25C-195 (7) 11 - 13 HIGHLAND AVE BP-2019-1141
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Map.Block: 25C- 195 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Categom ROOF BUILDING PERMIT
Permit# BP-2019-1141
Project# JS-2019-001851
Est Cosr. $11000.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sa.R.): 4181.76 Owner: TARNOWSKI CHRISTINA RYAN
Zoning: URC(100)/ Applicant: TARNOWSKI CHRISTINA RYAN
AT. 11 - 13 HIGHLAND AVE
Applicant Address: Phone: Insurance:
11 HIGHLAND AVE
NORTHAMPTONMA01060 ISSUED ON:4/16/2019 0.00:00
TO PERFORM THE FOLLOWING WORK:REMOVAL OF SLATE ROOF AND REPLACE
WITH ARCHITECTURAL 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# 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 Sienature:
FeeTYDe: Date Paid: Amount:
Building 4/16/2019 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck-Building Commissioner
(Lot)
City of Northam ton RECEI �,' �°
Building Depart enl Pemtlt 'llj°I
212 Main Str t vailebit
Room 100 APO 1 6 2 I !alaTM " x
,1
Northampton, MA 010 0 of „ Pers; O
phone 413-587-1240 Fa 41 _ o, . iLn�ni.mis P :!;:I
,iIu) it
NorTW1,A„or ,l " ', �•,•
APPLICATION TO CONSTRUCT,ALTER, REPAIR RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION i-SITE INFORMATION 9> t?-rry/
1.1 Property Address: � This section to be completed by office
eI,I2 ��Oxd �r� Map �'`SC Lot ( • ” Unh
�ort-k ZP v�1/ ./V' O ID rpO Zone OwfdayDisWct
Elm St DISai CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2. wn rot Record:
nM feta as
Name(Print)) J Current Mailing Atltlress:
Telephone
Signature
2.2 Authorized Anent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit apotcant
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 it
6. Total=(1 +2+ 3+4+5) Check Number
This Section For Official Use Onl
Date
Building Permit Num r: Issued:
Signature: z6)9
Building Commissioner/Inspector of Buildings .{ J Date
CifZJ R�v�—' Oe SyYCc/�7 , 2 rY�
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Mus(Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to b,fillcd in by
Building D,smmoa
Lot Size
Frontage --
Setbacks Front
Side L R L:—.... R .—._. _.
Rear _
Building Height -
Bldg.Square Footage % "—
Open Space Footage
(Lot area minus bldg&paved ....
arkin
N of Parking Spaces -----
Fill: ......... .. _..
volume&Location) _.....
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES Q
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 A'.
B. Does the site contain a brook, body of water or wetlands? NO O 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 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(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 Q
IF YES,then a Northampton Sic"Water Management Permit from the DPW is required.
SECTION 5.DESCRIPTION OF PROPOSED WORK(check all applicablel
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[[:l]
Brief Descr tion cf Propas�d / ) ,./ /
Work: /kl✓0./0/ 5t�ry CZCt bN 56yn Cl P.d.i
Alteration of existing bedroom_Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Rall -Sheet
Be. If New house and or addFEion to existinD housing, comi 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 arached?
J. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or WOodatoVes Number of each
g, Energy Conservation Compliance. Masscheck Energy Compliance form attached?
In. Type of construction
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 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building peroit application.
Signature of Owner ,, p Date
)V1-
y
I, �-/ /A R /V c- ,as Owner/Authorized
Agent hereby declare that the statemnts 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.
( //9I-SPAltr M. RY AI
Pn Name. ((--
/�,
Signature of OwnerfAgi Date
SECTION 8•CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
S.Replshred Homo Inigni wnrM Contractor. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10•WORKERS'COMPENSATION INSURANCE AFFIDAVIT(li c.162,§2506))
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
i
.�. Massachusetts
c
�/S z
DITJUZ 8 r OF BUILDING INSPECTIONS
' 212 Nain Street a Municipal Building
Northampton, M 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, 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 convectors.
Note:If the homeowner has contracted with a corporation or LLC, that entity muse be registered.
Type of Work: rul !7 I ' ' Est. Costf/
7 , /
Address of Work, —13AA1"l7 f�1&-,d ✓t&- eoY'&i�#2:nl kL
Date of Permit Applicatiort 'pY!/ )
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 mum 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 ffoor a building permit as the owner of the above property:
a e Owner Name and Signa e
City of Northampton
Massachusetts
c
3
DSPMTNETiT OF BUILDING INSFSCTZONS 2 Fe
212 main street a municipal aIdtl., C
Northemp[ovn, sh 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 I I O 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.RS,provided that if a homeowner engages a persons)
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 persons) you hire to perform work for you
under this permit.
City of Northampton
-..r,
Massachusetts � p
n
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Dai.NT OF BUILDING INSPECTIONS ,rk
21212 Mein Stha Mni..,.1 euiltling Cm
NosthempGonon, ML 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:
11- 13 1� �A )at, d Ave, /gdrt6( y-)
(Please pri t ouse number and street name)
Istobe disposed of at:
�bt/J<„�C�4 0 t��✓�^tib i aYr / �
(Please pri Vame a d location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
/ (Company,Name and Address)
r�z �aQ , 61-(
Signature of Permit Applicant o 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
V
Department oflndustrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-20177
wwmmass.gov/dia
Rockers'Compensation Insurance Affli BuBdeNContradom/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organiiatiorclicividuap:
Address:
City/State/Zip: Phone#:
Arc you an employer?Check the appropriate hos: Type of project(required):
L❑l amaempl.yerwit employ.uffill amilirpan-time).• 7. ❑New construction
2❑I am a sol,pmpriemr or pm enhy and have no empioyecs working forme m $. ❑Remodeling
any capacity.[Fo workerscomp.imumnce wormed]
3.❑l am a homeowner doing all work myself[No workerscom, insurance required.]' 9. ❑Demolition
4AII a homrnwner and will be holo 10❑Building addition
�'� g workermrsnwnductallworkon my . twill
ore mai an covuacmrs either have workers'<omperaaoon tsumnce or are sole I1.❑Electrical repairs or additions
pmpreams with no employees. 12.❑Plumbing repairs or additions
s❑1 am a general contractor and I have hired the sub-cmaractrs listed on the stmched shell. ]3.❑Roof repairs
These sub-commuss have employees and have workers'comp.msmance.
6.❑Weare curricula.ancl.liicem have exercised nicer right ofexemption per MGL c. 14.❑Other
152.§I(4),mdwehavenoemdoyees.[No,rdrkeR comp Durance req d.l
Any apphcant not checks box#I must also fill out the section below showing men workers'compensation policy information.
t Homeowners who submit tis an di vit com ming they are doing all work and Nen hoe outside ca means now submit a new affidavit indicating such.
IC.nnactors tat check tis Mx muse sayetwd an additional chem showing the none or Ne sub-contromors and state whether or not Nose entities have
employees. Ifthe sub-mnnac[ors have employees,they must provide their workers'com,policy number
I am an employer that is providing workers'compensadon insurance jar my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy ofthe 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 ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I da hereby�ce"rtify under thepaaiins and penalties of perjury that the information provided above is nue and correct
S' t itW /VI Date rd
Phone#: f !3. 5735- - 77z5-&'
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/Liemse#
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,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
ofthe 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 ofthe
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 ofthis chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely, by checking the boxes that apply in your situation and,if
necessary,supply sub-conamtor(s)name(s),address(es)and phone numbers)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 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 ifyou 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 of the 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