24D-062 (3) 12 PERKINS AVE BP-2019-1048
GISM COMMONWEALTH OF MASSACHUSETTS
Mgp:Block:24D-062 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:KITCHEN RENO BUILDING PERMIT
Permit 4 BP-2019-1048
project JS-2019-001709
Est.Cost:$10000.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO.
Const,Class: Contractor. License:
Use croup: Homeowner as Contractor_
Lot Size(sp.B.): 4617.36 Owner: AGAN LORI MARIE&ADIN MAYNARD
Zoning:URB(100)/ Applicant: AGAN LORI MARIE &ADIN MAYNARD
AT. 12 PERKINS AVE
ApplicantAddress: Phone. Insurance:
12 PERKINS AVE
NORTHAMPTONMA01060 ISSUED ON:312612019 0.00:00
TO PERFORM THE FOLLOWING WORK:KITCHEN RENO
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: Houselt Foundation:
Driveway Find:
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 Occuoancv Signature:
FeeTvpe: Date Paid: Amount:
Building 326/20190:00:00 565.00
212 Main Street,Phone(413)587-1240,Fmc:(413)587-1272
Louis Hasbrouck—Building Commissioner
• KIwo. Ono
g'• +_tJ Department use only
City of Northampton Ytatq of Pe Mir
Building DepartmentSAA Z 5 20 curb¢uuD veway Permit
212 Main Street we Septi Amiability-
Room
miabiliyRoom 100 Wate ell vailability
' Northampton, M* or Structural Plans
Nf.IN=. .
_ phone 413-587-1240 F#41 g +I a� oN.mn Site P s
Other Specify
APPLICATION TO CONSTRUCT,ALTER REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION jig
1.1 Property Address: This section to be completed by am"
Map y Lot ' Unit
Zona Owday Dlatrl
,aYa
Eke sr.pindriat ee ol.ma
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 n of a ord:
a6 0 /L At,
Name(/Iry, i i Cunent tailing Addrges
Telephone
Signature
2.2 Authorized Anent:
Name(Pent) Cunent Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed bnnitapplicant
1. Building L.- /b' sw (a)Building Peri[Fee
2. Elect ical q S D y (b)Estimated Total Cost of
N Construction from 6
3. Plumbing �p I r,ti-� Building Penult Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) 0 Check Number
This Section For Official Use Only
Building Permit Number. Date
Issued:
Signature: 3-Zlr•20TH
Building Commissioner/lnspector of Buildings Date
coh , M M h are( @ 'Al all (ar)
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 be filled in by
Building De mnrnt
Lot.Size
Frontage
Setbacks Front
Side L:_— R:— —. L:._.._. R:__.._
Rear .. _..
Building Height - -- -
Bldg.Square Footage % -
Open Space Footage %
il.a area minor bids
mtie
#of Parking Spaces — —
Fill:
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW O 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 O NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb(Gearing,grading,excavation,or filling)twer t acre oris 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 b DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteratlon(s) ❑ Roofing ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ ,^I,,New Signs 101 Decks [q Siding[01 Other(Ol
Bnef Wont Description of Prof IhSf�°'K �1I 1ST !L ,( , �(i -,NO A034
VJ W04
rrd/r or
Alteration of existing bedroom_Yes_No Adding new bedroom Yes No OGS+
Attached Narrative Renovating unfinished basement _Yes _No !/ c
Plans Attached Roll -Sheet
an.if New house and or addition to existing housing, complete the following:
a. Use of building : One Family Two Family Other
b. Number of roams 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 fl.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
SECTIONTa-OWNER AUTHORIZATION-TO BE COMPLETED 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 Owner Date
f 1� AW4 kI a Y" ,as Owner/Authorized
Agent hereby declare that the statementif and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed untler a Daina an aities of perjury.
k
Print Name
Signature of Ovnar/AgaM Dare
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Molder
License Number
Address Expiration Date
Signature Telephone
8.Reaistered Nome Improvement Contractor. Not Applicable ❑
Comoanv Name Registration Number
Address Expiration Date
Telephone
SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.162,S 28C(6))
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....... ❑ No...... ❑
City of Northampton
C16Massachusetts S-
DEPAR1fffirr of BUTWIMa Z ZCTioMB -
212 win Street a Nunioip.l auilai,p 0C1
Nortfi ton, M 01060 nit
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. Prim 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,modemizadon,conversion,
improvement,removal, demolition, or construction of an addition to any pre-existing owneraccupied 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:/f the homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: Est.Cost:
Address of Work
Dare 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(exptain):
_Building not ownerbccupied
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 a owner of the above property:
3l Asti &hAW - -
ate Owner Nato and Signature
City of Northampton
- Massachusetts �� '�
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xgctha .., 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
Massachusetts
c z
LTPaR])RMl 08 BDILDZPG IPBPSCTZOPa
212 actin etree! •Punicipal 6uil,Ung
PerNaepton, !A 01060 n�^6
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 Ur and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
2� tN4 - '�rv-j-aa S
Company Name and Address)
Signature of Permit Applicant or Owner Dat
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 ofMassaehuseus
Department of IndustrialAccidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
t,nemmass.gouldia
WIVorken'Compensation Insurance Affidavit:Builders/Coutractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lestibly
Narne(Business/Organ¢atioNlndividuap:
Address:
City/State/Zip: Phone M
Asarco an employer?Cbeao me appropriate box: Type of project(required):
LUtameemployerwilb anployem(Ml mNarlun-timet.' 7. ❑New construction
2.rllam a sole pr Metworpumcrshipaodlmvewemployees working farmers
y.,parley.Mw
IN. takers'comp insurance re,moul.l 8. Remodeling
i tam a homeowner doing all work itself(No wmkers'wmpisssumsee required] 9. ❑Demolition
4.0 I am a hmnmwner and will be blurt,mntmetors to condwt all work on my properry. I will 10❑Building addition
ami that ell canuamms eithmbev<wodem'compemnwn announce or me sole 11.❑Electrical repairs or additions
ptuptemrs wall no employees.
12.❑Plumbing repairs or additions
Sr]I no a g®.shortt ra ba eM l have o,an as, wmrnua'emup rmmt the attached shares. 13. Roofs airs
nese anbmntrecmm base employees and have wotkem'comp.ths�ttmcn. ❑ R
b.❑We emawryomton cod iu off Mve exercised thehnght ofexcmpeon pm MCsLe. 14.00ther
152,§l(4),acrd we haver employees.[No workers'comp insommerequard.]
'AnY apptiunt slut checks bon#1 most also fill out the semiao below showing their workers'compensation policy information.
i Homeowners who submit this afi suss indicating they are doing all work and tMn hire outride contractors most submit o new affidavit indicating such.
:Conbacmrs Net check this box most attached an adelmorml short showing the came of the suhmnwctors and sure whether or nor those entries have
employees. If the sub-coneodors base employees,they now,provide Neu w olrem*comp.policy numb.
J am an employer that is providing workers'eompenseaann insurance for my employees Below is the polity andjob she
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Dare:
Job Sire Address: City/Srate/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure m 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,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.
J do hereby cerdfy un %th/�e J�'f andpe doe f that the information provided above is nue and correct
Sitmatum `_�'//?'� Date 3�/-2-0
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 ane):
1.Board of Health 2.Building Department 7.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 w"...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,§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)name(s),address(es)and phone numbers)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 aiBdavin The affidavit should
be renamed 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 a[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 permitlicense 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 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 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
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-7274900 ext.7406 or 1-877-MASSAFE
Fax At 617-727-7749
Revised 02-23-15 Wxvw.mass.gov/dia