38A-082 (4) 48 CHAPEL ST BP-2019-1201
GIs#, COMMONWEALTH OF MASSACHUSETTS
MWp:QIak:38A-082 CITY OF NORTHAMPTON
Lot:-W PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catenorv:ROOF BUILDING PERMIT
Permit# BP-2019-1201
Project# JS-2019-001950
Est Cost S8000.0
Fee;$40.0o PERMISSION IS HEREBY GRANTED TO:
Const,Class: Contractor: License:
Use Group: PAUL MCCUTCHEON 062544
Lot Size(su.ft.): Owner: WILDWOOD COURT CONDO ASSOC
Zoning:URB0001/ Applicant: PAUL MCCUTCHEON
AT. 48 CHAPELS
Applicant Address: Phone: Insawnce:
134 EASTHAMPTON RD (413) 584-3352 0
WESTHAMPTONMA01027 ISSUED ON:4/262079 0:00.00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE GARAGE ROOF ONLY
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector otWiring D.P.W. Building inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Fivah Final:
Rough Frame:
Gas: Fire Department Fireplaea/chimney:
Rough: Oil: Insulation:
Final: mok • 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 Pdd: Amount:
Building 4/26/20190:00:00 $40.00
212 Main Street,Phone(413)587.1240,In:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Nort mp n a of emit,
Building De ftm nt Cu CW nveway Permit
212 Main tre APO 2 6 2019 rrS tic Availability
Room 00 WerNV II Availability
Northampton, T Se of Structural Plans
phone 413-587-1240 4 - . I N$PEo She
MAM0 lane
y
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE
OR TWO FAMILY DWELLING
SECTION 7-SITE INFORMATION
1.1 Property Address'. This section to be cc yeabed by office
a- I S,�( - Map Lot (//7d Unit
1 �/Q- J , _ 1 A ^ . Zone Overlay District
1.eYL` 'S'IN Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORRED AGENT
2.7 caner /Reeo \1
C mss. ygCt Skal- c>,; F
Nt)^ /- Current Mailing AGEress
ra��
:
Telephone
ignet e
2.2 Authorized Agent:
a, XTAA&Wk
Name(Print) Current Mailing Andress:
413 - 'z�3 - -31(4
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
coin leted 4 rink applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fw
4. Mechanical(HVAC)
5. Fire Protection 11,7
6. Total=(1 +2+3+4.5) Check Number
This Section For Official Use Only
Building Permit Number: Date
f�
Signature: Issued: I ' ZL'�19
Building Commissionerdnspector of Buildings Data
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING AR Information Must Be Completed. Permit Can Be Dented Due To Incornplete Information
Existing Proposed Required by Zoning
Thu column to be filled in by
Building Depa,4amt
Lot Size
Frontage
Setbacks Front
Side L_. _.. R: _. U R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(tot arta mina bldg&pew
akin ) __...._
k of Puking Spaces
Fill:
vid ane&Lacvion
A. Has a($�pedal Permit/Variance/Finding ever been issued for/on the site?
NO s0'— DON'T 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 4§— 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 G NO O
IF YES, describe size, type and location: I }o ,k- X Z
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO tV
IF YES, describe size, type and location:
E. NAZI 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 Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ FRepiacementlillindows Ateration(s) Q Roofing
rs O
Accessory Bldg. ❑ Demolition ❑ 1 igns [E3) Decks [O Siding[01 Other(U
Brief Description of Proposed >^7 {n I ,�S LI I �R f 1 U�' Ciu /,a��
Work. l• / p�j l
Alteration of existing bedroom_Yes_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _Yes _No
Plans Attached Roll -Sheet
ea. If New house and or addition to existing housing, colnolttte 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?
I. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
1. 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 regulators? Yes No.
1. Septic Tank_ CitySei Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETEDWHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Ac2c, to as Owner of the subject
property �` ( _
hereby authorize !n 0 . Ac� it JVC ,
to act on my behalf,in all re to work authorized by this building permit application.
Signature of Owner Dale
I, as Owner/Authorized
Agent hereby declare that the statements antl information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the ins a d penalties of perj
R.
Print Name
Signature of cwnenAgei Dab
M1
SECTION 8•CONSTRUCTION SERVICES
8.1 Licensed Construction Su isor: Not Applicable 0 /y ,�
Name of L / -S
icense Holder'. l -0rz !^'4Y
License Number
">q
Address E piraaon Date
Signature Telephone
9.Re catered Home I etor: Not Applicable 0
pct C.,R1 . 1 tee-, /CYV;>le
Company NameRegistration Numbe
F-MASel"I'l I at RIAARS
Address Expiration Dat
Telephone
SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(Ii c.152,S 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted wth this application. Failure to provide this affidavit vdll result
in the denial of issuance of the building permit.
Signed Affidavit Attached Yes....... No...... 0
City of Northampton
Massachusetts ,'rS. '�✓4
c
L
LSPARO'MIIlT
OF BDILDING INSPEOSZONS
212 Iain oust • Nwicipel au1161nq
NnrthL ten, 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 most be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration,renovation.repair,modamization, conversion.
improvement,removal,demolition,or construction of an addition to any pre-existing owneroccupied 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: 12 CA'),1' a /'y Est.Cost: 8
l
Address of Work:P LI CS d— �-adli�O.
Date of Permit Application: [2
1 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:
1 hereby apply for a building / v I C t as the agent of the owner:
7l�lis 14 ,, l�2►�
Date Con actor 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 5- :4
l
- � DE0?ARTl6NT 08 80ILDZNC ZN8P8CTIONB
212 l in St—t • E nici"I Building
NorthBry n, I 01060 »le
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 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 110.115, 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
a _ -..•.
Massachusetts
i
1ffi'PMaPRNT or HUZLDxaG xNSPlCSZONs
xlx win etr.at *N icipal Ruildinq
N.t=zt0n, M 03060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, 554, 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
ff at:
l�A1a.1 Sd-l —
(Please print house number and street name)
Is to be disposed of at:
0't[ , R
(Pleasel print name am iocatiorKbi facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
qILV t9
Signature 6f Permit Applicant or Owner Dat
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 ofMassaehusens
Vivarkers'Compensiation
Department of IndustrialAccidents
1 Congress Street,Suite 100Boston,MA 02174-10177w vIamass gov/dia
Insurance Affidavit:Builders/Contrastors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print L&Abl
Name(BusinesslOrganizatiowindividml): 11 el'� �/
Address: 130H -lata C11
CN
City/State/Zip: /4 Phone#: 40-7-0 — 3 I N"1
arersa v mnployer.eh=k tae app.apdate hos:
Type of project(required):
1.E3 1 sat a employer wit employees(full anduor pan-tuned a 7. ❑New construction
2.❑I am a sok pmpnewrorpa =hip and have no employ=s wodtg forme m S. ❑Remodeling
my capacity.(No workers'comp.wamnce "uued.]
r.❑I an ahomevwmm doing all wand myself.(No workers'comp,momence rryuirtd.] 9. El Demolition
4.111..hom=wner it will be having contnda t to conductau wark an my M, rry. [win 10❑Building addition
ewne tat all conoacmrs eifhmhava workers co�eavdon immanccmare role ll.❑Electrical repairs or additions
pmpnmors with an employee,
12.❑Plumbing repairs or additions
AM 1an.hevc ge==l cuntracuor anal haw,c1havehindtheve windnacwrs IutNs to a=ched sheet 1J (repairs
� subcontructon have employe==d have wanders'comp.immmce.:
6.❑We are a corymmion arta in officers have exercised tau right of excoriation per MGL e. 14. Other
152.§1(4),and we have no employees.[No workeri comp.wurence national]
eMy applicant Wt checks box mus
ox#1 t nut,fill am the section below showing tet,wodns'compensation policy mfunnawn.
e Homeowners who submit tis affidavit indicating they are doing all work and Wen hue outside conusmors must submit a new aflduvil indicating such.
1(ontractors than check tis box must atwched an additional shed showing he wme of the sub-contractors and ecru wheWer ue nut thus.amities have
conclaves, If the subcunaacmrs have nnployevs,hey must provide teff woders comp.Wficy numM,
I on an employer that is providing workers'compensation insurance jar my employees. Below is Me policy and jab site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 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. 152,425A 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.
Ido Hereby certify de the/p ins and penalfies of per%ury that the information providedI a iis//brue end co rea
Sienaturc: eG �t(_/�� Date:
Phone#: OD
Oficial use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle ane):
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
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or tmstee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than throe 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,§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 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 tarty workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit maybe 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 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 a[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 permitilicense 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 in the
applicant as proof that 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 Cormnonwealth 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.nhass.gov/dia