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25C-173 (4) 125 NORTH ST BP-2019-0068 GIs#: COMMONWEALTH OF MASSACHUSETTS Mia ::Block:25C- 173 CITY OF NORTHAMPTON Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit. Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Categom demolition BUILDING PERMIT Permit# BP-2019-0068 Proiect# JS-2019-000102 Est Cost: $1000.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use croup: Homeowner as Contractor_ Lot Size(sp.ft.): 6098.40 Owner: SIRECI STEPHEN G& Zoning:URC(lo0)/ Applicant: SIRECI STEPHEN G & AT: 125 NORTH ST Applicant Address: Phone: Insurance: 125 NORTH ST NORTHAMPTONMA01060 ISSUED ON:7/17/2078 0.00.00 TO PERFORM THE FOLLOWING WORK:REMOVAL OF OBSOLETE CHIMNEY TO INSTALL NEW CABINETS 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: OoI• 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 7/17/2018 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner City of Northampton Building Department 00 212 Main Street Room 100 Northampton, MA 01060 kp 'v phone 413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER, REPAIR RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION I SITE INFORMATION I This section to be completed by office 1.1 Property Address' No , Lot Unit A/ 06l- Zone Overlay District El.SL District CB District SECTION 2-PROPERTY OWNERSHIPAUTHORIZED AGENT 2.1 Owner of Record: .Name(Print) 4e Current Mailing Address: Signature 4 A/pL-1 Telephone y/ 2 Authorized Agenti Name(Pant) Current Mailing Address Signature Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only wan pleted by permit applicant 1. Building (a)Building Permit Fee 2. Electrical f (b)Estimated Total Cost of Construction from 6) 3. Plumbing Building Permit Fee 00 4. Mechanical(HVAC) 5. Fire Protection 6. Total =(1 +2+3-4+5) 01J Check Number ?00 This Section For Official Use Only Date Building Permit Number: Issued: Sign ure ,7 w Building CO;z--ionedInsxx3or of Buildings Dele �-L re r 1 0 0✓T 10 0 D Ll 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 'Ibis column to be filled in by Building Deparurmt Lot Size Frontage Setbacks Front Side L:—.-. R: L: R: Rear Building Height Bldg. Square Footage % - -- --- Open Space Footage (Lot area minus bldg&paved arkin ) — #of Parking S paces -- ---- Fill: (volume&Locanonl -------- ----I-------------- A. Has a Special Permit/Vanance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © 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 O DONT KNOW ® YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained © , Date Issued: C. Do any signs exist on the property? YES © NO O 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 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading excavation or filling)over 1 acre or Is R part of a common plan that will disturb over 1 acre? YES O NO O IF YES,then a Northampton Storrn Water Management Permit from the DPW is required. SECTION S.DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(a) ❑ Roofing Or Doors13 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding [p] Other[p] Brief Description of Proposed Work: kx".'Jol aF o�s�jt/c C�lrrnr i�sk//n ti. r,� ;,.c�l Alteration of existing bedroom_Yes_No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet le ff New house and or addition to existing houi comofete the following a. Use of building : One Family Two Famiy 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 I. Is construction within 100 ft.of wellands?_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 AUTHOR17ATION-TO BE COMPLETED WHEN OWNERS AGENT gO/RJCONTRACTOR APPLIES FOR BUILDING PERMIT I, S'/u// as Owner of the subject property hereby authorize ��//��{ �T Si "'e'to act on my behaR, ii II ens relative to work authorized by this building permit application. Signature of Owner Date 1 ,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 of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor. Not Applicable ❑ Name of License Holder: License Number Address Expiration Dale Signature Telephone 9.Registered 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(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this a davit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste 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. Address of the work: I�r / 04 (�-i /V` 14 \ 0/1G0 The debris will be transported by: -�rf't C' i The debris will be received by: o l r Building permit number: Name of Permit Applicant Date Signature of Permit Applicant City of Northampton Massachusetts DWARTNEtiT OF BUILDING INSPECTIONS 212 win Street • Municipal Building Nontha ton, as 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. 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 RESPONSIBMTES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PACE FOR MORE INFORMATION. Signed under the penalties of pequry: I hereby apply for a building permit as the agent of the owner: Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice,l here�ly f a uilding permit as the owner of the above property: � //3 Z/ Date O e ame an Signature City of Northampton Massachusetts Y DEPARTMENT OF BUILDING INSPECTIONS 212 Hain Street • Nunitipal Building Northampton, MA 01060 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 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 persons) you hire to perform work for you under this permit. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-20177 www.mass.gov/dia Workers'Compensation Insurance Affidavit;Builders/Contrastors/EleMricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Nadne(Business/0rgmuavbw11w1 iidual)/A S? Address: City/State/Zip: ���"� '�— ➢ '0 Phone#: Are you me employer?Check to approprooe ox: Type of project(required): I I am a employer with ecapioyees(fol motor pan-t®e).` 7. ❑New construction 2❑I am a sols pmpriemr or pnrtnership and have vo employtts working forme t S. ❑Remodeling any capacity.[No workers camp.meurmne required] )❑I am a homeowner doing all work mywlf(No workers'comp.hmumnce mp=d.1 1 Demolition 1 am a homeowner and wdl be turf amUsn,to cowwt all work on m 10 Building addition a gmv my twill rre that au oornacmrs eiNer nave workers'compevsaoon mautance or are sole 11.[:]Electrical repairs or additions pmpdemrs with ne employees. 12,❑Plumbing repairs or additions 51 are a grneml contractor and 1 have hired fe sub<m doaewrs listed on is nourovd et she . '❑ _rer 13.ERoof repairsThese sub<ovdors trahave employees and have workers'comp.ha 6.❑We are a cmpormoo and its officers have exercised rite.tight of exemption per MGL c. 14.IRIther l7 f o l e x (f 152,§Ito,and we have no employee.[No woricen'comp.a sumnee mgohed] Y-d, * Any applicant that checks box#1 must also fill out the section below showing ten workers'compensation policy tfmmadon. t Homeowners who submit this affidavit ivduadag try are doing all work and ten hoe outside comawnea must submit n new at5davit indicating such. :Ceauactors not check this box mum mmched as additional sheet showing do rome of Ne sub-craowwo;and mon where,erupt Lose modes have employees. Ifte sub-m cmn have employees,fey must provide Nein workers'comp.policy rumba. am"employer that is providing workers'compensation insurance far my employees. Below u the policy and Jab site information. Insurance Company Name: Policy#or Self-ins.Lia #: Expiration Date: 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 e. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-yew 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 cop of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify ander ' s and pe Nes ofperjury that the information provided above u no and correct Si nature: Date: Phone Official use only. Do not write in this area,to be completed by city or town offrciaL City or Town: Permit/License# Issuing Authority(circle one): I.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 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)slates"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-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)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 maybe 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 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 proofthat a valid affidavit is on file for future permits or licenses. A new affidavit mus[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, 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 ,�;� ! �,; �� 7, ����.. �� & e ©: •�2 \ ? � �§4/\ & �« & , Cl � � P Iry y 4 .T � o eV 671 i��n_ � �� `� ^ „ r. 4. F� F�tY tea_ �, ��I. .. ,*, t� . tY Z...'� . .. yh•. y' � .. t+K`,... �9. � .E.i } u'�~_ �� �'.'�� ' � f r- � ; 1 t ,�,'; � �11 R fYj' .:r� �� K� N.r{ �r a, Y F' _,�.�. 4� a• �..� � I CE K11Ot'v, P-M VI,W C&5 vGHC N P\�MObF