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23A-108 (2) 133 SOUTH MAIN ST BP-2019-1059 GIS 4: COMMONWEALTH OF MASSACHUSETTS MamBlock:23A- 108 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cmeeorv: ROOF BUILDING PERMIT Permit 4 BP-2019-1059 ProiectN JS-2019-001726 Est Cost$9000.00 Fee:sw ho PERMISSION IS HEREBY GRANTED TO. Const.Class: Contractor: License: use Group:_ JAMES ROBERTS 99404 Lot Size(sa It.): 14069.68 Owner. FITZGERALD JOHN E Zonine: URB(100)/ Applicant.. JAMES ROBERTS AT. 133 SOUTH MAINS Applicant Address: Phone: Insurance: 30 Edwards Rd (413) 527-6078 WESTHAMPTONMA01027 ISSUED 6N:3/27/2019 0:00:00 TO PERFORM THE FOLLOWING WORKSTRIP & 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: OJ_ 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 s¢nature: FeeTvpe: Date Paid: Amount: Building 3/27/20190:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use,any City of Northampton Status of Penne Building Department CurbCuvDrWreaay Permn 212 Main Street S0amanSeNic Avaitebillry u '(. Room 100 Water/N/ell Avagabiliry Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 - I plain RECEI ersp dry APPLICATION TO CONSTRUCT,ALTE ,RE AIR,RENOVATE OR DE OLI A ONE OR TWO FAMILY DWELLING MAA 28 2019 SECTION I -SITE INFORMATION n�p1 �r n ThI section to be completed by oifiw 1.1 Property Atltlress: U"Lf]IP:G INepECTIONjS 1.OnTH4!.p10 M.A OIDfiO /� z ���� Lot J Unit J Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT Owner Record. Na - Name(P Cum:nl Mailing Address: Telephone Si at re 2.22.2 Authorize Name(Prim) Current Mailing Atltlress'.�c 51 nal Telephone / '(� � S ON 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only combleted by verrit aoplicant 1. Building (a)Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) / 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number Dasste Signature: 3 n-27- &0) Building Commissioner/Impemor of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed.Perm Can Be Denied Due To Incomplete Information , Existing Proposed Required by Zoning This cnlmnu to be filled u,by Building Department Lot Size _ Frontage Setbacks Front --- Side U R: . U R:. ... ... _._.. Rear Building Height Bldg. Square Footage % - -- Open Space Footage % - - (LaareamumsWe&pavW __.. _.. arkin ) At of'Parking Spaces -- -- (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'TKNOW © 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 # B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES 0 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 ® 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 filling)over 1 acre or is it pan 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 e-DESCRIPTION OF PROPOSED WORK fcheck all applicable) New House ❑ Adtlition ❑ Replacement Windows Alterationls) ❑ Roofing of Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[oI Othi Brief Description of Proposed Work'. Alteration of existing bedroom_Yes_No Adding new bedroo Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Sa.If New house and or addition to exlstina housini complete the followinn: 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? J. 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 1. Is construction within 100 fl.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 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 myb If, in all afters rets ive o work authorized by this building permit application. o Signaure4of Dwaer Data I, ,as Owner/Authorized Agent hereVy declare at the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed u der the pains and penalties of p Print Name Signet m OvmerlAgent Data SECTION 8-CONSTRUCTION SERVICES .1 Licensed Construction Sr ervis r: Not Applicable ❑ Name of License Molds,r'. License Number ter �// qCy Address Expiration Date Signature lepra ne .� v Re is erect N me rowmeM Contractor: Not Applicable ❑ �� om N me Rei ration umbe—fir Address Expiration Date ,5 Telephone )c�� SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) O V 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 � Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 .it, Stzaet a .N icipal Building i CS Northampton, I 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 few 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 ofan 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 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$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 z ' I DEPANTNENT OF BUILDING INSPECTIONS 2 , 212 Hain Street • Municipal Suiltl ng \ Northampton, H 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 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 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 Oficial, 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 � DEPARTMENT OF BUILDING INSPECTIONS x 212 Nain atrwt •Municipal Building b Northampton, ! 01060 Y� 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 pont hou a number and street namej Is to be disposed of at: (Please phrit'nathe and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: �T'r/✓ s (C m any Name and dd ss) /- .Sign 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. The Commonwealth of Massachusetts Department of industrial Accidents I Congress Street,Suite 700 Boston,MA 02114-2017 www.mass.gov/dia porkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le2ibly Name(Business/Organ¢afiowlndividual): Address: y City/State/Zip: GI/ U Phone#: Are you an employer."Check the appropriate box: Type of project(required): LLJlam ploycrwish employees(fall andor part-time)' 7. E]New construction 2. sole pmpnetor or partnership and have no employees working game in 8. [D Remodeling any capacity.(No workers comp_insurance required] l l am a bomeowner doing all work mvsu f No workers'comp. J 9. ❑Demolition ❑ [ p.„amanne regain .l. 4 I am a homeowner and will be hiring contmmom te conduct as work on my . Iwill 10 ❑Building addition are that an contractors either have workers compensation insurance pram sole 11.❑Electrical repairs or additions imprisons wish no employees_ 1 sM lama I cnnoacmrand l have hired me sub-con 12. Plumbing repairs or additions These sub-mnnwtors have employees workers co Iielinsn�m the sneer. p p yeas and have wodcen'comp.N 13. Roof repairs 6.❑wemeacotpom tiononditsofficemhaveexemisedthebri tofexemtiun 14-00ther gb P Per MGL a. 152,d1[q),and we have no employees_INa wohers camp.insurance mquimdJ 'Any applicant met ehecks has di most also fill out me section below showing their workers'wmpensalia r polio,Int ncrom i, 'Ifinnouxions who submit this aeidavi,indicming carry are doing all work and men hire marmt cnntmetors as,submit anew affidavit indicating swh. :Conaaemre mat check this box must arched an additional sheet showing the name of she sub conanctors mo stare whether or not those entities have employees. Itthemb<uwoe,orshavee. Ooyces,meymustpmvdemevwmken CCMP,POILCynumber. I am an employer that ie providing/w 000rk/erss''cao enation insurance for my employees Below is the polity and job site information. _(i!/b^'Li ✓/i Insurance Company Name: i v � 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 a 152,p25A 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 STOP WORK ORDER and a tine 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 under the pains and alties afperjtary that the information provided above is true and correct Phone#: Offleial use only. Do not write in this area,to be completed by city or toren 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 ofanother 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 certificates)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 permitllicemc applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"lob Site Address"the applicant should write"all locations in_(city or town)"A copy ofthe 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. Anew 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, NLA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia