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17C-005 (5) 30 LAKE ST-UNITI BP-2019-0983 CIS 4: COMMONWEALTH OF MASSACHUSETTS Mao:Block: 17C-005 CITY OF NORTHAMPTON Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category: Bath reno BUILDING PERMIT Permit# BP-2019-0983 Project# JS-2019-001618 Est. Cost: $8000.00 Fee:$65.0o PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group, HANS DALHANS 101628 Lot Size(sp ft), Owner: HILTON TIM Zoning: URB000)/ Apolicant HANS DALHANS AT: 30 LAKE ST- UNIT 1 AoolicantAddress: Phone: Insurance: 11 CHERRY ST (413) 977-6094 EASTHAMPTONMA01027 ISSUED OM3/1112019 0:00:00 TO PERFORM THE FOLLOWING WORK.REMOVING TUB AND INSTALLING NEW SHOWER 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 3/11/20190:00:00 $65.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File k BP-2019-0983 APPLICANT/CONTACT PERSON HANS DALHANS ADDRESS/PHONE i l CHERRY ST EASTHAMPTON (413)977-6094 PROPERTY LOCATION 30 LAKE ST- UNIT 1 MAP 17C PARCEL 005 000 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin Perini[Filled out Fee Paid TypeofConstruction: REMOVINGTUB ALLIN NEW SHOWER New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 101628 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 _ Fell Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Sheet Commission Permit DPW Storm Water Management _Demolition Delay 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. City of Northampton Building Department 212 Main Street Room 100 N� Northampton, MIA 01060 phone 413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,AL ER, EMO ISH A ONE OR TWO FAMILY DWELLING SECTION I -SITE INFORMATION 1.1 Property Address: T ile section to be tuatinplitited by office, f(t7 DFRT OF FUH PING I It M 48 Lot --Unit - 30 La- N�RTH4:—ION.MA01060 -------------ZUrW—_Overlat Y District gim at Detect- CB District- SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.7Owner r: 50 1 '�4 *1 '910&2- Name(Print) Current Mailing Address tyr�- �w' 75V Telephone Signature 2.2 AuthorizedA. nt: I r P"i sl - fe''A,Y-v4� IN;;rae�(Pri � CurnentMailirigAdel as. _g& Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 6o 0� (a)Building Permit Fee , 2. ElectricalEstimated Total Cost of jv/A (b) Construction from(6) 3. Plumbing ), uuo Building Permit Fee 4. Mechanical(HVAC) vilrA 5. Fire Protection I 1 1 9 6. Total m(1 +2+3+4+5) OU0 I Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: 5-11 Buil Commissionedinspector of Buildings Data 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 column to h filled in by Building Depadment fAt Sim __... _.____....__.. Frontage ' L_. t ...------- Setbacks .__ :Setbacks Front t-......_ —. Rear Building Height Bldg.Square Footage - - % Open Space Footage % _._. (Int area minus bldg&paved parking) ---- - #of Parking Spaces '- Fill: A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO © DONT KNOW Q YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DONT KNOW © YES IF YES: enter Book Page, and/or Document# B. Does the site contain a brook, body of water or wetlands? NO © DONT KNOW O YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained © , Date Issued: F C. Do any signs exist on the property? YES © NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO Q IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over I acre or is it part of a common plan that will disturb over 7 acre? YES O NO 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 Alteration(e) ® Roofing Or Doom Accessory Bldg. ❑ Demolition New Signs [0] 1 Decks [� Siding[O] Other[OJ Workription of Prgpos Q �.__� O 6C J "I \J P 5 kw Work. I 1 i ��,Zj' �- Alteration of emsting betlroom Ves No Adding new bedroom Yes No Attached Narrative \\ Renovating unfinished basement Yes No Plans Attached Roll -Sheet N V Re..H Nm h6ul"iRgi,,jaraddhiiiIi'ttOUsina noinDlefe f Mil Ina: a. Use of building :One Fani 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 SECTION Te-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 1 l✓��N(LSO t� as Owner of the subject property J hereby authorize LV5 to a all thorai by this building permit application. i Signature of f1 Date I. C"5 F Lw as Owner/Authorized Agent hereby declare that the statements And ipformation on the fbregoing a ptitation are true and accurate,to the best of my knowledge and belief. g under the and penaltief;of paryu Print Name i,,vrG„ 2c of Owner/ nt Dale SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su rvieor: Not Applicable ❑ v Name of License Holder R I Gv5 C S— I l7 1 6 a r License Number AtlC -T TT Exl Date Sgnature Telephone vc m Im m '• r ctar:' Not Applicable ❑ Company Name Registration Number A dress / Expiratibn Date Telephone 6 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(8)) 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....... A No...... ❑ City of Northampton Md99dCIlll9Bt:1:8 DEPARTDfENT OF EOILOING MSPECTIONS �1 212 Main Street • lNnicipal Building •>• is Northampton, 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 Pour 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 mast 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.C.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 m 4 Z DEPARTMENT OF BMIDING INSPECTIONS 212 Main Street • Municipal Suiltli,a ���, p0•� Northa ton, MA 01060 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 rf Massachusetts ( r c s t DEPARTMENT OF BDILDING INSPECTIONS Z ;� 212 Main te Mun • icipal 0viltling Vi . \` 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: S - r16(ty.,tc (Please print house number and street name) Is to be disposed of at: V fa kc ( (Plate pant n ne and I cation of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Com-p/anyy Name and Address) Si re of Permit Applicant 6rQwner 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 IndustrialAccldents 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 Please Print Le ibl Native(Business/OrgmimtioMnldividual): Address:_ STfut5k `, i City/State/Zip: Phone#: � clllr Are you an employer?Check the appropriate box: Type of project(required): LL]l am a employer with employees mll and/orpart-time).* 7. New construction 2.M 1 am a sole proprietor or partnership and have no employees working for me in g, r Remodeling any capacity.[No workers'comp.insurance required.] }uY 3M I an a homeowner doing all work myself Mo workers comp.insurance required.]t 9. Demolition 4.F1 I am a homeowner and will be hiring contractorsto conduct all work on my property. Iwill 10 Building addition ensure that all contractors either have workers'compensation announce or are sole II.❑Electrical repairs or additions proprietors with no employees. 12. 'jPlnmbing repairs or additions 5r I arae general cocturs h and 1 have hired the sub-contractors listed co the attached sheet. 13.E]Roof repairs These sub-mntmcrors have emplayces and have workers'wrap.insurance.[ 6 OWe we a corporation and its omcers have exercised their night of exemption per MGL c. 14.E]Other 152,§I(4),and we have no employees.[No workers'comp.insummv required.] *Any applicantrhat checks re box a most also fill othe section below showing their workers'compensation policy information. t Homeowners who submit this atfidmit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. �Coatomvus that check this box most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. Ifthe sub-contractors have employees,they must provide their workers'comppolicy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name: Policy#or Self-ins.Lie.#: 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, 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 cop ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do her cer ' n t p sand ens/ties ofperjury that the information provided above is nue and correct Sianam e: �y Date: -S Phone#: G 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: 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 another under any contract of hire, express or implied,amt 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 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 simation and,if necessary,supply sub-contractors)turrets),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 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 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 proof that a valid affidavit is on file for mime 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-MASSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia