17A-258 (8) 103 OAK ST BP-2019-0099
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-258 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catecorv: ADD BATH BUILDING PERMIT
Permit# BP-2019-0099
Project# JS-2019-000159
Est Cost:$4600.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Grouo: Homeowner as Contractor_
Lot Size(sp. ft.): 14679.72 Owner. STOPPLE AARON
Zoning,URB(100)/ Applicant: STUPPLE AARON
AT: 103 OAK ST
ApplicantAddress: Phone: Insurance:
103 OAK STREET (607) 435-46610
FLOREN CEMA01062 ISSUED ON:7/25/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.CONVERT COMMON ROOM TO BATHROOM
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 7/25/2018 0:00:00 $65.00
212 Main Strect,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File k BP-2019-0099
APPLICANT/CONTACT PERSON STUPPLE AARON
ADDRESS/PHONE 103 OAK STREET FLORENCE (607)4354bn1 Q
PROPERTY LOCATION 103 OAK ST
MAP I7A PARCEL 258 001 ZONE URB(I00V
THIS SECTION FO9,OFFICIAL I ISE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: CONVERT CO O TO BATHROOM
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
INFO'AMATION 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 Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
D lition Delay
of uildin O w' ,/ Date y /
Note: Issuance of a Zoni 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 we granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
- MDepartment use only
City of Northampton status of Permit:
Building Department Curb CudDriveway Permit
,( 212 Main Street SewerrSepfic Availability
il, Room 100 waterNteii Availability
Northampton, MA 01060 Two Sets of Structural Plans
_�'.. home 413-587-1240 Fax 413-567-1272 Plot/Site Plans
Other Specify
APPLICATI TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 1 q—�q
1.1 Praa i Aadrms: This section to be completed by office,
1103 Pa14 t Map L7--I Lal O�'.SO Unit
Okl>& i zone overlay Diidrla
Elm at Damict C9 obakt
SECTION 2-PROPERTY OWNERSHmtALITHORMED AGENT
of neon er ,t
pry,. .SFwhbk i NTt,4 d U.30 kr lo? o-k Shruh &.a„ 44A otor. 2
Name(Prou Curent Wane Address, T
('07 u39' y6vt
Tele%mone
Signature
2.2 Authorized Agent:
Name(Pnna Current Mailing Atldress:
Signaaae Telephone ."—
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be O(fidal Use Only
win leted by permitapplicant
1. Building �Jo 0 (a)Buitdsrg Perm#Fee
2 Electrics .$a (b)Estimated Total Cost of
Construction from S
3. Plumbing wV Building Parsed Fee
4. Mechanical(HVAC) "5
S. Fire Proh'aion
B. Total=(1 +2+3+q+5 N. aaO Chadc Number Ino.
This Section For Official use Only
Budding Permit Number: Date
Issued:
Signature:
' ��
4ST(L)( Pt_ 49 oma 1. c.„ @
EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information most Be Completed.Permit Can Be Denied Due To Incomplete Infpmlation
Existing Proposed Required by Zoning
This column to Is,MW in by
Building Dapama.,
Lot Sim 0. 34
Frontage 0 °2
Setbacks Front at ' Ar '
Side L: 2'Z R:_37 L: R:
R= 7 ( . 71 .
Building Height 23r/A., ;3,/a t,
Bldg.Square Footage '�. a fan 'Y' J,QP y°e Y.
Open Space Footage %
(tom.minus bldg At paved 13,04 �I� 13 du
vki,
#of Parking Spaces
Fill:
vnlume B Irca4on
A. Has a Special Permit/Variance/Findin r been issued for/on the site?
NO O 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 V 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 V
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,ex tion,or filling)over 1 acre or is it pan of a common plan
that will disturb over 1 acre? YES O NO tV
IF YES,than a Northampton Storm Water Management Permit from the DPW is required.
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Constmctbn Supervisor: Not Applicable D
Name of Llraniat holder:
License Number
AEdress Eyirabon Date
Syneture Telephone
9 RMIStemd Home Improvement Contractor Not Applicable D
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 16 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152,§25C(6))
Workers Compensation Insurance affidavit must be cornpleted 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....... D No...... D
SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicable!
New House ❑ Addition ❑ Replacement ows WindAlteraUon(s) ❑ Roofing L1m Doo s
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks 10 Slding(0] Other(Oj
Brief Desorption of Proposed /+
Work: l Jv+ Cr)/ ('Doryx a a r
Alteration of ewsting bedroom_Yes N/ No Adding new bedroom Yes 1ZNo
Attached Narrative Renovating unfinished basement _Yes d No
Plans Attached Roll -Sheet
ae. If New (rouse and or addition to existina housing, complete the fol(owina:
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 stones?
I. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
K Type of construction
I. Is construction within 100 R.of wetlands? Yes _No. Is construction within 100 yr. floodplain_Yes No
I. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
1, 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, as Omer of the subject
property
hereby authorize
to ad on my behalf in all matters relative to work authorized by this building permit application.
Signature of Owner Date
NONSENSE
I, u1 St`+ �< as Omer/Authorized
Agent hereby declare M. the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signs tl/yllniter the pains and penalties of perjury.
Prim Name
a v
Signature of ent Date
City of Northampton
jis
Massachusetts
ffiPARD51.`T G IHSP oS Bzrrw Xcus
j 212 Nein 8traat 0 lNnicipal Building
f NortAarytOn, ML 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, innovation, repair, modernization, conversion,
impmverm nt, removal,demolition, or construction of an addition to any pre-existing owner�arupied building containing
at least one but not mom than four dwelling unts .orto shuctums which am adjacent to such residence or budding"be
done by registered contractors.
Note:/f 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 owneraccupied
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 RESPONSHIILITES 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,l hereby apply for a b ilding permit as the owner of the above property:
7 �y IB 4r" D¢_
IL
Dae Owner N e and Sign
City of Northampton
Massachusetts
'(I..tt nlo? TAT Or amrw AG I ZCTIOPS
)SC �{ 212 Main Stz t of wiclpsl H ldin
0�Y�_ MOr�, M 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 property licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
103 Dak Sf /H/f OI o (.;?
(Please print house number and street name)
Is to be disposed of at:
gt'Ur- A%l ' f
ease printriame am location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
7 ,y 8 _
S' o Permit Applicant or ownev 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 Coinitninwealth of Massachusetts
St Department oflndustrialAccidents
I Congress Street,Suite 100
_ Boston,MA 02114-2017
www.massgov/dia
NN orkers'Compensation Insurance Affidavit;Builders/Contrastors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITI'.
Applicant Information Plea Print Legibly
Name Busi ess/Organiratioanndividuaq: 4r f
Address:
City/State/Zip: Phone#:
Arc you m employer?Chmk f6e appropown,bra: Type of project(required):
I.E]I an a mnploym with mplrn,xx(fuli arwm pan-time)• 7. []New construction
2.❑I an a sole protractor or partnership and have an employoca working for m,in 8. ❑Remodeling
s' ay.[No worker'comp.a... re .xvil.l
.QI a�homwwrer doing all wakmyself lNoworkers'com q. El Demolition
3
p.ireumee requi�.l'
4.0I am a romenwner and win be hiring convectors to conduct all work on my pmpmty. twin 10❑Building addition
tame dout on emarsomis out.have Workers'compensation insurmree or are sale 11.❑Electrical repairs or additions
pmpro mrs with mmnpl.,. 12.❑Plumbing repairs or additions
5❑I an a gmeml commnor,and I have moral the subruntraclors listed on the mmchd sheet. 13❑Roof repairs
These sal,am ixima have employes and leve workers'camp.irtsumtrcel
6.❑ m We me a co,i .not its officers lave exercised dear n htoroxern tion cer MOL c. 14.❑Other
I az,§I(4),tato we have ria employes.[No coolers'came.insurmae requimd.l
•Airy applianm Nm checks lox ai run also fill out Ne seliun below showing Neirwolen,compenmetion policy mifmmelun.
