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23C-071 (9) 67 WILLOW ST BP-2019-0145 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23C.071 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-2019-0145 Project# JS-2019-000235 Est. Cost: $5088.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: KIM RESCIA 022464 Lot Siae(sa.IT): 17685.36 Owner: SILVER ELIZABETH A&MARY VIRGINIA LEE BADGETT Zoning URA000)/WSP000U Applicant: KIM RESCIA AT: 67 WILLOW ST Applicant Address: Phone: Insurance: 311 Locust St (413) 320-18310 FLORENCEMA01062 ISSUED ON:8/912078 0:00:00 TO PERFORM THE FOLLOWING WORK:12X14 DECK ON REAR OF HOUSE 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 4 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: FeeTvpe: Date Paid: Amount: Building 8/9/2018 0:00:00 $65.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2019-0145 APPLICANT/CONTACT PERSON KIM RESC'4 ADDRESS/PHONE 311 Locust St FLORENi E (413),10-1831 Q PROPERTY LOCATION 67 WILLOW ST MAP 23C PARCEL 071 001 ZONE URA(l0u"WSP(100) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION<ffECKLIST NCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid TylaeofConstructiom 12 I4 DECK ON EAROFHOUSE New Construction Non Slrucmral interior renovations Addition to Existing Accessory Structure Buildine Plans Included: Owner/Statement or License 022464 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF AT PRESENTED: 2 Approved_Additional permits required(see below) p I PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major PmjecC 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 Demolition Delay / �-� a 911e, Signature of Building Official 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 arc gaited oil,,,mos"applicants Who meet the strict standards of MGL 40A.Contact Office of p\anning&Developmen,for nye information. 114 kitlluse only City of Northampton Building Department GuuDrt+evreyrt (, 212 Main Street SepbcA ,i, Room 100 WatertWell Availability, Northampton, MA 01060 Taro �_+� ' tarra phone 413-587-1240 Fax413-587-1272 f6 dWi ) APPLICATION TO CONSTRUCT,ALTER REP )USH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 ooeis s on to be completed by office Pr// rN Address: Lot 071 Unit or�T or r.WIDIN,IN9 " ppglm/PTON,MAD10am Ylwence CIo62 Overlay District Elm St District CS District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: rlweJt<e o1�62 Name np /l Current Mailing Address: 4 13 �31 - 9 9 37 �(rft/,� Telephone Signature 2.2 All odzed A an Name(Print) Cument Mailing Address: Signatur Telephone SE ION 3- STIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by penoun applicant 1. Building So </ 100 (a) Building Permit Fee 2. ElecMcal O (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) / p`J 5. Fire Protection VVV 6. Total=(i +2+3+4i5) S I O Check Number This Section For Official Use Only Date Building Pemlit Number. Issued: Signature: Building Commissioneninspector of Buildings �r Date V EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed. Permit Can Be Dented Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Depnrwcnr Lot Size Frontage — _ Setbacks Front - Side L R: L R _... ...--..__ _..... Rear _. Building Height Bldg.Square Footage % -- -- Open Space Footage (Lm boon minus bldg at paved Parking) N ofParking Spaces Fill: ...._. . _.. __..... (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NODONT KNOW O 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 N B. Does the site contain a brook, body of water or wetlands? NOb 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 b 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 O IF YES, describe size, type and location: E. WIII the construction activity disturb(clearing,grading excavation or filling)over 1 acre or Is it part of a common plan mat will disturb over l acre? YES © NO i IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION b DESCRIPTION OF PROPOSED WORK leheck all auolicablel New House ❑ Addition ❑ Replacement Windows Alteration(s) E:] Roofing F1Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding(0] Other[M Brief Description of Proposed " Work: ZX I LI 'r Alteration of existing bedroom_Yes_No Adding new bedroom Y No `JQ7pp 1t/t�lA.W Q)<l Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Ga.M New hoose and or add3ticn to existing housing complete the foltowina a. Use of building OneFamili 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? In. Type of construction i. 