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16D-022 (13) 141 NORTH MAIN ST BP-2019-0866 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 16D-022 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation BUILDING PERMIT permit a BP-2019-0866 Project# JS-2019-001447 Est.Cost:$105000.00 Fee:$715.50 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: GERALD ARCHAMBAULT 010788 Lot Size(sa.ft.): 24611.40 OWner. KIRKPATRICK REALTY LLC Zoning; URB(292y Applicant: GERALD ARCHAMBAULT AT. 141 NORTH MAIN ST Applicant Address: Phone: Insurance. 68 AMHERST ST (413)552-7410 O Workers Compensation GRANBYMA01033 ISSUED ON:212112019 0:00:00 TO PERFORM THE FOLLOWING WORK:RENO KITCHEN, BATHROOM, FINISH BASEMENT WITH BATHROOM, NEW SIDING, ROOF 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 OccuoancY Signature: FeeTYoe: Date Paid: Amount: Building 2711/20190:00:00 5715.50 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2019-0866 APPLICANT/CONTACT PERSON GERALD ARCHAMBAULT ADDRESSTHONE 68 AMHERST ST GRANBY (413)552-74100 PROPERTY LOCATION 141 NORTH MAIN ST MAP 16D PARCEL 022 001 ZONE URB(292V THIS SECTION FOR OFFICIAL USE ONLY: PERIVITT APPLICATION CRECKtW CLOSED QUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid 1b It TvneofConstruction: RENO KITCHEN BATHROO BASEMENT TuROOM.NEW SIDING,ROOF New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included' Owner/Statement or Licensee 010788 3 sets of Plans/Plot Plan THE WLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN MATION 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 Demolition Delay Signature of Building Official Dam 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 mote information. Department use only -- City of Northampton Status of Penna: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availabilay Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 PlotlSae Plans APPLICATION TO CONSTRUCT,ALTER,REPAIR REN OVA OR ISH A ONE OR F ILY DWELLING FEB _ 6 2019 rr'' SECTION 1 -SITE INFORMATION 1 ( n d2 2— 1.1 Prot»riv Address: This secti Is byrd/ice ,1 yy� OF /11DEPT. aUILOMAIN5PFO90lI Unit Il mGCIN 5-`" MOIL{ lL� Ma PTNA+ImDr . Zone Overlay District Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Tom kirkprk rl'e- Name(Print) - / Cunenl Maung Address: Signature 2.2 Authorized A eM: 6e �� „ �a„/t 6B rw /ylaoio MCurrent yelling A4Ness: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit ap licant 1. Building 0 C360 r o0 (a)Building Permit Fee 2. Electrical 000 r O p (b)Estimated Total Costo' Construction from 6 3. Plumbing /n 0O0 C) () Building Permit Fee 4. Mechanical(HVAC) 1yL)06 "10 5.Fire Protection 6. Total=(1 +2+3+4+5) 000 00 Check Number This Section For Official Use Only Date Building Permit Number. Issued Signature: Building Commissioner/Inspector of Buildings Data EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING AIL Information Must Be Completed.Permit Can Be Denied one To Incomplete Information Existing Proposed Required by Zoning nis column m be fined in by Building Depanmem Lot Size Frontage Setbacks Front Side L R- L: R: Rear Building Height Bldg,Square Footage Open Space Footage °o Itnt ara minus bog&paved akin I N of Puking Spaces Fill: volume&Lourbn) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO ® 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 Pageand/or Document# B. Does the site contain a brook, body of water or wetlands? NO ® 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 ® NO O IF YES, describe size, type and location: F0yr_dyl}t Ve Stpr-4, 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,excavation,or filling)over t acre or is it pan of a common plan that will disturb over t acre? YES O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5.DESCRIPTION OF PROPOSED WORK(check all applicablel New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [0) Decks [O Siding[0] Other[QI Brief Demotion of Proppoosed (� �j Work: Mcy.at< IC\KMe'n ,Baxi�n;" IAi.Senend W�TI1 & rwiviy Nfw SIIXt.R9 �Oa�lbe� Alteration of existing bedroom_Yes X No Adding new bedroom Yes A No Attached Nanative Renovating unfinished basement _X Yes No Plans Attached Roll -Sheet se.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 stones? f. Method of healing? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 R.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?a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR II CONTRACTOR APPLIES FOR BUILDING PERMIT I, Tam i Nk�Jetii?;G ,as Owner of the subject property / 1 (� hereby authorize IcrPt-nlr� ir.�dmbg/t to act on my behalf,in all maxers relative to work authorized by this building permit application. Signature of�p g Date I, h tss�.dL /-YFtll a,n6It .as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true end accurate,to the best of my knowledge and belief. Sign/e�d under the pai�ns�an(d penabiles of pde�rjury. U' tun l TT a.�.F]r.,,ll pSigri�me nature W OwnerlAg end Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: 11 Not Applicable ❑ Name of License Holder: 6CA%" Assn. dA� CS-0 10 7 9 8 License Number T 5� l7Fa.n�ou Iflti Mlr) 33 11�-,9 Address Expiration Date 11 y/ 3 ,5_5_:> -71Veo Sign ture Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Geuga) �jo `idu�t 15, 991 Comlunv Nam, Registration Number Fib «v,sy S'f GI-[Lvt 6y �lcl. 610 3.3 11-9-1-11 Address Expiration Date Telephone`ll3 SSS 7 N/0 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,$2SC(S)) 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....... 21' No...... ❑ City of Northampton Massachusetts sett f. 11 L DFPARr4NZWe OF BUILDING ZNBPSCSLONa \\ _ 212 Main Str t a Municipal auilaina pC� NorTd toa, 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, aheration,renovation, repair,modemizetron, conversion, improvement, removal,demolition, or construction of an addition to any preexisting owneroccupied building containing at least one bul not more than four dwelling units....or to structures which are adjacent to such residence or budding"be done by registered contractors. Note:If the homeowner d wner has contracted with a corporation or LLC,that entity must be registere IL Type of Work: ?inok i C'. Est.Cost: 10 S b f)0 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 permit as the agent of the owner: Date Contractor 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 c DEPARTMENT OF BOZt.DING INSPECTIONS 212 fain S9v t a Municipal Building Nonthau n, M 01060 Massachusetts Residential Building Code Section I I ORS.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 IOR5.13.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR I l ORR5, 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 - DMPAa1}BMS OF aVXU)I ZNSP=rTWS 212 Main Stzc*t *Municipal Guild nq '\ Moutba t., 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: 141 J" �c�.�M �& Ttdrenc -e- (Please print house number and street name) Is to be disposed of at: U l'-4 VC2.5yG�InS (Please print name and loca on of facility) Or will be disposed of in a dumpster onsite rented or leased from: 1 (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. The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Sheet,Suite 100 Boston, MA 01714-1017 www,mass.gov/dia UIN orkers'Compensation Insurance Affidavit:Builden/Contractors/Electricians/Plumbers. TO BE FILED PITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organim' tion/IIndivid.1): t Address: (nS /i-,Ne MT 5 - City/State/Zip: 6" 33 phone#: yl 3 .T_5-9 7`1 /O Are you an employer?Check Me appropdam box: Type of project(required): La§l an a smloyer wish employem(full aaNm wn+irml.' 7. ❑New construction 2❑1 em a sole proprietor or peanenhip and have no employees working forme he g, m Remodeling may capacity.[No wedanx mmp.insurance required] 3.0 1 am a hommwner doing all work,myself [No wohet%w rap.insumocc mquredI9. Demolition a.❑lama hemmmus,andwin mcontractors conduetall work one, . twin 10❑Building addition g my mile um at all either have wodceaz'ememotions..tinsurance in are sole 11.®Electrical regain or additions Proprietors with no cmploycm. 12.®Plumbing repass or additions 5.❑1..general eonand«avd 1 nave hired th<wbconrn,cow, on rhe anached sheet. 13,®Roof repairs Thesee subconbacars have employees mad and woheri have .insurmce 6.❑Weareacorsimation and itsoffem have exercised their nmd of exempaion per MGL,. 14,❑Otber 152.§I14k and we have no em loycea.[No workers'com,.inwamc required.] •Any applicem that checks box 41 must also fill out the seetion below showing their wmkers'compensation policy information. Homeowners who submit this affidavit indicating they me doing all work and men hire outside contractors mesa submit a new affidavia indicating such. lConmumrs mat cheek this box must moseded an additional slice,stowing the name ofthe sub-em macmra and was wbethm m nm those entities have enrylovees. If the sub<xdrxeh s have employeea they must provide their womerscomp.policy mi mbe'. I am an employer that is providing workers'cumpensution insurance for my emploJres Below is the policy and job site information. Insurance Company Name: Aa /•f��1 Policy#or Self-ins.Lit.N: ' W C[ T', 100-(Ods I,'O9 —�/txpintion Date: 9"-/40-_' M Job Site Address: I4 j o.tu ,7 a City/Smte/Lip: Flavea.,c a /s0. 6 3 3 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to sectue 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 5250.00 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 hereby certify under thepains and penalties ofperjury that the information provided above is true and correct. m Sianare: 447 dJk� Date' Phone#: y/-3 - �5-0. -7v/O 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Persian: Phone#: 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 mother 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 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 mother 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"even'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 subs tractor(s)morels),address(es)and phone number(s)along with their cestificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required m 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 my 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(heir 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 permits icense applications in my 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 to 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 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. #617-7274900 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 of the foregoing engaged in a joint 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""am 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 yaw 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,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 permit/license number which will be used as a reference number.In addition,an applicant that must submit multiple pea-mut/license applications in any 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 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 Boston,MA 02114-2017 Tel.#617-727-4900 ext. 7406 or 1.877-MASSAFE Fax#617-727-7749 www.mass.gov/dia From Rm,ei 02-21-15 I� aiOS h59 D J Ma � ravaa,}� w..y a6wy5 }aso» - woa�a8 ai�s F'L9 I an wawa ew n,1 ' aeA w.aw�a woai�'a$ -ov,m9 �J t ' '"4y� re C doJ I - Ma yxaw.a5� .g yrM�a4m1� I o � / ar.1a� Id ♦i4s 8 s. � 0 due LC I \ £ f ,9 ,a