tfiammwners whosubmit tor,
att indica tingtheyare doing allwork end den hireoutridecurradomi mmrsubmitanew not davitiMiratingeach.
tCono-emrs that clack itis box must attazlvA an edditiarml sheet stowing de tame of the subcontrecwrsand sate wheNmm not thoseentities have
rown,ae, lfne submnaeclors have employee,they must provide Heir coolerscamp.pony manber.
I am an employer arm is providing workers'eompensadon insnronee for my employees. Below is f reprdley and joh site
inforomdon.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Dote:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date)f
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 imprismtment,as well as civil penalties in the form ofa STOP WORK ORDER and a fore of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations ofthe DIA for insurance
coverage verification.
I do herebyser/tJj'under alre paths d�penalffes of perjury that the informadan provided above a true and correct
Signature, 1' 'I a^'F7/ Date-
Pho #, ( ul 935 566
007cial use only. Do not write in this area M be completed by city or town o$wiaL
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#:
Building Proposal July 24, 2018
103 Oak Street Florence MA 01062
1 plan to convert an existing 113"x 99"second Floor common room into a full
bathroom. Installations include a 60 x 32 x 19"bathtub with tile tub surround in the
northwest corner,a toilet in the northeast corner,and a double sink with vanity
along the southern wall.Since there are currently two entry points to the room,an
L-shaped 62 x 46' wall with a single door will be installed.A 32" interior wall will be
demolished.Two outlets along the southern wall will be raised above the vanity and
replaced with GFCI outlets.An overhead light will be installed with a switch located
in the new wall.
I propose to complete the building and electrical work myself.An electrical work
permit is filed separately.
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City of Northampton
Massachusetts
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Massachusetts Residential Building Code
Section 110.85.1.2
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 110.85.1.3.1
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.
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 those 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 construe[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 am any of its political subdivisions shat l
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 yew situation and,if
necessary,supply your insurance company's time,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,we 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 andevit. 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 pertnit/license applications in my 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 titian is obtaining a license or permit not related to any busirass
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 fnx number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston,MA 02114-2017
Tel.#617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
www.mass.gov/dia
Fw Revised 02-23-15
Information and Instructions
hbssachuulm General Laws chapter 152 requires all employers to provide workers'corgensatim for their employees.
pursuant to this statute,an employee is defined as"...every person in the service of another under any conduct 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 deceased employer,or the
receiver or Wstm of m individual,pratmship,association or other legal entity,employing employees. However the
owner of a dwelling home having not more than throe 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 amt because of such employment be decreed to be an employer:'
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shag withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the eommunwedth for say
applicant who has not produced acceptable evidence of compliance with the insurance coverage required:'
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth net any of its political subdivisions shall
enter into any contract for due performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented no the cc rimming authority.'•
Applicants
Phase till 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 certificetc(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 thaions 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 refined to the city or town that the application forth,permit or license is being requested,wat the Deputation 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 primed legibly. The Department has provided a space at the boom
of the affidavit for you to fig out in the event the Office of Investigations has to contact you regarding the applicant
Please he sure to fill in the pmmitflicesse mmbm which will be used as a ref nvocc mother, in addition,an appiicanf
that must submit multiple permit/liconse 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
awn)."A copy of the affidavit that has been officially c emped or marked by the city or town may be provided In the
applicant as proof that a valid affidavit is on file for fimue permits or licenses. A new,affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit rat related to any business or commercial venture
(i.e.a dog license or pemtit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Deparmnent's address,telephone and fax comber:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-7274900 elft.7406 or 1-877-MASSAFE
Pax#617-727-7749
Revised 02-23-15 www.mass.gov/din