24A-182 (8) 35 NORFOLK AVE BP-2019-1097
GIs tb COMMONWEALTH OF MASSACHUSETTS
Mau:Block:24A- 182 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Cateaorv,ROOF BUILDING PERMIT
Permit tt BP-2019-1097
Proiect9 JS-2019-001782
Est.Cost:$77000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License.
Use Group: MICHAEL STOSZ 002209
Lot Sizc(so.ft.): 293158.80 Owner., peter whalen
Zoning: URA(100)/ AAPp4cant. MICHAEL STOSZ
AT. 35 NORFOLK AVE
Applicant Address: Phone: Insurance:
115 MARKET HILL RD (413) 374-4715 WC
AMHERSTMA01002 ISSUED ON.4/4/2019 0:00:00
TO PERFORM THE FOLLOWING WORIGSTRIP & SHINGLE ROOF WITH NEW WOOD
SHINGLES
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 0 Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: '1: 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 OccupancV Signature:
FeeTvpe: Date Paid: Amount:
Building 4/4/20190:00:00 $40.00
212 Main Street,Phone(413)5874240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
P on ;�:
Department use only
- City of NOftha kj to of Permit:
.> Building D partgnent uro udDriveway Permit
212 Mair street APO 4 2019 ewer cAvailability
! Room 100 ' ater all Availability
Northampton, MPS .runrm:in-�=cn S of Structural Plana
` phone 413-587-1240 �Fax4f3-5 9 �AgOtcF Its Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR RENOVATE OR DEMOLISH QA ONE OR,
FA/�MIILLY DWELLING
SECTION 1 -SITE INFORMATION P P' f I
1.1 Property Address: pThis motion to be comp by office
/�1d��a �) ��� Map R Lot=nit
Unit
�J h Zone Overlay District
Ebn SL Diceict Ca District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZEDRGENT
2.1 Owner of Record:
5
Neme( in1J CurrentMarg Address:
Telephone Or 7p
Signature ll
2.2 Au prized A ent:
iC,
Name( n / Current Mailing Address:
Signa rd Telephone
SECTION 3-ESTIMATE6 CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by Permit applicant
1. Building dW (a)Building Permit Fee
2. Electrical W (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee J{�/
4. Mechanical(HVAC) " qa
5. Fire Protection
S. Total=(1 +2+3+4+5) 1 1 Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued: p
Signature:
Building Commissioowlinspector of Buildings Date
/J
`� EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
51657-
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Ibis column to be filled in by
Budding Departmont
Lot Size
Frontage
Setbacks Front
Side L R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage so
(Lot area minus bldg&paved
parb,A)
#of Puking Spaces
Fill:
volume&I,ocarion
A. Has a Special Perm it/Variance/Findpin�(g�ever been issued for/on the site?
�(l
NO O DON'T KNOW YES
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 aril/or Document#
B. Does the site contain a brook, body of water or wetlands? NO (0 DON'T KNOW Q YES
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
IF YES, describe size, type and location:
D. Are there any proposed charges 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(Clearing,grading,excavation,car filling)over 1 acre or is it part of a Common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Stone Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK Icheck all applicable)
New House ❑ Addition ❑ Replacement Windom Altention(s) ❑ Roofing s'
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O) Decks [Q Siding[Ol Other(OI
Brief Des tion of Proposed
work: mou✓ Ekty}... 5 ��r.,.(?s��ns�L�� law IllmrJk
Alteration of existing bedroom_Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ga.If New home and or addhlon to exlstina housing-complete the followlna:
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?
d. Proposed Square footage of new construction. Dimensions
a. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance forth 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
A
I, as Owner of the subject
property
hereby authorize
to ad on my be )hAviethoff Ztfoir rize by this building permit pl!qbtion.
Signature of er Date
h f CLQI- R I Z ,as Owner/Authorized
Agent heralm,becifire that the statemerritif and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed and a pains an pena of perjury.
Pont NameI.
SignatureJ1 r1A9Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Hos 14 11:1'1 (_,:.) u6a2oq
License Number q
11� fn(a4i 01 Del pK �- G, �� � Expire o ate e /20
Si elephone
, 6aWI Not Applicable 11�Un N Q I e(�IC cS
Comoan R17i0tr2tion)
Number
Qko} Qbo
Address ExpiraVion Date
Telephone LAI3
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(e))
Workers Compensation Insurance aMdavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the bu'ding permit.
Signed Affidavit Attached Yes....... No...... ❑
City of Northampton
''L"' Massachusetts
~ P
��.' DEPARTI S OF BOZL ci INSB&ldiONB �. b
212 Mein atbw • Municipal auildinq
Nontfiaepton, Na 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
perforating work on such homes,a contractor must be registered as a Home Improvement Contractor(.'MCI').
M.G.L.Chapter 142A requires that the"reconstruction,alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction or an addition to any preIexisting owner-occupied building containing
at least one but not more than four dwelling units....or to structures which am adjacent to such residence or building"be
done by registered contractors.
Note.,If the homeowJner has contracted with a corporation or LLC,that entity must be registered
Type of Work: ow66� eeI/ (n� Est. Cost:
Address of Work: !1� c V Nt
Date of Permit Application: I 4 ;N, I C1
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
Job under$1,000.00
_Owner obtaining own pennit(explain):
_Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITIES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the a�eat of the owner:
4 �N aJ401 (6PpirU c.�in^H (,a&4 &Iiitws Ti,L
Da& Contractor Narhe J HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
�
Massachusetts
i
{ 'F 1)ZPARIAffiiT OF BGSLDLNG INSPLClIONS
YS$ Nain St.t • Municipal 0ui1[ling up\ OCC
Northa ton, M 01060
Massachusetts Residential Building Code
Section i I O 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
i Massachusetts
!/ 's
( DEPARTMENT OF BUILDING INSPECTIONS
212 Hain 01 Sthw n iBuilQing Jp, Cp
Northempton'nn, NI. 01060 sf"""ygOe
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:
Y fL
(Please print house number and street name)
Is to be disposed of at:
V4\VA Q. , "Ah�
( le se I rTt na a and location of facility)
Or will be disposed of in a dumpsler onsite rented or leased from:
P�RahS�jIAA C6 urn (] A
(company Nail and Address)
Sig rte f P Wpplica t 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 ojMassachuseas
DepartnuentCongr ss Street,
Sua10Accidents
I Congress Street'Suite 100
Boston, MA 02114-1017
wwsi mass.Sov/dia
Wil.ken' Compernation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Org//miinbon/Individual): M (�1ZH
Address: lib Q)
i
City/State/Zip: .1 Phone 4:
Are you an employer?Check the appmprlam box: Type of project(required):
t.[IIamaemployer wit Ib employees(full and/or pm-tive).e 7. ❑New construction
2.❑1 am a sole proprietor or partnership and have no employees working for me in g. ❑Remodeling
any capacity.Mo workerscompivsmance mune l.]
9.3.❑1 am a homeowner doing all work myself INr workers'comp_vuurevice regalrea1I T El Demolition
4.E]I am a homeowner and will be hvhrg ernmectors W emducl all work en my property. I will 0❑Building addition
we mal all earramouns eitherheve workerscornpenauon ewarame.,me sole 11.❑Electrical repairs or additions
proprietors wim no eugdoyees. 12 lumbing repairs or additions
5�l am a general contactor and l have hired the subcon melors listed on toe ausehed sheet 13.[ARoof repairs
'(hesesub-covtraeWrs have amployeesand have workers'rcar, insuan t
6.❑We arca corpoaunnnnl,ocAresuhaveem...sed Nei de of excmpiov per MGL a 14.QGthCr
152,§l(4),aM we heveno employees.INo works'comp.insumnea requimd l
'Any applicant that checks box#1 mat also fill ora me sation below showing men workers'compensationpolicy irdorustion
t He...who submit tis atfadne,indicating they are doing all work and then hire moside contractors most submit a new afielsot indicatin,such.
tCmametors tont check anis box must attached en additional shost showing tole rerre of da mbconnacmrs and slate whemm or not torso entities have
en�plo}ees. If the sub-contractors have empbyeea,they must provide tors( worlcracomp.policy number.
I am an employer tkat is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name��L'jdef{>I ^ 'I q �/
Policy#or Self-ins.Lie. #'. 1I l) IJfn��- ��'d�I'l 1 d Expiration Date: �7
Job Site Address: _ of WUI K l'Clt,° City/State/Zip: c Gn , 6/ebe
Attach a copy of the workers' compensation policy declaration (showing the policy number a d expiration dale).
Failure to 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.
I do hereby cert the ' s andpenahies of perjury that the information provided ab is true and correct
Sirnature: Date: a
Phone# ko-� I f `,/VS
Official use only. Do not write in this area,w be completed by city or town ojjiciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk d.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: