32C-283 (7) 18 MONTVIEW AVE BP-2019-1214
GIS 9, COMMONWEALTH OF MASSACHUSETTS
Mao:Block:32C-283 CITY OF NORTHAMPTON
Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Casgoa demolitim BUILDING PERMIT
Emit# BP-2019-1214
Project# JS-2019-001966
Fs Cost:$6000.00
Fee $30.00 PERMISSION IS HEREBY GRANTED TO:
Const.Glass: Contractor: License:
Use Groom Homeowner as Contractor_
Lot Size(so. ft.): 43560.00 Owner: LEWISDORA&JAMESNASH
Zoning URCOOOI/ Applicant. LEWIS DORA & JAMES NASH
AT.- 18 MONTVIEW AVE
Applicant Address: Phone: Insurance:
18 MONTVIEW AVE 0582-0637(
NORTHAMPTONMA01060 ISSUED ON:5/3/2079 0:00:00
TO PERFORM THE FOLLOWING WORK.-DEMO RED BARN
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 5/3/2019 0:00:00 $30.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File ft BP-2019-1214
APPLICANT/CONTACT PERSON LEWIS DORA&JAMES NASH
ADDRESS/PHONE 18 MONTVIEW AVE NORTHAMPTON (1 582 0637(1
PROPERTY LOCATION 18 MONTVIE W AVE
MAP 32C PARCEL 283 001 ZONE URC It 001/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin¢Permit Filled out
Fee Paid
Toeof Conshvction, DEMO RED BARN '
New Construction
Non Structural interior renovations
Addition to Existin¢
Accessory Structure
Building Plans Included:
Owned Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON t
INF,91IMATION PRESENTED:
Approved_Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§_.
Intermediate Project: Site Plan AND/OR _ Special Permit With Site Plan
Major Project Site Plan AND/OR_ Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: § _
Finding Special Permit—- Variance*_
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW __Water Availability ____^Sewer Availability
Septic Approval Board of Health _._Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Ehn Sheet Commission Permit DPW Storm Water Management
Demolition Delay
_
Signature of Building Official lla[e
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
FIVED ,
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APPLICATION TO CONSTRUCT,ALTER REPAIR RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 P,mwtv Add.... This section to be completed by office
It r,1 -,A)04vieavz— Map �Aof- Lot— 12163 Unit
YV0rRAQ'y)F-+,V\ Zone Overlay District
Elm St District CS Dfstrfct��
SECTION 2-PROPERTY OVINERSHIPIAUTHORtZED AGENT
2.1Owner ofRecord:
r r rS I.S
-ct- �)—G mei
current Mailing
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Wing Mdress,
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
corroleted by permit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee *30
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(I -2-3.4+5) Check Number
This Section For Official Use OnDate
ly
Building Permit Number.
Signature:
Building Commissionedinspecor of Buildings Data
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
y6 0'- (c�,'r r) .",
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column m be fdlN or by
Building Dcpemmmt
Lot Size
Frontage
Setbacks Front
Side L: R:._. L:- R -._.. ... ... .....
Rear
Building Height.
Bldg.Square Footage - / - --- ---
Open Space Footage % -...
(Lot mm minus bldg&pavM
pride ...... ....... _.. _...
#ofParking Spaces --
Fill: -. .. ..._. ... ..-.. ....
vulumnffi
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 O
IF YES: enter Book Page.. and/or Document #'
B. Does the site contain a brook, body pf water or wetlands? NO DONT KNOW O YES O
— coit o , (OV 44- buFF-ice"
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
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 -0`
IF YES, describe size, type and location:
E. Wil the construction activity disturb(clearing,grading,excavation,or filing)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Stone Water Management Permit from the DPW is required.
R
SECTION S DESCRIPTION OF PROPOSED WORK icheck all applicable
1
New House ❑ Addition ❑ Replacement Windows Altaraganla) ❑ Ring ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition New Signs [0] Decks [0 Siding[0] Other Ili
Brief Description of Proposed pp '
Work'. �0.�G1✓1� �tVJ '�'�� ' l P� r10 r"N P✓1�'t i ���
Alteration of existing bedroom_Yes_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes _No
Plans Attached Roll -Sheet
Be.ff Now house and or addition to existing housing,conn iete the following:
a. Use of building One Family Two Family Dther
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 Woadstoves 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 regulations? Yes_No.
I. Septic Tank_ City Sewer_ Private well_ City water Supply_
SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Sgnature of Owner Date
1, 0(-G L-2-uin as OwnerlAuthorized
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 and penalties of perjury.
"D o r
Print Name
Signature of OwnerlAgenl Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Morass Expiration Date
Signature Telephone
9.Reals%md'Nome lmproyeenent Coduitti Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 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 affitlavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
City of Northampton
-....::,
Massachusetts
tir F
DEIP.ita� OF BUZIOZ� INSPECTIONS
s
312 Main Street • Municipal Building
Northampton, MA 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 few 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, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pro-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 contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: Est.Cost:
Address of Work:
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 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:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property:
�Za CR boI Leu I5 �a C__
Owner Name and Signature
City of Northampton
-._.,.
Massachusetts
DEPART T OF BUILDING INSPECTIONS
Z
212 M+in Street • Municipal Building
tl, V• D
Norampton� !A 01060
Massachusetts Residential Building Code
Section I I O 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.R5.13.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.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.
City of Northampton
Massachusetts �" S
'i 4c
i s
V Dj'RdR1'bENT OF BUILDING 1XSVEOTI0N9 ig
1 212 Main Street *Municipal Building 5 S 0r9
Norttamptco E 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:
(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:
-L&- h l de ls �
(CorniparryNarriie an Address)
Signature of Permit 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.
'1 The Commonwealth of Massachusetts
Department alcIndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-20177
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer. Check the appropriate Imx:
Type of project(required):
to I am a employer With_employers(full and/or patn-dme),* 7. ❑New construction
2.�1 am a sole proprietor nr patmership and have vo employees working forme N 8. ❑Remodeling
any capacity.IN.workers'comp-insurance morel.]
3.[J l am a homeowner doing all work myself,[No workers compinsurance required.]' 9. ODemolition
61 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10❑Building addition
awe that all commerors eimer have work.,compensation iner—seor aremle I LE]Electrical repairs or additions
proprietors with no employees.
12.[—]Plumbing repairs or additions
5 M 1 am a general contractor and I have hued Ne ve..fl ws',or Ils[N on the cached sheet. 13.❑Roof repairs
"Ilrese sub<ontra:mrs have employees and have workers comp.insurance.
fi.❑We are aco timavd its officershaveamo iocithehn mfeximtion 14.❑Other
rpom gJt p per MGI.°.
Isz,§I(4),and we have no employees [No workers comp.Ncumvice required.]
II
*,,ay applicant that checks box#1 must also fill out the wereen below showing their workers'compensation policy infotnation.
'Homeowners who submit this affidavit indicating drew,are doing all work=it Nen hire outside contactors most submit a new affidavit indicating such.
:Cre vaMrs that check this box mut attached an additional.sheet showing the came ofthe sub-conoamom and sure whether or not those entities have
employees. If the sub-cmerna mix have employees,they must provide Neu workers'comp.policy vooplaw
I am an employer that is providing workers'compensation insurance jar my employees. Below is the policy andjob 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,§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.
ldoherebycerti underthepaams andpeaahies afperjury that the information provided above is true and correct
Signature- G C,- Date- I(
Phone# yj3 L-q,�— 73 �6 'Z—
Official
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#:
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 ofan 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 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),addresses)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 az 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 permiWicense 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 proof that a valid affidavit is on file for more permits or licenses. A new affidavit must be filled out ex
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