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 OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, L z G-bt I VQ/ . as Owner of the subject property 1/ p hereby authorize f ICP S cl to Tin y behalf -n all m tters relative to work authorized by this building permit application. Signatuile of Owner Date I, IL, 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 uri the pains an alties of perjury. Print Namer l / Signature of erlAg t Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction S e isor: Not Applicable ❑ Name of License Molder: e I CS o2zy 6 / � 11� License Numbe Address Expirfivor,Me Signature Telephone l� A &QeX4 Y/3 3ZD S- 9.111 3/ "me lm C Not Applicable ❑ 19 1? z Company Name I Registration Number 11 12 Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152'§25C(6) ,§25C(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial oftheisuiacice,of the building permit. Signed Affidavit Attached Yes...... No...... ❑ r City of Northampton Massachusetts Y ' k DEpARTME'NT OF BUILDING INSPECTIONS J ,212 Min Street • Hunicipal Building Northan,ton, 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 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 preexisting owners upled 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 pe e a the owner: Dafe nu r Name HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton .5 — Massachusetts ® c x t' � DEPARTMENT OF HpILDING ZNHPECTIDNS 212 Main Street • ILn 010 Building Northampton, Ml1 OlOfiO 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 . . Massachusetts e3 Q c s { DBFABT.NFNT OF BUILDING INSPECTIONS 212 Min Street •Municipal Building Ia JCD Northaz,ten, HN 01060 .yp� 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: & 9 Willow S-¢ + )G , (Please print house number and street name) Is to be disposed of at: (Please print n� ye and ocation- f f\a)clllty) Or will be disposed of in a\ dumpster onsite rented or leased from: (Company Name an Address) s S' at e P t Applicant or caner Date If, for m eason, 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. e The Commonwealth ofMassaehuselts Department oflndustrialAccidents I Congress Street,Suite 100 Boston,MA 02174-10177 loww.massgov/dia R orkees'Compensation Insurance Affidavit:Builders/ContractorsMectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organ1izatioWIndividuap: Address: 3 I Ili !J D� <` -V— City/State/Zip: City/State/Zip: 'TI O OjQGa Ph,,C#: '3 Are you an employer?Check the appropriate box: Type of project(required): L[:]I am a emplayerwah employees(Nil mad or part-time)• 7. ❑New construction �Iamasole pmpriemr or pmmership end harm employees working forme. 8. E]Remodeling any capacity.[No workers'comp insurance requncd] 3❑l on a homeowner doing all work n wff IN.warkrncomp.ur.r requlmdJ` 9' El Demolition 4.❑1 am a homeowner and will be hiring reactions to conduct all work on my property. 1 will 10❑ Building addition onsure mat all conawbox onset have w.rwrx' rdagoduo assurance orm,sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions s❑1 am a general connector and 1 hove hired the sub-cono-acWrs listed on Ne attached shed 13.[] re s These subcnntracmrs have employees and have workers comp.wmmncet 6.❑W'e are azoryomtion anJ in officers have exercised Net right orexemptron per MGLc 14.❑Other �C� 152.$1141,and we have no employtts.(Nn workers'coW..sumnce required] 11 "My appllonat that checks box#1 must also fill out the section below showing Net workers'compensation policy.rmmati m I Homeowners who submit this andavit.dicat.g new are doing all work and then has outside contactors most submit a new affidavit indicating such. :Contractors that check Nis hox must attached an eddiaanal sheat showing are time of the sub-conanemr:and sone whether or not Nose entities have employees, rthe subconfideret have employees,they mua,dowidethere wodwrs'mmp.pslicyaumber. lam an employer that is providing workers'compensation insurance far my employees. Below is the policy andjob site Information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$t,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 DLA for insurance coverage verification. I do hereby certify u e pan enalhes of perjury that the information provide(d)above is ore and correct Signs" ! Date: 6 Phone# M 3 ^ / &-3 1 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): L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: t 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)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 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 your situation and,if necessary,supply sub-contractor(s)tunnels),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 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 cent=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 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 burn 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-NIASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia a 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 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 my 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 efthe 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 permtdicense number which will be used as a reference number.In addition,an applicant that must submit multiple perinitdicense applications in any given year,need only submit one affidavit indicating current policy information(ifnecessary). A copy ofthe 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 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 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 Foam Revised 02-9-15 -7J -I7�OV� Vi --r7AC;'pOtCC'! �� 7 C Yj C Oi LM1 1 j CC;�7. ) C '1yn l✓ I 1I `c� 1 bU iu b'O`�ti 7 r-- 1 I 4 3 o"El