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42-095 (5)
220 GLENDALE RD BP-2019-1038 GIs#: COMMONWEALTH OF MASSACHUSETTS Ma Block:42-095 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit- Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cateeor : ROOF BUILDING PERMIT Permit# BP-2019-1038 Proiect# JS-2019-001695 Est.Cost, $4900.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CHARLES LAVECK 08399 Lot Size(sp. ft} 52272.00 Owner: BRESNAHAN SUSAN&DEWS RABTOR zonine: Applicant. CHARLES LAVECK AT: 220 GLENDALE RD Applicant Address: Phone: Insurance: 25 DAVIS ST (413) 527-1142 O WC EASTHAMPTONMA01027 ISSUED ON:3/21/2019 0:00:00 TO PERFORM THE FOLLOWING WORK:REPAIR ROOF FRONT SECTION 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 Shmature: FeeTvpe: Date Paid: Amount: Building 3/2V2019 0:00:00 540.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner r IN City of Northampton 0:1, Building Department C1dlgWnvayI ° `4"' 212 Main Street Semer/Sapi Room 100Ave 4A i& A4 "IN Northampton, MA 01060 "of Plans T� phone 413-587-1240 Fax 413-587-1272 A Dow APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Pnooertv Address: This section to be Completed-by offI08 '�!zo Map Lot 095 Unit Zone Owrlay Distinct Elm St District CB Distrid SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT RECEIVED 2.1 Owner of Record: MAR 2 0 2019 Current Mailing Address: I Tele DE"OF BUILOPuri INSPECT Signature NORTHAMP'TON,MA 01060 2.2 Authorized Agent, K�Zh—*�,e ZZ�ILA-' Current Mailing Address 709 (115- -,4Y4-971r (ageefure Telephone SECTION 3-ESTIMATED CONSTRUCTION COM I Item Estimated Cost(Dollars)to be Official Use Only completed by Permit applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 1 Plumbing Building Permit Fee /-/0 0 4, Mechanical(HVAC) 5. Fire Protection 6. Total=(1- 2-3+ 4+ 5) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Coninnossioner/laspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) R Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Del>amneat Lot Size Frontage — ._. ....._. _ Setbacks Front - - Side L. R: _. L:_. R _.... Rear Building Height Bldg.Square Footage % -- Open Space Footage (Lot area minus bldg&paved _..... pimeamr, .... .. I - #of Puking Spaces Fill: _ ...._. . _... _.. ..... rand &Loestan A. Has a Special Permit/Variance/ ever been issued for n the site? NO O DONT KNOW O YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of D eds? NO O DONT KNOW O YES O IF YES: enter Book Page'' and/or Document q B. Does the site contain a brook, body of water r wetlands? NO O DONT KNOW 0 YES O IF YES, has a permit been or need to b obtained from the Conservation Commission? Needs to be obtained © btained O , Date Issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and cation: D. Are there any proposed Chang to or additions of signs intended for the property? YES O NO O IF YES, describe size, type d location: E. Will the construction activity dist No(clearing, grading,excavation,or filling)over 1 acre or Is it pan of a common plan that will disturb over 1 acre? ES O NO O IF YES,then a Northampton toren Water Management Permit from the DPW is required. SECTION S-DESCRIPTION OF PROPOSED WORK/check all aoolleable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks jq Sidini Other(Oj Brief Description of Proposed //�Jr r ' Work: Yl�"iil2 /Cx�n.+�' �/loq 'E ✓!e),xc /T7n ) Alteration of existing bedroom_Yes_No Adding new bedroomYes No Attached Narrative Renovating unfinished basement a No Plans Attached Roll -Sheet w.M New house and or addition to existing housing,complete the followino: a. Use of building One Family X- Two Family Other It. 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? In, 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= OMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Omer/ _ /y Data 1, as Owner/Authorized Agent hereby declare thdt 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. Cf/v Print Nam 3 z� Si atur rmgenl Date R SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su/pervisor. /- NotApplicable ❑ Neme of Licanae Molder: �//�/e�� r (��D.�� CItS X�� %Siari License Number Atltlreest � Expiration Date 1/{e % Z Telephone S..Realstared Home lmprownMnt Contractor. Not Applicable ❑ Company Name Rzlon 9m be /o P Address Expiration Date Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152,§M(6)( Workers Compensation Insurance affidavit must be completed and submitled with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ City of Northampton _i Massachusetts �' r ` y c x s ➢212 i. S OF BUILDING .1 buE dIO S \� 21'1 Mein zt[ • lNn 010 Builal�q VL \ CD Noitfiampton, !A 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 owneroccupied building containing at least one but not more than/our dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner hos contracted with N corporation or LLC,that entity mustberegistered K Type of Work: o of 9�iA/C Est. Cost: /1('OU Address of Work: ZCJ 67 L-rndot Z /CJ! ��o✓!U/L� Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): _lob 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: 3-z0 / 9 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 212A ins OF BUILDING INSPECTIONS x 211 Mein rtha • Municipel 9viltivng C NaeCLGOP[an, !A 01060 Massachusetts Residential Building Code Section I IO.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 I IO.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 11 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. f City of Northampton Massachusetts f 1 DEPAR2MENT OF BOZWZNG ZNSFBCTZONS /1 212 Nin Street Municipal Building Northau,ton, 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 properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from construction work being performed at: (Please print house number and street name) Is to be disposed of at: (Please print nam nd l ti.h i offac Iy� Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) �21 Si6d9krFe-&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. 41 The Commonwealth ofMassaehusetts Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02174-20177 www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information q / Please Print Legibly Name (Business/Organization/Individual): Z'Y"fIGQ��- Address: City/State/Zip: Phone#: Are you as employer?Check the appropriate sax: Type of project(required): I.n l am a employer wits emplayees(frn and/or pearthec)' 7. ❑New construction 2. 1 am a sole proprietor or pasmership and have no employees working fm me in any capmay.[No workers'comp.ins required.] g. E]Remodeling 3Olamahomcnwnerdoingallworkmysn [Noworken'comp.insciancerequicif' 9. El Demolition gwu 4.❑Iamzhumwwnermdwill ah o-a.1oconductallworkonm 10 E]Building addition y property. 1 will cam me oat all cnnmacmm dthv have workers'compenaatiov insmmne or are sole 11.❑Electncal repairs or additions pmimeass with no empbyees12.❑Plumbing repairs or additions 5j`7 I am a general consscmrand l have hired the sub-commatrs timed on theaaached sheet 13.�ROOf repairs These sub-contractors have employees and have workers comp.iommence. 6F We are a corpamtion and its officers have exeaised their eight ofexcerpran per MGL c 14.00ther 152,9 halt and we have no employees.[No workers'camp iwmance required.] 'Any applicant that checks box#I must also fill out the scamn below,showing their workers'compensation pnlicy information. 'Homeowners who submit this affidavit indicating they am doing all work and Nen hue outride cnnnvmom moa submit a new affidavit indicating such. :Cpnhamors that check Nis box must atbcbed an additional sheet showing the name ofthe sub-contractors and some whether or not those entities have employees. [fare su emaracrors have employees,they must provide their workers'comp policy munbw. /am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information /e Insurance Company Name: /v�p Policy#or Self-ins.Lia#: Expiration Date: �ZU 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 a 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$250.00 a day against the violator.A cc of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verifieai I /do Hereby fy tN pairs perjury thot the information provided abo tt fru and correct 77� Sign . Date: 2 tie: Phone#: 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/fown 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 tmshc often 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 bean 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 political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements ofthis 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)morels),address(es)and phone number(s)along with their certificatc(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/licence number which will be used as a reference number. In addition,an applicant that must submit multiple permivucense 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. A new affidavit must he 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-NIASSAFE Fax #617-727-7749 Revised 02-23-15 www.mass.gov/dia -2- Maza6 20,2019 I/WE AGREE TO THE ABOVE PAYMENT TERMS,AND ALL PAYMENTS WILL BE MADE AS OUTLINED ABOVE.ALL EXTRAS WILL BE IN WRITING PRIOR TO STARTING.THIS IS A BINDING CONTRACT,ANY PAYMENTS NOT MADE AS OUTLINED ABOVE WORK WILL COME TO A STOP UNTIL PAYMENTS ARE MADE,ANY PAYMENTS NOT MADE MAY BE CHARGED ANY COLLECTION COST,AND REASONABLE ATTORNEYS FEES.THIS CONTRACT DOES NOT IMPLY ANY LIENS OR SECURITY INTEREST ON RESIDENCE.ALL MATERIAL, PERMITS,INSPECTION FEES,AND LABOR,AND SUBCONTRACTOR IS PROVIDED,AND INCLUDED TO JOB PROPOSAL SPECS. HOMEOWNERS WHO SECURE THEIR OWN CONSTRUCTION-RELATED PERMITS OR DEAL WITH UNREGISTERED CONTRACTORS SHALL BE EXCLUDED FROM ACCESS TO THE GUARANTEE FUND.WORK MAY BEGIN AT ANY TIME.HOMEOWNER HAS THE RIGHT WITHIN 3 DAYS OF CONTRACT SIGNED TO CANCEL JOB,WITH DEPOSIT RETURNED,LESS ANY SPECIAL ORDERED MATERIALS,OR PERMIT FEES PAID.HOMEOWNER HAS THE RIGHT TO REQUEST REFERENCES,OR INSURANCE CERTIFICATE OF LIABD.ITY.HOME OWNER HAS THE RIGHT TO VALIDATE CONTRACTOR REGISTRATION BY CALLING DIRECTOR OF HOME IMPROVEMENT REGISTRATION @1-800-223-0933,OR CONSUMER INFORMATION HOTLINE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATION,10 PARR:PLAZA,ROOM 5170,BOSTON.MA 02116 ALL WORK WILL BE PERFORMED TO THE HIGHEST QUALITY WORKMANSHIP,ACCORDING TO JOB PROPOSAL.ALL MATERIALS AND LABOR WILL BE SUPPLIED BY CONTRACTOR AS OUTLINED IN PROPOSAL. ANY EXTRAS WILL BE IN WRITING PRIOR TO STARTING.ALL WORKMANSHIP GUARANTEED FOR ONE FULL YEAR AND WARRANTIED 201 CMR 18.00 AND M.G.L. C. 142A. CERT.OF INSURANCE PROVIDED UPON REQUEST. ,DO NOT-SIGN THIS CONTRACTIF THERE ARE ANY BLANK SPACES. I � DATE DATE ��6 jj//'' T CK HOME IMPROVEMENT/BUIILDZREMODELING