38B-219 (3) 17 FAIRVIEW AVE BP-2019-1185
GIS x: COMMONWEALTH OF MASSACHUSETTS
Map-.Block:38B.219 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category:window replaced BUILDING PERMIT
Permit a BP-2019-1185
Proiectp JS-2019-001923
Est.Cost.$6000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use croup: Homeowner as Contractor_
Lot size(se.R.): 4399.56 Owner: POTTER DAVID
Zoning:URB(100y Applicant. POTTER DAVID
AT: 17 FAIRVIEW AVE
ApolicantAddress: Pkone: Insurance:
47 FAIRVIEW AVE (612) 363-9171 1)
NORTHAMPTONMA01060 ISSUED OtK412412019 0.00:00
TO PERFORM THE FOLLOWING WORK REPLACEMENT W I N DOWS
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:
Driecwey Final:
Final: Final:
Rough Frame:
Gar: Fire Department Fireplace/Chimney:
Rough: (ZB's 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:
FeeTvoe: Date Paid: Amount:
Building 4/24/2019 0:00:00 540.00
212 Main Street,Phone(413)587-1240,Fax:(413)587.1272
Louis Hasbrouck—Building Commissioner
Sig ,� ��,,Vjeu1
47 FAIRVIEW AVE BP-2019-1185
GIs a: COMMONWEALTH OF MASSACHUSETTS
Mao:Block: 38B-225 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category window replaced BUILDING PERMIT
Pa reit# BP-2019-1185
Proicct# S-2019-001 3
Est Cosh$6000.
Fee:$40,00 PERMISSION IS HEREBY GRANTED TO:
Const.Claes: Contractor. License:
Use Group, Homeowner as Contractor
Lot Size(so.for 5532.12 Owner: POTTER DAVID
Zoning:URBnoou Applicant. POTTER DAVID
AT: 47 FAIRVIEW AVE
ApolicantAddress: Phone., Insurance:
47 FAIRVIEW AVE (612) 363-91710
NORTHAMPTONMA01060 ISSUED ON.4/24/2019 0.00:00
TO PERFORM THE FOLLOWING WORK REPLACEMENT WINDOWS
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: ()it,. 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:
FeeTvoe: Date Paid: Amount:
Building 4/24/20190:00:00 $40.00
212 Main Street,Phone(413)587.1240,Fax:(413)487.1272
Louis Hasbrouck—Building Commissioner
6V iNOoWS
Department use only
/— City of North imp I
s o Permit:
Building Dep rtm nt Cu Driveway Permit
212 Maln tree APR 2 4 2019 OS ptic Availability
?{, Room 1 0 r all Availability
Northampton, A Se of Structural Plans
phone 413-587-1240 ax4 F � �rea mitite Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION a^
1.1 Property Address: 1:1 FhRViF.uj AVE This section to be completed by office
ND I-If �fUs.l
etA o�060 Map_ !� Lot a 6- Unit
�
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
-DAVID p�EL y 7 �G it f/!Palms
Name(Prim) Current Mailing Address:
Telephone !� _ .3 _ 9 /1
SlgneNre -!
2.2 Authorized Agent:
Name(Print) Current Meiling Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building tGw (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee �{I
4. Mechanical(HVAC) 4�
5. Fire Protection
fi. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Porm Numb r: to (/
4Z Issued:
Signature: I' 24-
Building Commissionedlnspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Aust Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size �. J
Frontage
Setbacks Front
Side L R: -=-J U R:
Rear
Building Height ,...,.. -�
Bldg.Square Footage E= % r�
Open Space Footage
lea oma minus bLlg a paved
#ofPai Spaces
Fill:
wh.@Lwow
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO ® DONT 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
IF YES: enter Book Pagel— and/or Document#F
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW O 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 Q
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. Will the construction activity disturb(clearing,grading,(e�xcavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 aae7 YES O NO t�
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 ❑ Replacement�ndows Iteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding[O] Other[CQ
Brief Description of Proposed
Work:
Alteration of wasting bedroom_Yes V/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, complete the following:
a. Use of building : One Family Vill Two Family Other
b. Number of rooms in each family unit:� Number of Bathrooms
c. Is there a garage attached? ift
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 farm 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 CitySewer Private well City water Supply
SECTION Ta-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 matter:relative to work authorized by this building permit application.
SignatureOwner Data
I, as Owner/Authorized
ant h clare that the statements and information on the foregoing application are true and accurate,to.the best of my knowledge
n
Signed u /�_ a pains and penalties of perjury.
KIST/ANdp �
O /r I4Z
Print e
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of Liunae Holder
License Number
Address Eyiymation Date
Signature Telephone
9.Registered Home Improvement Contractor. Not Applicable O
Company Name Registration Number
Address E>i3iration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C.152,§25C(8))
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
n Massachusetts
L s
? moi''IfY D212 Win S OF BpIDniZIGci INaFacan,
212 Win atxwt •Mnniei 1 auiltli
W M < e
Northmg,tan, NA 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:
/4 441,eyjEu> fyf— . A)6zrMflml'ftw ij1
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
Vof�Permit
ess)
�9ig 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
Department oflndustrialAccidents
1 Congress Street, Suite 100
Boston,B14 0211 4-2 01 7
www.mass gow1di s
\\a-kers'Compensation Insurance Affidavit:Buflders/Contractors/Electdcians/Plumben.
TO BE FH.ED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name(Bwinsa/Orgaoixatiudlndividml):
Address:
City/State/Zip: Phone#:
Art.......turns?Check the.ppropri,te box: Type of project(required):
1.[]l ausaemptorer with mPioras(full and/or prat-bane).• 7. ❑New construction
2.❑Iamaaole proprietor or pereenhiP and have no employea wodrina for me in 8. ❑Remodeling
any capacity.[No worken'conµ.imumnce required]
3.❑I an.lut. cr doing all work myself Mo wmiro
kmrrµ.be.reµured.]t 9. Demolition
4.gf1 m a homeowner and will be hiring wnwc[onsm conduct all work on my..perry. I will 10❑Building addition
am=that an contrarom either have wodremsrnmprnation inaunncenrare sole 11.❑Electrical repays or additions
pmprietom with no employees.
12.E]Plumbing repairs or additions
50 1 am a general contractor and I have hired the subcontnctm listed on the attached sheat. 13.❑Roof[epere
Tbese subcontr ca ocoa have emptoyeand have worked comp.imen ace.
6.❑We m a wµomtiw and at officers have exercised their tight of exemption pa MGL c. 14.[]Other
152,41(4).aMwe have m employees.[No workers'comp.insuraae required.]
•Any applicant that checW box#1 most also fill out the section below showing thenwmkcn'comprnatien policy infomatie..
t Homrnwnm who submit this affidavit indicating they arc doing all work and then hire outside connacto a must submit a new affidavit indicating such.
tConnacto s that check this box must attached an additional sheet showing she once of the subcontractors and stage whether or not dunce entities have
mpleye.. If the sub-cor nam.have emptoyces,they most provide their workers'now.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the worken'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 imp nment,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 viola r.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage veriftc;r
I do hereby cent the pains andpenanies ofpedm y that the information provided abolle is hue Pred carred
Si a _ e� I Date: M
Phone#: � ( S8 U f
Official use only. Do not write in this area,to be completed by city or town official
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#:
City of Northampton
:yam
Massachusetts
l�
DiPARTMENT OF BOZLDING INSPECTIONS
i.
212 Nain Btcut • NaNA 01l Building
wp \ CD
aact� [on, as 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 CHIC').
M.G.L.Chapter 142A requires that the"reconstruction,alteration, renovation,repair,modemization, conversion,
improvement,removal, demoltt/on, or construction of an addition to any pre-existing owner-occupled building containing
at least one but not more than four dwelling units....or to structures which ere 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 registeredType of Work: Q;pWa: W;N�w `J .1 Est.Cost 6, Goo
AddressofWork: (-1 �ritkyi(Ew 'MN
/VE Off' ib� p1mA) f 01A Q/06'o
Date of Permit Application: �,� 4/ nZof9
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
_lamer(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 RESPONSIBH.ITES 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:
Notwithsran ',ng the above notice,I hereby apply for a building permit as the owner of the above property:
y la� /�Za 9f >k 1) 1�oTrF����
�
Date Owner Name and Signature �
City of Northampton
Massachusetts
(a DBPABTNIIrT or BUILDING INSPECTIONS
212 Gain St t a N ieipal BuilE ng
aosthan n, M 01060
Massachusetts Residential Building Code
Section 110.115.1.2
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 110.115.1.3.1
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.