31A-009 (6) 281 ELM ST BP-2019-1202
GIs 0, COMMONWEALTH OF MASSACHUSETTS
Magi§&k: 31A-009 CITY OF NORTHAMPTON
t 1 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category; ROOF BUILDING PERMIT
Permit# BP-2019-1202
Proiect# JS-2019-001951
Est.Cost: 85000.00
Fee: 840.00 PERMISSIONIS HEREBY GRANTED TO:
Const.Class: ContraMor: License:
Use Group: JAMES ROBERTS 99404
Lot Size(sa. ft.), 29620.80 Owner: DARDANO KRISTIN L&LILIBETH K DENHAM TRUSTEES
Zoning, URB(100y Applicant: JAMES ROBERTS
AT. 281 ELM ST
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTONMA01027 ISSUED ON:5/7120I9 0:00:00
TO PERFORM THE FOLLOWING WORESTRIP & SHINGLE ROOF **must meet historical
district requirements`"
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 Occupancy Signature:
FeeType: Date Paid: Amount:
Building 52/20190:00:00 840.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Lit"!fi'r/y a1�d2iC, CIO iF-^'- F
EC E I V Department use only
City of North mpt of rmit:
/ Building Depi rtme it Curb Cveway Permit
212 Main S reefIs, is Availability
Room t o APR 2 5 201 al rNVel Availability
Northampton, h A 01 60 Two iso Structural Plans
phone 413-587-1240 F ix 4697587+4162*iNqpf 6fdA59te Pi ins
NORTHAMPTON.MAV 1OF6 ty
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE�OR TWO TWO FFAMILIY�DTWEELLING
SECTION 1 -SITE INFORMATION lel // or fp—
to Property Address: .�This section to be completed by office
Map .�ti.� Lot `-"' vJUnit
�-t Y Zone Owday District
Elm St.District CS Diablo
SECTION 2.PROPERTY OWNERSHIPIAUTHORQED AGENT
2.1 Owner of Record: `�
1�i1-I r� an t,'''
Na / Current Mailing Atltlresa
J 0jP_ggAzSgGi :
Telephone
Signature
2.2 Authorized Agent: �y;
Name Cunent Mailing Atltlress:
�4- o&,s
Sig ' m
Telephone
SEC ON 3.ESTIMATED CONSTRUCTION C STS
Item Esti Cost(Dollars)to be Official Use Only
eted by permitapplicant
1. Building (a)Building Permit Fee
2. Electrical !� (/ (b)Estimated Total Cost of
Construction from e
3. Plumbing Building Parfait I" a
4. Mechanical(HVAC) �U
5.Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use On
Building Permit Numbs Date
Issued.
Signature: N-1-ZO►9
Bunting Commissioneranspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Must Be Completed. Permit Can Be Card Cu
Carved! To Incomplete Information
Existing Proposed Required by Zoning
Thia whmn b be filled in by
Building Drymtmcnl
Lot Size
Frontage
Setbacks Front
Side L: R: . L:.___ R:--
Rear
Building Height
Bldg.Square Footage
Open Space Footage
( ot out minus bldg&Wved
is ofParking Spaces
Fill:
volume a t.aarirn
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O 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 O
IF YES: enter Book Page 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 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
IF YES, describe size, type and location:
E. Will Me construction activity disturb(Gearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Stomn Water Management Permit from the DPW is required.
SECTION S DESCRIPTION F PROPOSED WORK check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors O
Accessory8lde ❑ Demolition ❑ New Signa [0] Decks [p Siding[01 Other[0]
Brief Description of Proposed Nl,>51 M&&T
Work: _
N1450¢K. 015TOL
Alteration of existing bedroom_Yes_No Adding new bedroom Yes 1100,
No
Attached Narrative Renovating unfinished basement _Yes No �R1
Plans Attached Roll -Sheat
Ga,ff New house and or addWon to existing housina. complete the following:
a. Use of building. One Family Two Family Other
It. 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 It.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, �tli t/-" � as Owner of me subject
grope
hereby authorize
to act o in behalf. in a a rs cal work auNonzed by thn bwklmg permrt applicauon.
Sign uniof Owner ✓ Date
I, as Owner/Authorized
Agent her by eclare that the staldmerft and information on the foregoing application are true and accurate.to the best of my knowledge
and belief.
Signed under the pains and penalties qury. n
5- I J
Print Name
Signet o OwnerlAgeM Dste
SECTION 8.CONSTRUCTION SERVICES
8.1 Licensed Constmction SuoerAsor: Not Applicable ❑
Name of License Holder:
n l roe NunYltt
Atltlre _ Expiration Date [
ig Use Telephone
Im nsvemellt Cont Not Applicable ❑ !/
// nZNfie
Co a Name - Registrat n Numbe
Address Expiration Date
Telephone ("3
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152,S 25C(8)) 0 U
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in th denial of the issuance of me building permit
Signed Affidavit Attached Yes....... ❑ No...... ❑
City of Northampton
Massachusetts F/ L rc4c
nCPARTIIINT OF BO WZM INSPBCSIONS
212 lLin etNun
Street • iol in 1 Build—9
Nosthaepton, !Y 03060 g
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
perforating work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconsfructian, alteration, renovation,repair, modernization,conversion,
improvement,removal, demolition, or construction of an addition to any pre-existing ownenoccupied 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 b registered 11
Type of Work `— Est. Cost: Z�r O
Address of Work
Date of Permit Application: 4-( ���
I hereby certify that:
Registration is act 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 fm a building pemut ,�agge/ent.of the owner:
U7 %may
Date C&dractor Name HIC Registration No.
OR:
Notwithstanding th above notice,I hereby apply
�for
raa building permit as the owner of the above property:
Dam
�� �Q�2avSi /
Dale O ne time and Signature
_ City of Northampton _
Massachusetts
o<
DE12 1. S ..BUILDING INSPECTIONS odt
312 Main rfr u /Lon 010 luiltlin9
MuctAa�lun, !P 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 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 110.85, 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
Massachusetts
z
nseaanmvz or soraozac zasnscazaas
212 M.ln sts«t .N iciwl Buildup
xo:th. .n, . 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:
� i r4- a. 7
(Plea print house number and street name)
Is to be disposed of at:
( se print name and location of facility)
Or will be disposed of in a dumpsler onsite rented or leased from:
O(Uornpail;YjName And ss)
Sin ure o PermiA plicant or Owner Date
If'7r 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.
r-"` The Commonwealth of Massachusetts
Department of IndiustrialAccidents
I Congress Street,Suite 100
Boston,MA 01114-2017
www.mass,gov/dia
VxXidirken'Compensation Insurance Affidavit:Builders/Contrastors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Letibly
Name(Business/OrganizatioNlndividual):
Address:
City/State/Zip: Phone#:
Are you m mauda, .Ch7i roe appropriate boa:
Type of project(required):
L�❑�//l`em ecmploym with employees(bill and i-pmt-amok• 7. ❑New construction
2.1 .(J.amd9olt pmpsietnr orpermershipand have no employees working humans 8. []Remodeling
''--rP^any capnary.INa workers'comp inv. required]
3.❑I am a homeowner dews all work myself[No wooer'comp.insurance required.] 9' ❑Demolition
4.❑1 run a homeowner and will be hiring conaacom to cotdmt all work on my property. 1 will 10❑Building addition
rnsme mm anwmecmrs eimer have wmkeri compewtion-•.umnce or art sole 11.❑Electrical repairs or additions
'aromenera with tw employees. 12.❑plumbing repairs or additions
5❑1 am a general mntracmraM I have hired the sub-somerm.listed on the attachee sheet. 13.�ROOf repairs
These subemmutue have employees and have workers'comp.inm
sume.t
6.❑We are a cotpnrdion and its nouns have exercised they east ofexe,ams.per MGL c. 14.❑Other
152.G 1(a),arW we have no empwyees.[No workers'compmomenx required.]
•AnY applinm that chicks box#1 must also fill out the section below showing Mev workers cmrtpureamin policy information.
r Umne wners who submit Nis aaidavit ndicatng the,are Jong all work and then hire outside contractors must submit a new affdavlt iMimmng such.
lCoommums that check this box must sumited an additional shed showing the name of da subematmel rs and sere whether or net Nasse imides lave
employees. If We sub-conaadom have empbytts,thry must pmvidc Neu workers sum,i.yliry number.
I am an employer that is providing workers' pensaaon WIumunce for my employees Below is the policy andjob.site
information.
Insurance Company Name:
100o—
Policy#or Self-ins.Lic.#: Expiration Dam:
Job Site Address: City/StatdZip:
Attach a copy of the worker'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,✓t25A 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 ccrdfy der the pains andpe s Of erjuy thatthe information provided above is true and correct
P
Si natur Date:
Phone#:
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.Citylrown 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 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 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 waste 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-contractors)morels),address(es)and phone number(s)along with their cenificate(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 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 pemtitAicense number which will be used as a reference number. In addition,an applicant
that mus[submit multiple permitAicense applications in any given year,need only submit one affidavit indicating current
policy infamnation(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 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 lineman to bum 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