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32-015 (2)
130 CROSS PATH RD BP-2019-1022 GIS#, COMMONWEALTH OF MASSACHUSETTS Mao:Block: 32-015 CITY OF NORTHAMPTON Lot;.001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT permit BP-2019-1022 Proiect# JS-2019-001678 Est.Cost: $8200.00 Fee: $80.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor., License: Use Gro= JAMES ROBERTS 99404 Lot Size(sa.ft.): 133685.64 Owner., FUSCO LISA L Zoning: Applicant: JAMES ROBERTS AT: 130 CROSS PATH RD Applicant Address: Phone: Insurance: 30 Edwards Rd (413) 527-6078 WESTHAMPTONMA01027 ISSUED OM3120/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE 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 Occupancy Signature: FeeTvpe: Date Paid: Amount: Building 320/20/9 0:00:00 $80.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner RECE Daps tmXonly City of Northampt n Building Departt Cue4 212 Main Street A liability Room 100 MAR ) 9 al Avail Ikty Northampton, MA 01 60 Two Seta S rel Plart%li phone 413-587-1240 Fax4 3-58 r un rm,r a NOFTHa'n�TO APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE/OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address //� � w I This section ,, completed Q be eoPleted by office � 3 � Map Loi �1 1!5 unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHHOORIIZZEgD�AGEN�T 2.1 Owner of Rewrd: Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Adam: 30 Name(PdnQ ��AAb Cunent Mailing Adtlress. _ yy/ Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Astimated Cost(Dollars)to be Official Use Only m leted b eunit applicant 1. Building ij (a)Building Permit Fee 2. Electrical C/ (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 0 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Data Building Permit Number: Issued. Signature: Building Commissionerlinspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) s Section 4. ZONING AD Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information , rip Existing Proposed Required by Zoning This eolumn 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&pave Poking) #of Parking Spaces -.._. _.... Fill: _.... _.... (volume&Locvdom A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW © YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW © YES O IF YES: enter Book Page and/or Document# 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 © NO O IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading, excavation.or filing)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. • SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicablel New House ❑ Addition ❑ Replacement Windows Alteradon(s) ❑ Roofing Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[[ ] Other[M Brief Description of Proposed r� _ Work'. V' Alteration of existing bedroomes_No Adding new bedro Yes No Attached Narrative Renovating unfinished basement _Yes No Plans Attached Roll -Sheet Be If New house and or addition to exislina housing, complete the following a. Use of building '. One Family Two Family Other to 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. Nunrberofstories? f. Method of heating? Fireplaces or Woodsloves 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, as Owner of the subject Properly hereby authorize to act on my half, in all ve to work adthon ed by this building permit application. Signature of caner Date 1 as Owner/Authorized Agent here eclare that the statErMeTs and information on the foregoing application are true and accurate,to the best of my knowledge and belief. 66¢bbbrrrvvv Signed unde the pains and penalties of pe' �n / //✓/ Print Name /•/ Signature of0 , rlAgent Date SECTION 8•CONSTRUCTION SERVICES 8.1 Licensed Construction Sue isor: Not Applicable ❑ Name of License Holder \/ License Number Atltlr ss Expiration Date Signn urs— Telephone 9.RealliftlrnprowmntC r. _ Not Apphcabllee ❑ Regi;tr3tion Numb Y Ate/ 11-7 Address Expiration Date Telephone SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e.152,§25C(e)) (�v Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affdavd will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ City of Northampton Massachusetts i c h. z DEPAaTHCN'1' OF BU ILDING INSPECTIONS ,t 212 Main 9txaat • M.icipal auiltlinq `> a �e " Northampton, !m 01060 bN ':y jOa 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 preexisting owneroccupied 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 contracted with a corporation or LLC, that entity must 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 S 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 G J d z 1 H212 H xENT OF HeI nD .G INSPECTIONS li rt 212 Main Street a MuM 010 Builtling Northampton, 1M 01060 Massachusetts Residential Building Code Section 11085.1.2 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 L52 (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 forperson(s) you hire to perform work for you under this permit. ' City of Northampton S1S '.,Jin, ' Massachusetts � F A, t DEPARTMENT BUILDING INSPECTIONS Ma 212 in Stee Muni acipal Builtling \' xaxthanvhamptan, !P 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40, 554, 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: (Plea a print hous6 number and street name) Is to be disppoossed%d of at: Pleaserintlocation of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name andAddress)// Signature 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 1 Congress Street,Suite 100 Boston,MA 02114-20777 www.mass.goP/dia R sellers'Compensation Insurance Affidavit:Builders/ContractorsMectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Ple a Print Legibly Name(Business/Organizatiomindividual): Address:' City/State/Zip: Q Phone#: Are you mi employer?Check the appropriate box: Type of project(required): I��emp1,ye+ +'i� employea(Pou and or part-time)' 7. ❑New construction masme 1,you mm lmve no empmree working formcm 8. E]Remodeling capacity.[Now.,ors cmaFinsumer, required] s 3 l am a homeowner doing all work myself[No workers compinsurance requirsiJ 9. Demolition a.❑I am aHomo lo m aha ot be biting ntractoronauan work un mr propem. I will 10❑Building addition allcono-cors either nave wwud,ers cocam wmm ae or mesas 11.[]Electrical repairs or additions ensure 0"' with w employees. 12.E]Plum - repairs or additions Z?.o I ur a general mntracmr and I have hired thesubconaeomrs listed on the atbehed sheet 13 oof These sub-contractors have employees and nave workers'comp.irnumnce 6.❑Vve are a curpomtion and its omcem have exeresed their right ofexemption per MGL e. 14. [her 152,$1(4),and we have no employees.[No workers'comp,haumnce requfryd] *Any applicant that checks box#1 must also fill out de Median blow showing dee workersaompenealmor pubcy information. t Homeorwism,who submit this affidavit indicating they are doing all work and darn hire outside contractors most submit a new affidavit indicating such. :Cunnactors that check this box muU utached an additional sheer showing the name ofthe sub-contractors and sate whether or not those entities have employees Ifthe subconbacters have employees,they must provide their workers comm.policy number I am an employer that is providing workers'co)npensado5jobsurance for my employees. Bela.is the policy and job site infhrmaaan. Insurance Company Name: 9 Policy#or Self-ins.Lic. #: Expiration Date: 3 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 punishabl e 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. I do hereby certify oder theme p�oin�s art�dp/end' perjury that the information provided above is true and correct Si Date: Phone#: Oficial use only. Do not write in this area,to be completed by city or town official. City or Town: PermittLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cky/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 4 I 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,§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,§25 C(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)comets),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 maybe 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 homeowner 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 I Congress Street, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-NIASSA-FE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia