29-612 629 BURTS PIT RD BP-2019-1099
GIs#: COMMONWEALTH OF MASSACHUSETTS
MV.,Blmk:29-612 CITY OF NORTHAMPTON
Loc-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildine DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category, Bath reno BUILDING PERMIT
Permit# BP-2019-1099
Proiect# JS-2019-001784
Est.Cost:$12500.00
Fee:$81.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Grow: GARY J RUEL 97190
Lot Size(so.R.): 30012.84 Owner: KATZ ELIZABETH&LETICIA MUNOZ
Zoning: Applicant. GARY J RU EL
AT: 629 BURTS PIT RD
Avolicant Address: Phone: Insurance:
50 SUNBRIAR LANE (41 3)519-5465
LUDLOWMA01056 ISSUED ON:4/0019 0:00:00
TO PERFORM THE FOLLOWING WORK.,RENO BATH AND INSTALL 2 NEW WINDOWS IN
MASTER BEDROOM
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: oke: 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 4/4/20190:00:00 $81.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File M BP-2019-1099
APPLICANT/CONTACT PERSON GARY I RUEL
ADDRESSIPHONE 50 SUN13RIAR LANE LUDLOW (413)519-5465
PROPERTY LOCATION 629 BURTS PIT RD
MAP 29 PARCEL 612 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
OSED REQUIRED DATE
Z FILLEO T
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: RENO BATH AND INSTALL 2 NWWINDOWS M MASTER BEDROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 97190
3 sats of Plans/Plot Plan
THE Pott6wING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN ATION 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
Demolition Delay
// '//_ 4 N zbiq
Signabre of Building Official hate
Note: 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.
Deparbnent use only
iaar>, City of North pt n of P unit
f Building Dep met ]1buY 'veway Permit
r. 212 Main reef APA 4 201 /Sep'cAvaiisbiltyRoom 1 7eI Availability
Northampton, A 0� ew Structural Plans
-�' phone 413-587-1240 F 41 Efragrl.lm
a n 9090,PI ns
011ier Speo
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Propel Address'. This section to be completed by office
Gal dunk tj'9• L A10, Map -;L--tepLot (1J >Unit
Zone Overlay District
Elm SL District CB District
SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: II-- ��y. .� /�
L'L' 4-ici ct M toi; OZ 62,q BUA45 rl� gs
Name(Pdn Current Mailin?Address:
� eY,�°ylCr� M � 062
JZ Telephone �
Signature
2.2 Authorized Agent
CAM T. A?.48L So SS't41R3V L„ r O/ 0S6
Name(Pdrn7 ' ,r Current mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ar S� ./ (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) 9 I
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number 7
This Section Fa Official Use Only
Building Permit Number Date
Issued:
Signature: q-4-101q
Building Commissionedlnspector of Buildings Date
AR; 14,71 iq -Z G rra C !pO M
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING Nt Information Meat Ise Completed.Permk Can Be Dented Due To Incomplete Information
Existing Proposed Required by Zoning
This waw.b be filled N by
Building nelmmnrnr
Lot Size
Frontage ---
Setbacks Front
Side L R: L: R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot arra minas bug&Paved
4 ofParking Spaces
Fill: ---- -
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT 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 N
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 wil 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 applicable)
New House ❑ Addition ❑ Replacement Wjndows AKeration(s) ® Roofing Q
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks (E:3 Siding[0] Other[
Brief Description of Proposed
Work: (if 4C4,%4 .z hdre/ IV k��✓S yn M. .B6,1!
Alteration of existing bedroomVes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes --,>C-NoPlans Attached Roll -Sheet
Sa.N New house and or additn to ex]atina howling. complete the following: `IG 61MR-'&A L`
a. Use of building '. One Family Two Family Other /IV / �Md•�� J 97
b. Number of roomA
s in each family unit: Number of Bathrooms �y
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstaves 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
I. Depth of basement or cellar floor below finished grade
k. Will building wnform to the Building and Zoning regulations? Yes No.
I. Septic Tank_ City Sewer_ Private well_ City water Supply_
SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENN/T�OR CONTRACTOR APPLIES FOR BUILDING PERMR 1 �1A
I, eL� A !1 r�.— /-/•[ WVuii�//� '��//� L 1 1 G 1 V,— ' 1 w ri zas Owner of the subject
property G a�+W � t v-ia.n-'r a
hereby authorize
I aG an my behalf, in all matters rel 've to work authorized by this building permit application.
Signature of Owner Date
I, J2, (( /(µ//' as Owner/Authorized
Agent hereby declare that 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.
GARN 'TR , 6L
PnM Name
Signature of0wineriAgM Date
SECTION e-CONSTRUCTION SERVICES
3.1 Licensed Construction Suoervlsor: Not Applicable qO / r1
Name of LicenseHolder: `.� /Y L \ S — C( /q ( �V
License Number
S � SuySn:Krz Ln , 3/a4/ 7oJ�a
Patlress / Expiration Dab
Sa 6S
Signature Telephone
9.RRenistered Home Improvement Contractor: Not Applicable ❑
1 S6'?0O
Company Name Regisbaa'gn Number
S)M1� ns /�bpvr£ 7 a-v /�i9
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT Ili c.153,S BqG))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will resu0
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No......
City of Northampton
�f Massachusetts "
a212 sai. s or . ni.a zMs?.Lft ldi., p
211 win s!r«t . wni°lpal anilsinq
xoeNuepTon, 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 perforating 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,modemizatiar, 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 sln ctures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with o corporation or LLC,that entity must be registered
Type of Work:/A,j6 VA, -t- AsA p?O;mrscht L Est.Cost: X102/ Ste•
Address of Work: 6.;)9 !lwef$ fG' Pc�. fl Rh. &f
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 RESPONSIBILITIES 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:
Y13I11 Gam, 7. /%f IF 1SG7o0
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice, 1 hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
Massachusetts \.tf
DEPARTMENT OF BOILDZNO IESPECTIOEE
212 Win Str t • Mnicipal suil,UW
Nonthw ton, NA 01060 P6
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 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 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
D212 ... . OF BOZLDZNS ZNS ullT n NS i.
212 ILin rtz •1Lnicipal BvilLinq T
Noz@,espton, !IA 01060 ♦�:yj�a`
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:
Ka9 &,?4g Pig- J?CLt
(Please print house number 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:
13"dJ-e i G%. 'psfF2
(Company Name and Address)
nd
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.
The Commonwei ofMassaehuseds
Department of IndustrialAccidents
1 Congress Street,Suite 100
Boston,MA 02174-20777
umrry mass.gov/dia
UwWorkers'Compermandon Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information � �f Please Print Legibly
Name(Business/OrgmizatioNIndividual): GT S J /GMA'C-
Address: ,SO .SCf,1AR.(0K LN r
City/State/Zip: to F/o•4/I MMIM of o SG Phone#: / —4(13— ,S/1-5'f/ 6 s
Are sin•m enpbrm?Cheek fhe.pproprwe boa:
Type of profeet(required):
I.[]l am a employerwith employees thou ptWm part-rhne).' 7. ❑New construction
2.(.711 am as ole proprietor or patheraM and have no employees working format Ips
Many capnity.[No workers rump.warmuse rehaihed.l 8. Id Remodeling
J❑I an ahonmwoer doing an work myself[No wasins'comp.inmmae hei,mad.]' 9. ❑Demolition
4.❑1 am a homeowner and will N hiring contractors to coMuct all won,on my prolmty. I win 10❑Building addition
oppose oat an committers either haw workers,continuation lmurmtoeerhim sole 11.❑Electrical repaas or additions
popnmors with no employees. 12.❑Plumbing repairs or additions
5❑lson a general contractor and l have htiM the sub-cmuxiws listed on the ltmchnd sh¢t 13.❑Roof repairs
These subm
-emarsers have employee and have workerms'emn,imu ee.
6.❑We are a automation and as officers have esereined area right of exemption per MGL a 14.❑Other
152,§1141,and we have no®pbyeea[No workers camp.mawmne required]
•Any appkeirm am[checks box ti l most also fill out the section below showing their workers'compewation policy Intimation
'Homeowners who mbmlt this affidavit indicating they are doing all work mal then hire ampule emometors must submit a new affidavit indicating such.
:Contra hors Wet think this baa must amched an additional sheet showing the wnm ofthe sub-contractors and store whether or not thou entities have
employees. Ifthe sub-commiaurs have etwovees,thev must provide their workers camp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-firs.Lie,#: Expiration Date:
Job Site Address: City/Stare/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,p25A is a criminal violation punishable by a free up to 51,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 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 a r the pastheraj andpenaides ofperjury that the information provided above is nue and comers
Signature: ��a(e++5 Date. y13119
Phone#: 1- 11 Sly - S44T
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/ own Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
r
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 m 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 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 insmance. 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 confirnation 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 m contact you regarding the applicant.
Please be sure m fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pcmut4icense 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 furore 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 ctc.)said person is NOT required to complete this affidavit.
The Departments address,telephone and far 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.na .gov/dia
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