30C-028 82 CLEMENT ST BP-2019-1123
GIs H. COMMONWEALTH OF MASSACHUSETTS
Map:Block:30C-028 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2019-1123
Project# JS-2019-001824
Est.Cost:$8900.00
Fee,$40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DANIELWEST 106007
Lot Size(sp.ft.): 13808.52 Owner: KELLOGG WILLIAM C&THERESA M
Zoning, SR(100)/ Applicant: DANIEL WEST
AT. 82 CLEMENT ST
Applicant Address- Phone: Insurance:
11 PLYMOUTH AVE (413) 695-7311 WC
FLORENCEMA01062 ISSUED ON:411112019 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & 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:
Drivenay 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 signature:
FeeTvpe: Date Paid: Amount:
Building 4/11/20190:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck-Building Commissioner
ECEIV DepaMenNuse o �
o
City of Northa pto of Imu
Building Depamet Cody uVD Mi Permit
y 212 Main S eet APR 1 0 20 se aAv ilabi5ty
Room 10 Wats valYdbdi(y
Northampton, M k 01 60 Two oi Structural Plans
phone 413-587-1240 F x 4T3--587 127Zl,m«MMIle
P
11P y I^']p ilAl 0
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address' I / ?Thh'iiss/se�ctionito be completed by office
8L Ckuw ,,,(nn,�AA-L�/-II S'f Mapes Lot 0,;I Unit
po&44C4 f04. Zone Overlay District
Elm SL District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Pring4T-
I ICurrent Mailing Address'.
9z L U 12 1=N G t_ ,,,n R..
V✓ I1_ I, i ttM' {i 91-7,ry Cf- Telephone
Signature STS 14
2.2 Authorized Agent:
to
Name(P i Current Mailing A dress:
S Telephone
SECTION 3•ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com letedib e"it applicant
1. Building C] O [J (� (a)Building Permit Fee
i `
2. Electrical (b) Estimated Total Cost of
Construction from 6
3, Plumbing Building Permit Fee
4. Mechanical(HVAC) �V
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Onl
Building Permit Number. Date
Issued: p
Signature: LNO-) 1
Building Commissionedinspector of Buddiigs Data
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING An Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column m be filled in by
Building Dcpumnent
Lot Size ..__.
Frontage ..._.
Setbacks Front
Side L _ R: ........_ U R. .._. ._..
Rear _...
Building Height ---
Bldg.Square Footage
Open Space Footage % --
(Lot men minor bldg 6 paved
. . .....
arkin
#of Parking Spaces --
Fill:
(volume&Locmlon)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW 0 YES O
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 ® DON'T 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 40
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
IF YES, describe size, type and location:
E. Wil the construction activity disturb(clearing,grading, excavation, or 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 Storm Water Management Permit from the DPW is required.
SECTION 0-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ElRoofing
Doors 7
Accessory Bldg. ❑ Demolition ❑ New Signs j01 Decks [0 Siding[0] Other [31
Brief Desc- tion of Proppos
Work. y
Alteration o exis edro m is o ddin new bedroom_Ves No
Attached Narrative Renovating unfinished basement _Ves No
Plans Attached Roll -Sheet
ea. If New house and or addition to existina housing, complete the following
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
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
It, 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_Nc
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
y/A.�`r,.L_nvw✓ _/L /O'(.2/ as Owner of the subject
property ��\� f 1 ,, J1�-� j� f2
hereby authorize '+u"A f ( KlQ-�l \J I\ �'/f{-' �� w � VI I.0✓Ll if P'L 4 L�
to act on my behalf, in all mayt r1elative to work authorized by t s building permit application.
AAS(•::( IAJr�'D}'� N^ Q ' �O f q
Signature of Owner Date
I, 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.
Print Name
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Constroc0ioonS.Suo�ervisor: Not Applicable ❑
Name of License Holder'. 1.1�\�.�
License Number
MA - oloceZ (SSL- L(b[DL-,}
AddressExpiration Date
r�6213) �IrS ' 3(� /g/��g
SIg( dv Telephone
9.Reolstilmd Hong ImnrovemeM Contractor. Not Applicable ❑
Company Name Registration Number
`V), L. W Ij8327-
Addrree�s�s �//// ���/—�' Expiration Date
1 (I�UW i ��* L/�V1r 61U1'ZTelePhone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provitle this affidavit will result
in the denial of the issuance of Me building permit.
Signed Affidavit Attached Yes. .. No...... ❑
City of Northampton
Massachusetts si' >;- r
x
DEPANTNENT OF BNILDING INSPECTIONS � 1S\� 'b
212 Nein Street • Municipal Building v V C�
Northampton, !p 01060 3'bti y'jl
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
perforating 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 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:If the homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work:. �b✓NSi4 o Est.'C�o^st�:
SZ i p
Address of Work: O �u� r '�'K`�i Vp 1vT' neo e
Date of Permit Application:L C.oN
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:
1,4�/.:�'�v uxst 1Is
DD t9 el 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
l DEPARTMENT OF EUZLDING INSPECTIONS 5
213 Min Street • Municipal Building C`
Natthan�pton, !NW 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 1 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
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
s
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 .in Street •Municipal Building `y c
�\
Northampton, MA 01060 'rYry-piP°
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:
8Z (_leatnetA& 5E _
(Please print house number and street name)
Is to be disposed of at:
Pleas printname and location of facility.A*A O(04e
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
( `/ 6)1cf
Si n re o P mit Applicant or Owner at
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
F
Department oflndustrialAecidents
1u I Congress Street,Suite 100
Boston,MA 02114-2017
S
Iwww.mase'.gov/dia
R"orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information11 p � Please Print Eligible
Name(Business/OrgenizatioNlndividual): \ Q/ J
Address: Vih bokst A-4 _ / `
City/State/Zip: _V , C')(6 - Phone#&Q3 )
Are you an employer?Check the appropriate box: Type of project(required):
mgq
la
aemploycrwith l/ employeeslhllland/orprrhtime)" 7, ❑New construction
21__I I am a sale proprietor m partnership and Mve no employees working Ibr me in
any capacity.[No workers'comp.Ineumna required.] 9. Remodeling
3❑I an a homeowner doing all work mymlll[No worker, comp,insurance required.]' 9. ❑Demolition
4.❑1 am a homeowner and will be hiring connectors to conduct all work on my property. 1 will 10❑ Building addition
enure that an contractor,either have workerscompensation insurance or are sole 11.0 Electrical repairs or additions
pmpriemrs with no employees.
12. Plumbing repairs or additions
50 1
am ahave gunemlcontmctoraemplohave es ed and
have wornw'co listed monthe atmehN sheee k
These subcontrdemrc have employees and have workeri comp insurance. 13,h[IROOf Capaer5 YYQkiCek�
Cf—
fi.❑We coporation and its officers home exemsed their right or-rinption per MGL e. 4.E:]
152 4447,and we have no employees[No workni camp.insurance required.)
"Any applicant that checks box#I must also fill out the section below,showing thew workers compensatmn policy mformmion.
'
Iloweavivoi who submit this atrumo iodinating they arc doing all work and Met hire outside mnwuors must submit a new affidavit indicating such,
rconwctom that check this box must utmcbsd an additional sheet showing the name ofthe subcoawetom and state whether or not those entities have
employees. Ifthe sub-conwcmrs have employees,they must provide thew worows'comp.policy number.
I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy andjob.site
information.
Insurance Company Name: f�A, .,'1•I 'Mr �C�tITZ.I ,�15U4�/sQ VICQ `O
Policy#or Self-ins.LLiic.#: 1'i�'� Y L� �O/�,1"�ee {�'�G) I� Expiration Date:
Job Site Address: OZ �CL✓'�T( �C- City/State/Zip: dd2 -( •D�z)�p Z
Attach a copy of the workers'compensation polity declaration page(showing the policy number and ex iration 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
anchor 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 venficatic .
I do hereby car ' tide, a ai and pe ldes oftweiml y that the imformadon pravided a ve i nue and corrrct
Si nature: Date:
Phone#: l —
Oficial use only. Do not write in this area,to be completed by city or to orcofcial.
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 of another under any contract of hire,
express or implied,amt 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 m 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 152,425C(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 ofcompliance 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)name(s),addresses)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 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 data 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 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 ofthe affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proofthat 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
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.mass.gov/dia
nc R CERTIFICATE OF LIABILITY INSURANCE 1071"8/2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
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BELOW. THIS CERTIFICATE OF INSURANCE ODES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER.
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DESCRIPTION OF OPERATIONS 46.
EL pSEASE-PoIICV LIMIT 500,00D5 r 'BBB
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CERTIFICATE HOLDER CANCELLATION
SHOULDANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
EVidanxi W Insu2Wx ACCORDANCE WITH THE POU"PROVISIONS,
AVTNORISDREPRESENTATNE
0IM-2015 ACORD CORPORATION. All rights reserved.
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