29-411 (3) 113 SANDY HILL RD BP-2019-0966
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:29-411 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Stairs and porches BUILDING PERMIT
Permit# BP-2019-0966
Proiect# JS-2019-001598
Est.Cost:51800.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO.
Const,Claes; Contractor: Lkeme:
Use Group; JERICHO BUILDERS 044643
Lot Size(sa.ft.): 11499.84 Owner. PINSONNEAULT BRIDGET C&GREGORY 1 PINSONNEAULT
Zoning; AanlicanI. JERICHO BUILDERS
AT: 113 SANDY HILL RD
ADalkant Address: Phone: Insurance.
6 HIDDEN PLACE (413) 569-9081
SOUTHWICKMA01077 ISSUED ON.•31&2079 0:00:00
TO PERFORM THE FOLLOWING WORK.BUILD LANDING AND STAIRS AT FRONT
ENTRANCE -ALL WOOD STRUCTURE
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: 01—.1 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:
FeeTvue: Date Paid: Amount:
Building 3/8/20190:00:00 $65.00
212 Main Street,Phone(413)587.1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File k BP-2019-0966
APPLICANT/CONTACT PERSON JERICHO BUILDERS
ADDRESSIPHONE 6 HIDDEN PLACE SOUTHWICK (413)569.9081
PROPERTY LOCATION 113 SANDY HILL RD
MAP 29 PARCEL 411 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit illed out 4649)
Fee Paid
f Construction: BUILD LANDING AND STA199 AT FRONT ENTRANCE-ALL WOOD STRUCTURE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 044643
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN TION 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
ADemolition Delay
0 3-G-2o)9
Signature of Building Official Date
Now: 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.
i
t
rlu Deparbnem use only
City of Northamp on Slaws of emi
LUr
Building Departm nt curbc rive ay Permit
r212 Main Stre MAR 6 aQAos icA stability
Room 100 WaterNV II Avg lability
Northampton, MA 0 06 prpF�ij1rtrna, gf s aural Plans
phone 413-587-1240 Fax 13 /ND�I{jdMP101 pppASFA Elaoli
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 once
//3 S")hc ,_ //, 1j � Map a' ( Lot zil I Unit
T Zane Overlay District
/e+l1.sG<
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1Ow�/�'ne�_r/af Reeord:
fY dPi/l� EA40.nAmJIY
Name M(Prim) °' Cunem Melling Address:
J ' � Telephone
Signature
2.2 Authorized Agent:
Name(Pent) Current Mailing Moses:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building �/ (a)Building Peri[Fee
2. Electrical (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number iaL78
This Section For Official Use Only
Building Permit Number. Date
Issued: 2 ��,�11
Signature: 3-6-w'?
Building 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 on k filled in by
Building Dgremnrnt
Lot Size
Frontage
Setbacks Front
Side L:. R::_.___ . L:_____ R:._
Rear
Building Height
Bldg.Square Footage % -
-
OpenSpaceFootage % ----
Itus mrn minus bide a Mrad
if of Parking Spaces
Fill:
vohmKaL shm,
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW O 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 Page and/or Document At
B. Does the site contain a brook, body of water or wetlands? NO O 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 O
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 part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
r
SECTION 6 DESCRIPTION OF PROPOSED WORK(check all applicable(
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ED
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks 1O Siding/[011 Other[[:A
Brief po
WorkDescriptienc
Alteration of emsting bedroom_yes_No Adding new bedroom yes No
Attached Narrative Renovating unfinished basement yes No
Plans Attached Roll -Sheet
Sa. H New house and or additlon t exlstin 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 naw 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_Ne
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? yes No.
I. Sepbc Tank CitySewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 13n/�Sw Q)/1 'j']M(Q /['� as Owner of the subject
herebyauthorize
to act on my behalf, in all matters relative to work authorized by this building Permit application.
17,Ae- -1/
Signature of Omer /� -�- / q Date
I. JYeA,,,,& /�'"ia.r.3C. �a/'�iu/�U /l w�iil.-c .as Owner/Authorized
Agent hereby declare that the statemenfill,and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
signs under the painsannd
dd Zpenalties of
perury.
ame
3 (
ignature of OvmedAgent Dat
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction
SuoeryirO
so ./q � �//� Not Applicable
Namoof License Holder:.DEXf AAP ZZ+'r+G O�YG y3
Ucense Number
Add s Eigiralion D e
i 21-
ignarure Telephone
9.Registered Home Improvement Contractor. / ^ Not Applicable D
&"//,"�
Comoanv Name / Registration umber
Addrose[[ / E natio Date
Telephoner I?y3 7O3�'
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....... Ci/ No...... D
City of Northampton
i '..k
Massachusetts �
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c
212A ins OF Ba ?Wu O al liui TIONS
212 Win rVsa • I, M 010 aulltlinq O�
ao+Nampton, W 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.Lf the homeowner has con&acted with a corporation or LLC,that
LC,that entity must be registered
Type of Work: W,�� F,oe...f (,.9�i>r � t/S w�7�iFW.r r Est.Cost:
Address of Work: 113 5S'9,4Av GYi
Date of Permit Application:
I hereby certify that:
Registration is not required for the following mason(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:
31/ ` wAN[ l� �osd�Tr
Dae 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
OSHAN181SNT OF BMWZNO ZNSP XONS
212 Nein St[Mt • l icipal Building
Horth
upCon, Nh 01060
Massachusetts Residential Building Code
Section I 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 11O.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 person(s) you hire to perform work for you
under this permit.
City of Northampton
.�
( Massachusetts� OF BUIWXM INSPECTIONS
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ziz xsin scc«c .iftniciwi eoiieio8
xo:cnavg,wn, ea. oioso
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:
/y3 S,oegl1 /d,G /IQ.
(Please print Nous numberandstreet name)
Is to be disposed of at:
Aws
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
14�kX moo, ,4 eU,/6,ti 1144, ','P? A-
(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.
n` The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
wwB:mass.gov/dia
VWorkers'Compensation Insurance Affidavit:Builders/ContractorsM"tricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lezibly
Name(Business/OrganieatiorolMividual):
Address: 6
City/State/Zip:.Sova_ 0/O7/ Phone 0: Y/3 ).9-37 d.7y'-P,
Are you an employer Check the appropulaw box:
Type of project(required):
I.01 anibyer with employes tall and/or pan-tune).* 7. []New construction
2. 4pmpnet««parmershipmdhavemempbyees waning finew 8. remodeling
my ca,xxao.[No workers'comp.inammrce required.]
].�1..Immmwner doing all wank myself.[No waders come bnumwe required.]' 9. ❑Demolition
s.❑l am a homeowner and will lac hiringtmcton to conduct an work en 10 C]Building addition
can ypmperry. Iwill
ore mut all contractors eithm have workers compcmetion imumnce«are rule I1.❑Electrical repairs or additions
pmpnetors with m employees.
12.E]Plumbing repairs or additions
SC3 1 o e geoaal contowinay.have
and I have hired the have
wartena cn listed on the atrnrlmdshect. 13�Rwf repairs
Iltese subcovvuctors have mNbyes and have waken'come.insurans.
b.❑We arc a capontion and in omcers Mve exercised their right of eumption per MGL c. 14.❑Other
152.3 a41,and we have no employees.[No workers camp tmwence required]
*Any applicant that checks box el must aim fill out the section below showing their worker%compemation policy infmmance.
'Hommwners who submit oris affidavit indicating they are doing all wink and then hire ouuide ci nrmemn must submit a new idl davit indicating such.
:Cmantel s that check this bas mint mobvil an additional sheet showing the dame of the subcontracmrs and state whether or not those entities have
emPluyecs. Ifthe subcan caetors have en,d.yees,they must provide their workers comp W hey number.
I am an employer that is providing workers'compen.caflon insurance for my employes. Below is the policy and jab site
information.
Insurance Company Name:
Policy#or Self-ins.Lia M 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,sk'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.
/do hereby cera�infiader lhr pQyfns an naldrs perjury that the information provided obo/v/f Is ue and correct
Sixnature:os Date' 3/
Phone#- e//Z 9f r—,"
Official use only. Do not write in this area,to be completed by city or town official
City or Town: PermitfLicense#
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,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 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,✓j25C(6)also sates 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, ss'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 sub-contractor(s)morsels),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
he 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 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 hat 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 Departments 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.mms.gov/dia
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