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17C-086 (9)
96 CHESTNUT ST BP-2019-0166 GIs s: COMMONWEALTH OF MASSACHUSETTS MayIllock: 17C-086 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categorv: chimuey rebuild BUILDING PERMIT Permits BP-2019-0166 ProiectN JS-2019-000280 Est. Cost: $3500.0 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor_ Lot Siu(sg.ft.): 11107.80 Owner. HART REBECCA F&JONATHAN OLANDER Zonina� URB(100)/ Applicant. HART REBECCA F & JONATHAN OLANDER AT. 96 CHESTNUT ST Applicant Address: Phone. Insurance: 96 CHESTNUT ST FLORENCEMA01062 ISSUED ON.8.11012018 0:00.00 TO PERFORM THE FOLLOWING WORK:rebuild chimney POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Budding 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 Sienature• FeeType: Date Paid: Amount: Building 8/10/2018 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax(4 B)5874272 Louis Hasbrouck—Building Commissioner 4, phone413-587-i240 Department use only City of Northampton Status of Permit:Building Department Curb CuVDdvai Pen h 212 Main Street Sewerl5eptic availabilityRoom 100 Water/Well AvailabilityNorthampton, MA 01060 Tvro Sets of Structural Plans Faz413-587-1272 Plof/SltePlansOther Specify ION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING B(' , SECTION 1-SITE INFORMATION 1.1 Property Address: This section to be completed by office �)p �Ip/ e5'fn V+ " & t Map170,_ Lot D� Unit uki 0 1vbi;& Zone Overlay District / Elm SL Distrkt CB BIaMa SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 0J DLhNDAt IL Gks}'-� n rip', ti 01062. Nama(P'a Current Mailing Address: I ( 3 q 2376 TelepM1one I Sgnaa` 2.2 Aut rued Anent: Name(Print) Current Mailing Adams: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bemmt avolicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee Y 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Date Building Permit Number: Issued. Sture' Build, 9Cois nedlnspector of Buildings Date +a (0,0 d e r @ M ca-sf e �'r 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 This udumn to be filled in by Building Department Lot Size Frobtagge Setbacks Front Side I,: R: L: R: Rear Building Height Bldg,Square Footage 9n Open Space Footage %n (W arm minus bldg&pave to) p of Parking Spaces Fill: volume&1-amilonl A. Has a Special Permit/Variance/Finding ever 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 © DONT KNOW O YES IF YES: enter Book . Page and/or Document If B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW © 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 O NO O IF YES, describe size, type and location: E. Will the construction activity disturb(Gearing,grading,excavation,or filling)over 1 acre or is it pad of a common plan that will disturb over l acre? YES NO O 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 Windows Altemtion(s) Roofing Or Doo s ❑ Aceesaory Bldg. ❑ Demolition E] New /']N� /rnNeew,/Signs [i Docks [0 Sitting(i Other Brief Description of Proposed Work: n E30r C I E Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes _No Plans Attached Roll -Sheet ee.If New house and or addition to existing housing,complete the following. a. Use of building:One Famill 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? h. Type of construction i. Is construction within 100 ft.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 I. Septic Tank_ City Sewer Private well City water Supply SECTIONTa-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, ",n,V QLD as Owner of the subject property he y aWb CI ft2l.l E M t a on all matters relative to work ae din pe it application. ign ieDate I, -301— ATY}4+) 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. Dnexobi Pdn N e S c8 Sign of Owner/Agent Dale SECTION 9-CONSTRUCTION SERVICES 9.1 Licensed Construction Supervisor: Not Appliwble,4 Name of License Holder. / ` License Number Address Expiration Date Signature Telephone 9 Registered Nome Improvement Contractor: Not Applicable Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT N.G.L.C.152,§2506)) 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 F25�s sc4 DEPA811OF BUILDING INSPECTIONS i. a 2. 213 Win tveet • .tlunicipal 6uilCinq Northampton, W 01060 urr✓�,a� 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 or an addition to any pro-existing owner-occupied building containing at least one but not more than Pour dwelling units or to structures which are adjacent to such residence or building"be done by re¢istered contractors. Note.If the homeowner has contracted with a corporation or LLC,that entity must be registered Typeof Work: MlNjat4R-y of-IiMO= Est.Cost: --- 3S00- Address of Work: I(C GflK51T o 1 t (�. C�,_o uDale of Permit Application: 1W 'P 1 g 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: 1 hereby apply for a building permit as the agent of the owner: Date Contractor Name HIC Registration No. OR: Nolwi s ding the above notice,I hereby apply for a building p 't as e o er o [ c above property: �h� I � uN rFrltk� D R*�J Date Owner Name and Signature City of Northampton •r_ . ` Massachusetts TBUILDING 212 Hain Street a ynicipal Builchng ;A c Northampton, 4A 01060 Massachusetts Residential Building Code Section 1 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 I I O.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 Ind Department Congress Street, S l e 100 sets I Congress Street,Suite]00 Boston,MA 02774-1017 www.mass.gop/dia Ulkvieri Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aonlicent Information Please Print Leeihly Name(BnaineesssAlMaturatior✓Individuap: -ro N 6-1-rFft-rJ ()Lok-fJf��SZ Address: 16 "Ckficu5"ROuT Sr. City/State/Zip: 7—a—.RFI'$C(�e Phone 4: k1k3 '7&, as Are you an employer?Gttk the appropdare box: Type of project(required): LE]Imnacurr eT with _.__ employees(full andlm parr-rime) 7. ❑New construction 2 F lama axle pre,msor partnership and have no employees working fncescn S. []Remodeling any winnow (Noworices'comp.insurance required.) )Flom a homwwnerdoing all work myself[Nowarkers con, arearencere,mod]t q. El Demolition 4�9�1 ahomeowner and will be hiring contractors to conduct all work on my progeny. l will IGF Building addition )'"'ecce that all wcmeran,®rder have workers'compenudon insurance or are sole I IQ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5 1 am a general uncommon and I have hired the subcontractors listed on ratified tched sheet 13.❑Roo f repairs These snbcon Tactors have employees and have workers'comp.insurance _ .-a/ 6FWe are avermilion and its officers have exercised their Tight ofexception perMGL c 14. OtherpeIt�ItA1yE � r 152,§I(4),and we have no employees.INo workers comp-muchave roquired.l 1-0 Any thalamus That checks box#1 must alto fill am the section below showing their workers'compensation policy information. ?Homeowners who submit this andavit indicating they are doing all was and then hire onside contractors mum submit a new affidavit indicating such. IConommors mat check this box must attached an additional sheet showing the mine of the subconrracors and state whether or not those entities have employee. If the sub commissions have employees,they must provide their workers wrap policy number. lam an employer those is providing workers'compensation insu ancefor my employees. Below is the policy and%ab site information. Insurance Company Name: Policy g or Self-ins.Lic.k: Expiration Date: Job Site Addrewe 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 MGI.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 herebyfy u r th and pe hies of perjury that the information provided above i nu�eyand correct S' t Date. !YI �e5 Phone h: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/Li.ense N Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector 5.Plumbing Inspector b.Other Contact Person: Phan.N: City of Northampton '" Massachusetts �... '®f 1 I)EPAAYMCNT OF BUILDING INSPECTIONS 212 H in Street eN nicipel BuilU nq JF C NorNamptan, . 01060 n,r�ri y„J 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: 176 Lf"f4rST/JUT JrF• �M4- 0 (06z (Please print house number and street name) Is to be disposed of at: ✓A' �e`/ 0CCY«d loNTdF4 IE1 67/Z , (Please print name ancation of facility) Or Will be disposed of in a dumpster onsite rented or leased from: (Company Name r Address) n �Snat re of Permit 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. 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 arm individual,partnership,association or other legal entity,employing employees. However the owner ofa dwelling house having not more than three apartments and who resides therein,or the occupant ofthe 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 pubic 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-contmetor(s)nam addresses)and phone numbers)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(I.LP)with no employees other than the members or partners,am not required to carry workers'compensation insurance. JIM 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 resumed 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 ofthe affidavit for you to fill out in the event the Office oflnvestigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used az 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 f necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."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 affidmit 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 many 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-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 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 of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the owner of 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 time,address and phone number along with a certificate ofinsurance. 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 ofthe 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(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 must be filled out each year. Where a home owner or ciliun is obtaining a license or permit not related many 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 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 www.mms.gov/dia Farm Revised 02-23-15