12C-012 (5) 97 MOUNTAIN ST BP-2019-0900
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map-.Block: 12C-012 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category-renovation BUILDING PERMIT
Permit# BP-2019-0900
Proiect# JS-2019-001502
Est.Cost: $25700.00
Fee: $182.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
UseGrouo VALLEY HOME IMPROVEMENT INC 112166
Lot Size(su.ft.): 25787.52 Owner: BIENKOWSKI PETE
Zoning: RI000INRA(100)/WSP(1001/ Applicant: VALLEY HOME IMPROVEMENT INC
AT. 97 MOUNTAIN ST
Applicant Address: Phone: Insurance:
P O BOX 60627 (413)584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.-212012019 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVAL OF INTERIOR WALLS, RELOCATION
STEAM BASEBOARD HEAT, NEW CEILING FINISH
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:
FeeTvpe: Date Paid: Amount:
Building 2/20/20190:00:00 $182.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2019-0900
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 97 MOUNTAIN ST
MAP 12C PARCEL 012 001 ZONE RI000VURA000VWSP(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
EN ED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildina Permit Filled out
Fee Paid
TymeofConstruction- REMOVAL OF INTERIO ALLS, RELOCATION STEAM BASEBOARD HEAT
NEW CEILING FINISH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 112166
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOFMATION 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&Recordedat 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
Q ( 7
!N�^—'�^-�` 20 r
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 are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
_ Department use only r
Cityof North mptcRECE�� bfrP
Building Dep Fri Curb BUD veway Permit z
212 Mpin S teat S`e`� /Se cAvailabnu a °tb s
Room1 0 F9 1 20 a( en vaitabil '^+
a a. rt..
Northampton, 01 60 7wQ e„so SWumlPlans su =;r
phone 413-587-1240 F x 41 PI -
nr-
APPLICATION TO CONSTRUCT, ALTER, REPAIR RENOVATE OR DEMOLISH A ONE OR TWO
/FAMILY DWELLING
yINGr711
SECTION I-SITE INFORMATION Qo (q-LI` Vv
1.1 ProQperty Adtlress: This section to be completed by office
l, .MapOC- Lot--v Z Unit
,
`of erxe— -Zone Overlay District
l Elm St District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of�Record:
QAe,. V7 ny'buWSka C(I (Y)nt)nKLlr 'Florey-,rte Mci o Qx0
NamPtl q Current Mailing Atltlmss:
X Telephone �x— SITS— Z� {S
Si lure
2.2 Authorized Anent:
L(J)ek Robo-45 Po Box (aOgoal Florenct He 01o(,Z
Name(Pont) Current Mailing Address:
t-tl?r58`1-�15�-
Signature Telephone
SECTIONS.ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by IFermit applicant
1. Building Z ( SD O (a) Building Permit Fee
2. Electrical J>00� (b) Estimated Total Cost of
' Construction from 6
3. Plumbing w oN E. Building Permit Fee
4. Mechanical(HVAC) )Z O
5. Fire Protection r
6. Total=(1 +2+3+4+5) 'L 1i 700 ' Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissionedinspeclor of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ FRcement Windows Alterations) 1�1 Roofing ❑
orsAccessory Bldg. ❑ Demolition ❑ Signs [O] Decks [E] Siding[0] Other[p]
Brief Description of Proposed
Work: e« 0 eat Vu ..FI th vvnQ.Q' " o.Aier sk �oeabaM.f ho.- / rmJ
Alteration of existing bedroom_,X Yes_No Adding new bedroom Yes JC No
Attached Narrative Renovating unfinished basement _Yes �No
Plans Attached Roll -Sheet
Ba.If New house and or addition to existing housing, oomDlete the following:
a. Use of building '. One[Famili Two Family Other
b. Number of rooms in each family unit Number of Bathrooms
c. Is there a garage attached?
J. Proposed Square footage of new construction. Dimensions
e. Number of stories?
I. 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
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, PQke- b] 1
en �i[WE k as Owner of the subject
property
hereby authorize Vrr 1� 1(� \Sb�9P, s
tc acto y It rni all matters relative to work authorized by this building permit application.
D/ 08- /9,
Signa re of Owners pp Dale
I, \1IIT e (�mlhei fW�P.✓ 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.
ai
&Lh6 f 60eA`3
Print Name/� //`/���j�jyy�
Signature of Owner Agent Date
City of Northampton
Massachusetts
c.
` DEPARTMENT OF BUILDING INSPECTIONS �{
212 MainStzeet • Municipal Buildi.,
Moithamptan, IM 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 Pour dwelling units....or to structures which are adjacent to such residence or building"be
done by reeistered contractors.
Note:If the homeowner has contracted with a corporation or LLC, that entity must be registered
Type of Work: nI -IP,✓It Di -f`whQ',�f� Est.Cost: $ZS- 700
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 TINDER 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:
02 ii II "J(l�AGt.1�f1Mf, 74t1t7/L1.tpma+ 111 1555y3
Date Con ctor 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
.�:
D212 MLn S OF BOI DTMG—ci INSPECTIONS yJr 5:
212 Main StreeC •Municipal aviltling
Northampton, HA 01066
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
l(from construction work being performed at:
'-1 ol)n l� �7ee+"
(Please print house number and street name)
Is to be disposed of at:
�In Ufu R�r L � n c 5k to �orNla r
(PI ' e print n and to a on of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature 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
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or notice 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 polifi cal subdivisions shall
enter into any contract for the performance of public work until acceptableevidence 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 numbers)along with their certificate(s)of
marine". Limited Liability Companies(LLC)or Limited Liability Patmersbips(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
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 permh/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pernindicense 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 proof that a valid affidavit is on file for future permits or licenses. Anew 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 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
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-W SSAFE
Fax# 617-727-7749
Revised 02-23-15 w -rnass.gov/dia
UV Commonwealth Messachuselts
Division of Professional Licensure
Board of Bruluml Regulations and Standards
Cons`yiiti'tS r�15 if p�,ry s o r
CS-112166prc, 0610112021
RACHEL KRORERTSII
10 CHAPMAN-AVE
EASTHAMPTON MA 01127 i
Commissioner Office of Consumer Affairs and Business Regulation
One Ashburton Place - Suite 1301
Boston, Massachusetts 02108
Home Improvement�C entractor Registration
Type: Corporation
VALLEY HOME IMPROVEMENT INC /17 Registration: 105543
yrFL
Expiration: 07/16/2020
P.O.BOX 60627
FLORENCE,MA 01062
\ inn
Update Address and Return Card.
>CA t n 20M-OV17
onoam�orgf�s&✓G&a✓es�.ulati -
OHI[0of MEIMPRerEME IMPROVEMENT
Regulation
HOMEIMPROVEMENT CONTRACTOR Registration
piratfor iati.If found
nd only
TVP :�prppration before the expiration date. If tguntl return to:
Registration\ Expiration Office of Consumer Affairs and Business Regulation
1554= D7/16/2020 One Ashburton Place-Suite 1311
VALLEY HOME�IME EGENEN INC Boston,MA 02108 /
STEVEN A. I`J
340 RIVERSICEDFi „'_tj U
NORTHAMPTON,MA'01062 Undersecretary Not valid without signature