25C-048 (7) 224 NORTH ST BP-2019-0816
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C-048 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:KITCHEN RENO BUILDING PERMIT
Permit# BP-2019-0816
Project# JS-2019-001347
Est. Cost:$2500.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DANIEL HEWINS 049714
Lot Size(sq. ft.): 7579.44 Owner: BRODWYN JANE MEYERSON
Zoning:URB(102)/ Applicant: DANIEL HEWINS
AT. 224 NORTH ST
Applicant Address: Phone: Insurance:
P O BOX 186 (413) 582-9929
CHESTERFIELDMA01012 ISSUED ON:1/18/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.-NEW CABINETS, COUNTERTOPS, REPLACE
WINDOW
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 Deaartment 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 1/18/2019 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
RECEIVED
Department use only
City of Northa pton tus f Per it:
` Building Depa ent JAN 7 c t/Driv way Permit
tF c 212 Main Str et Sewer/ eptic vailability
p�
t t �4 Room 10 il A ilabili
" DEPT.OF E3UILDING INih ry
Northampton, NORTHANiPION.M ctural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: / This section to be completed
by office
.�� ,1 Map C� Lot U D Unit
7 1 Zone Overlay District
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: * D
Y n %VY 1"
Name(Pri t) Y l� `, Current Mailing Address: 4 ) 21f. 37
Y . P 9 9 3
Telephone
Signatu
2.2 Augorized Anent:
DAdlEk � w � NS p BoX b
Name(Print) w Current Mailing Address: 10
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building Z D O D (a)Building Permit Fee
2. Electrical O ' (b)Estimated Total Cost of
Construction from 6
3. Plumbing .�0 0 0 Building Permit Fee
4. Mechanical(HVAC) 4/0
1007
5. Fire Protection
6. Total=0 +2+3+4+5) �-- S O 0 Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued: 1
Signature:
Building Commissionerfinspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ID Addition Replacement Windows Alteration(s) ED Roofing 0
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [[31 Decks [C] Siding[[3] Other[[7J
Brief Description of Proposed
Work
Alteration of existing bedroom Yes Y No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the following:
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 stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
1. 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
�J "
1, /�` �f A ,9 D-\v T ) ,as Owner of the subject
property
hereby authorize
�j to act on my beha in all matters relative to work authorized by this building permit application.
/ 1 17 I
Sign re Owner Date
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 paind penalties of perjury.
7Arit ,cL ON wiw )
Print Name
Signature of Owner/ Data
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L:-R• L: R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/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 O DONT KNOW 0 YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 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 0
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,a vation,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 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: rI L ( Not Applicable ❑
Name of License Holder: j C L o TTG W Jy 4 ( 7 14
P. O, B O x �� 1 L n License Number 1-to J p
Address Y Expiration Date
brviZ �+ �3 . �., � o . � fib ►
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
1 -1 7-6p
Company Name �11 Registration umber
bA1 (� � TTEr" r� �j r Z3 Izo
Address Expiration Date
sA 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 affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... L9� No...... ❑
City of Northampton
Massachusetts
DSPARTNEW OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
'v►, North- ton, MA 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: K) t x,o E ��o %/A l t a Est.Cost: '15 000
Address of Work: Z' 1 R Y �T
Date of Permit Application: ( ' 17 I I q
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 hereb apply for a building t as the agent of the owner:
i-7 1 1 �7b�
Date IContractor 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
Massachusetts
R
4 DEPAR229M OF BUILDING INSPECTIONS
g > 212 Main Street •Municipal Building
-' Northampton, MA 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 properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
-Z-Z4 �OKTH �T
(Please print house number and street name)
Is to be disposed of at:
VALLEwf A
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
V/ I ► � I
Sign 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.
The Commonwealth of Massachusetts
Department of IndustrialAccidems
1 Congress Street,Suite 100
Boston,MA 02114-2017
- www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information A ,
anPlease Print Legibly
Name(Business/Organization/individual):. n I EL w 1/'a 11
Address: 1" -Q pQ-A.
City/State/Zip: C �S i �, I F L,� , M A Phone#: t�' / 3
t' 5 `f
Are you an employer;Check the appSopriate box: Type of project(required):
1.❑1 am a employer with employees(full and/or part-time).* 7. ❑New construction
2.l=1 l am a sole proprietor or partnership and have no employees working for me in $. Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 Q Building addition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.C31 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.'
6.O We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[:]Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
(Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation Insurance for my employees. Below is the policy and job 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$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 verific ti
I do hereby cert" rider the pains and penalties of perjury that the information provided above is Ie and correct.
Si ature: '� Date: 1 l T ( t
Phone#: 4 1 1 '150 , 1461
Oficial 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):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: