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23D-175 28 BAKER HILL RD BP-2019-1192 GIs# COMMONWEALTH OF MASSACHUSETTS MU.Block: 23D- 175 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate¢orv:ROOF BUILDING PERMIT Permit BP-2019-1192 Proiect# JS-2019-001934 Est Cost $6500.00 Fee: W. PERMISSION IS HEREBY GRANTED TO.- Const. O:Const.Class: Contractor: License: Use Group: THOMAS QUINN 108861 Lot Size(sp.ft.): 15986.52 Owner: SWIFTBRIAN M&SUSAN H W SWIFT Zoning,URB(7001/ Applicant: THOMAS QUINN AT. 28 BAKER HILL RD Applicant Address: Phone: Insurance: PO BOX 247 OD) 320-2030 O WC LEEDSMA01053 ISSUED ON:4/25/2019 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: Driveway 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 Occuoancv signature: FeeTvpe: Date Paid: Amount: Building 4/25/20190:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner K-O-Qr nt use only / City of Northampton Statue of Permit:: ..3 BuildingD �C�` /C Avelledky 212 Mai St L V Gat 1 Roo 100 Ava%blagr Northampto M 11 9 a 9019 va: of Stmotlew Plate phone 413-587-1240 Fa 413=587=1272 I Plana APPLICATION TO CONSTRUCT,ALT R,p�PRAtFP1EoiN�7�tOR�DEMO ISpH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 PropertyAddress: r This section to be completed by offios �O 13A kE� 1411� /1�1 Map�� Lot /� /t7 Unit F11 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �( (� V tti SwiPah 2-19 19 ayf. Hill Name(Print) Current Mailing Address: ( Y✓'^ '� ✓�" t Telephone (7 Signature 2.2 Authorized Aaenl: 7 n1' �Gl-.✓�v 1��a Name(Print Current Mailing Address'. 62U .2L Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bpermit applicant 1. Building (� [G (a)Building Permit Fee C SDu 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) #L-/[/ D 5. Fire Protection 6. Total =(i +2+3+4+5) Check Number This Section For Official Use Onl B uilding Permit Numb r Date 9 Issued: 'J p : -� Building Commissionedlnspector of Buildings / Date TCJG66g EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING Ali Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This wlumn to be tilled in by Building DepaNnmt Lot Size Frontage I_. _.... Setbacks Front Side U—R: L:—R:— _ Rear _. . Building Height Bldg.Square Enrage - k Open Space Footage _ % (Lot area minus bldg&Paved - Oblong) #of Parking Spaces Fill: _. . _.... volume&Imation A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW O YES Q IF YES, date issued:'. IF YES: Was the permit recorded at the Registry of Deeds? NO © DONT KNOW O YES O IF YES: enter Book Pages. 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 © Obtained © , 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((cgl�aring,grading, cavation,or filling)over t acre or is it part of a common plan that will disturb over 1 acre? YES V NO IF YES,then a Northampton Stonn Water Management Permit from the DPW is required. SECTION S DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing tg or Doors Accessory Bldg. E3Demolition ❑ New Signs [[3I Decks Siding[0] Other[m Brief Descriptio of Proposed � Q Work' �/M_/LJ EXrS :.��narr/Uf S .-r l2 14"1 Alteration of existing bedroom_Yes_No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement _Yes No Plans Attached Rall -Sheet on.N Now house and or•ddFlton to axlstina housing.complete the followina: 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? h. Type of construction i. Is construction within 100 ft.of wetlands?`Yes _No. Is witstmction within 100 yr. floodplain_Yes_No j. Depth of basement or cellar floor below finished grade L Will building conform to the Building and Zoning regulations? Yes No. I. Septic Tank i City Sewer Private well City water Supply SECTION 7a•OWNER AUTHORIZATION•TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT r� c _ I, [ 7 l N�/ ,as Owner of the subject property hereby authorize to act on my behalf,in all matters relative to workauthorizedby this building permit application. Y lictiav� YL✓r-1 v" Signature of Omer Data 2 1 u--r. ,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 soca w les of pe 'ury. 1 Print Name '-(1( Signature of OwnedA t D SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor; �7 Not Applicable ❑ Name of Llcenee Holder: �h �+rn5 ✓ - a/i✓ / License Number S-7 0-1,J a,, 241 G,,V�h/.t Ck Atltlress /� ' Expiration Data 3?p ?a -Tb l Signature/ Telephone �/ // 9 Regi ster ed Home ImmoveMWd CprdrODWr: Not Applicable ❑ Comoanv Name Registration Number ///—/14 /--.) Address / � Expiration Date T % ///�../ !��/ �irdf�_ M/1 O/VS77elePhonek/1) 3Ja -3-- SECTION TSECTION 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 provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... 19 No...... ❑ The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Suite 100 Boston,MA 02114-2017 www mass.gov/dia Wil.rkers'Compentaition Insurance Affidavit: Builders/Contmctom/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly i Name (Business/OrgmimtioNlndividual): -f ri' Address: S"7 City/State/Zip: `rrr/< /77/1 0/O s'T Phone#: /t jj) 3a 0 -, )0 70 Arc you an employer!Check the appropriate box: Type of project(required): LQ I am a employer with employees(full and/or pmt-time)." 7. ❑New construction 2MIamasolepmprietormpp embipandhavenaemploymsworking fmmein g. E]Remodeling any capacity.Mo workers comp.insurance required.] 9. 1MIamahomm cownerdoingallworkorysolf lNoworkas'mp.iemommquadilt 10 Demolition 4,01 am a homeowner act will he hiring contractors to mnduct all work on my property. I will 1Building addition ensure that all conrmdors either have workers'wmpusahrai insmenm or are sole 11.❑Electrical repairs or additions prolamines with no employees. 12.❑Plumbing repairs or additions 5,C]1 am a general contractor and 1 have hired the subcontractors listed on the attached shed. 13Roofrepairs These sub-contractors have employees and have workers'comp.insurance) MMDQ' 6.❑We are a mrpormion and its omcers have exercised their right of exemption For MGL c 14.❑Other 152,§1(4),a we have m employms.Mo workers'comp.insurancerequired.) 'Any applicant dut checks box#1 must also fill out the section below showing their workers compensation policy information. t Homeowners who submit this affidavit indicates they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tCon awors that check ads box muss attached an additional sheet showing Ne name of the subcontractors and state whether or not those cooties have employees. If the sub-conhacwrs have wnployed,thry durst provide their workers'comp.policy number. I new an employer that isproviding workers'compensotion insurancefor my employees. Below is thepolicy andjob site information. , Insurance Company Name: Zu/11C17 —/3 ,,!Ai- Tk/SurA>rx �r Policy#or Self-ins.Lie.#: C.zz lr13 Expiration Date: Job Site Address: D 8 Qd nr✓ A /( (2C/ 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 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,cerafy/under e pains arl"alda ofperjury&m the information provided above is true and correct Z stare Date 7/ ///`i Phony/ ,p�V- DO 3C7 Official use only. Do not write in this area,to be completed by city or town offWal City or Town: Permit/License It 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#: NOTICE NOTICE TO a TO EMPLOYEES t` EMPLOYEES YV / y O,,y SJ♦ The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114 — 2017 617-727-4900 — http://www.state.ma.us/dia As r uired by Massachusetts General Law, Chapter 152,Sections 21,22&30, this will give you notice that IA(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: ZURICH-AMERICAN INSURANCE GROUP NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO MA 02344-1450 ADDRESS OF INSURANCE COMPANY (6ZZUB-7H73245-4-18) 10-17-18 TO 10-17-19 POLICY NUMBER EFFECTIVE DATES FINCK & PERRAS INS AGCY 6 CAMPUS LANE EASTHAMPTON MA 01027 NAME OF INSURANCE AGENT ADDRESS PHONE# QUINN. THOMAS 57 UPLAND ROAD LEEDS MA 01053 �e EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT ^c The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS Diem„ W20PIG15 TO BE POSTED BY EMPLOYER .�: 5\5...T....J/C Massachusetts e Z \ BEPArt21fEBT OF BOI=D IBSp=XWS 212 Nein Street .M .ipe Building Qp, C Bortbao W, 1 01060 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: a E, aabx 14-11 1,2-f F/� (Please print house number and street name) Is to be disposed of at: (Please print name and location of facility) Or rrywill be disposed of in a dumpster onsite/rented or leased from: & (Company Name and Address) "7 �Peerrmit 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. Masaachuaetta s ZZPAR491a'NT Or BtirwD G INEPLCTIONs 2� 212 Nein Street a Municipal Building Nortte ton, ta, 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 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, orconstruction of an addition to any pre-existing owner ccupied building containing at least one but not mora than four dwelling units....or to structures which am 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: Est Cost: &;n00 Address of Work: e4i'..r 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 pe it as the agent of the owner: �i/ (� r(� 74, f 62"w- /3y 3,2z 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 Maaeachusetta 4 L Db2ANifffi!T or BUILDING IN ZOTIONS 212 Nein Street0 . N ic.,a S 11,Un Northe ten, M 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 l 10.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.