:00 TO PERFORM THE FOLLOWING WORK 8X6 POOL 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# 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: FeeTYpe: Date Paid: Amount: Building 6/20/2018 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner i Department use only :144SA City of Northa "0Stat" ofP rmd:Building Depa en ,JUN 2 p Zp �"m ul/D Yeway Permit 212 Main St et /Se C Availability� Room 10 ell vailabiliNorthampton, M 01@6qORTH°MDING INSP °.S is Structural Plans i:,� phone 413-587-1240 Fax - - ahs . _ Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A OHNE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Properly Address: This section to be completed by office (_I L 2 t d � ccr- K u�U\\J Mep Lot Unit C-1 O (-e_w(r Zone Overlay District Elm SL District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: t� e.Uk)i S f e_ Name fl ) Current Mailing Address: IdfEH.CL MY} Telephone 11 3 S $ –716 Sign ture 7(P, A CimenlMailingAddress Telephone, SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Oficial Use Only completed bpermit applicant 1. Building L/ S60 . C)6 (a)Building Permit Fee 2. Electncal (b)Estimated Total Cost of Con on from 6 3, Plumbing Building Permit Fee 4. Mechanical(HVAC) r y� 5. Fire Protection S. Total=(1 +2+3+4+5) LSU p0 Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: A-�' 6 16 / Building Commissionerlinspedor of Buildings Date jg-25 @ W6 '6h 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 ]his column to be filled in by Building Depmonent Lot Size Frontage Setbacks Front Side L: k L: R: Rear Building}leight Bldg.Square Footage % Open Space Footage % (Int area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW © 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 ® 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 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO Ile IF YES, describe size, type and location: E. Nil the construction activity disturb(clearing,grading ation,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 Storm Water Management Permit from the DPW is required. SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Wintlows Afieratlon(s) Roofing Or Doors ❑ Accessory Bldg. ❑ Demoiitlon ❑ New Signs [0] Decks Siding IM] Other[m Brief Description of Proposed�; \.� s' v / �QL� For ouc ` r� \ �Oo \ Work: , /� b 1. rcel Alteration of existing bedroom Yes k No Adding new bedroom Yes 14 No 1. Attached Narrative Renovating unfinished basement _Yes F No Plans Attached Roll -Sheet ee.If New house and or a eMon to exiatina housing, complete the following: a. Use of b ding : One Famiy Two FamilyOther b. Number of rooins in each family unit: Number of Bathrooms c. Is there a garage+\ ed? d. Proposed Square footage ecu const wa Dimensions e. Number of stories? f. Method M heating? Fireplaces or Woodsloves Number M each g. Energy Conservation pYance. Maeacheck Energy Compliance form attachetl? h. Type of constructs I. Is consiruGi within 100 fi.M wetlantls?_Yes No. Is construction within 100 yr. floodplain_Yes No j. Depth basement or cellar floor below finished grade k. building conform to the Building and Zoning regulations? Yes No. I. Septic T. City Sewer_ Private well_ C' water Supply_ SECTION 7e-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 beh ,in all m am relative to work authorized by this building pemi plical n. Signatu of Owner bate 1 C Uw V S L C 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 penalties of perjury. Print Name Signature Date SECTION 8-CONSTRUCTION SERVICES .1 Licensed Construpervilpor: Not 7cable ❑ time of Ucense Holder LimnseN ber Address Explmtion Dat Signature Telep ne 9.RMISterad \ Not pplicable ❑ Comoenv Neme Registrab N ber Address Expir - n Date Telephone SECTION 10.WORKERS'COMPENSATION INSURANCE AFFI VIT(M.G.L c.152,§25C(6)) Workers Compensation Insurance affidavit must be tpl and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building pemlit. Signed Affidavit Attached Yes....... ❑ No..... ❑ of xQ 1(°u C� �C+Q ePra l l �bl Glc\ 2Xg —3 isrf ?6JIj Gh, Sf>v1 C, ( Ce4, 1)t,x J /../Lr�l chk I tZ� Gr JaSrS Tre-a �ni't--, `'jor - hew � City of Northampton 2s`s ( 4 Massachusetts i <` ffipART16aT o8 BUILDING 289pICTIQB 212 Nair str t • Municipal Building �'h Tz �.., ....... Northampton, M 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("MC"). M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any preexisting owneroccupied 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 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 wder$1,000.00 Owner obtaining own permit(explain): _Building not owneroccupied 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 above notice,I here ply f r a uildin miit as the owner of the above property: Date Owner N d Signature City of Northampton Massachusetts l`" 7pf x �,&RTMENT OP BGSLDffiG ffiS➢6CTSpr9 t6�J 212 [fain SC .t • Municipal Building Northampton, M 01060 L C* W � Y �^ 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 ass � Massachusetts flfu << �i- A i -.:I MMIE6T Gl B WTNG 1NPSWCTI�S 212 tl n Stc t 01 Iclp l Building QQ, anntn,.p , M 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 debris from construction work being performed at: L�� �\ r \�'wJcos 1'-�> (Please print house number and street name) Is to be disposed of at: i (Please print name and location of facility) Or will bedisposed of'ra dumpster onsite rented or leased from: (9mpany me dress) IV C' , (::� C F" /-- Signature ermit 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 oflndustriatAccidents 1 Congress Street,Suite 100 z.,.� Boston,MA 02114-2017 gas v. www mass.gov/dia -- r Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leelbly Name(Business/OrgmimtionMdividuap: Address: City/State/Zip: Phone#: Are you.o employer^. Cheek Ne.pproprl.h hoz: Type of project(required): 1.Q I am ser loyer with employees(fell se Vor pun-time)' 7. ❑New construction 2.❑I..,.In pr.prietoror partnership and haven.employees working for one in 8. Remodeling arry capacity.[N.workers'comp.insurmnm required.] 31!5 aro a homeowner doing all work myself IN.wmkers'crossassurerce re,excil l 9. ❑Demolition 4.❑I am u homeowner and will o hiring contractors w wndua dl work m my property. twin 10❑Building addition ensure that all contractor,either have wokeneurnsusmiossonurrre on me sole 11.E]Electrical repairs or additions proprietors withno employees. 12.E]Plumbing repairs or additions s❑Tome generaltoww"hrand1hoehired luho aye-c krs'oer,sanscrne oss crunched sh�r. 13.E]Roofrepairs These sub<ontracmrs have avployees and hove workem'comp.imurance. 6.❑We are a wrpomtion and its officers have exercisedthev rightof exemption per MGL c 14'[:]O(h¢r 152,§1(4),and we have on employees.psto workers'wrap.inamance required.] easy apphcwa that checks box#1 must also 511 out the section below sowing their workers'compensation policy int'mmation. I Homeowners who submit this affidavit iodicaing they ase,doing all work and then hire ou[side contractors must submit a new affidavit indieating such. lContractors that check this ox most Mould an add¢ional sheet sowing the own,of the sub-contractors and state whether or not those entios have employees. Ifthe subcontracmrs Imve employees,Ney moat provide tluk workers'comp.polity number. lam an employer Thal 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 of the workers'compensation policy declaration page(showing the polity number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a foe up to$1,500.00 and/or one-year imprisonment,as welt as civil penalties in the form of STOP WORK ORDER and a foe of up to$250.00 a day against the viola .A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verifica 1 do hereby cc u der f p ns andpenalties ofpedwry that the information provided above is true and correct. Sionatur Date: Phon # Official use only. Do not write in this area,to be completed by city or town offwial City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Towe Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Peron: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for thew 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,§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 he 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 To"Officials Please be sure that the affidavit is complete and printed legibly. The Depanment 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 he sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that must submit multiple pennidlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary). A copy of the affidavit that bas 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 most 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 bur 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 Form to vk A rl-2a-15 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 a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,parmership,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 bean 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 authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to you situation and,if necessary,supply sub-contractors)mantels),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 polity 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 To"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/licame number which will be wed as a reference number. In addition,an applicant that most submit multiple permit/license 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 proof that a valid affidavit is on file for fume permits or licenses. Anew 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