06-064 70 CHESTNUT AV EXT BP-2019-1212
GIs#: COMMONWEALTH OF MASSACHUSETTS
MawBlock:06-064 CITY OF NORTHAMPTON
Imo,-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categom GARAGE BUILDING PERMIT
Permit# BP-2019-1212
Project# JS-2019-001963
Est.Cost:$47000.00
Fee:$106.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JEFFREY MORIN 97133
Lot Siu(so,R.): Owner: IMRE LYNNE
Z ni : Applicant. JEFFREY MORIN
AT, 70 CHESTNUT AV EXT
AoniicantAddress: Phone. Insurance:
29 GRANT AVE (413) 374-7799 O
NORTHAMPTONMA01060 ISSUED ON:5/2/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.ADD 2 CAR DETACHED GARAGE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: semi": 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 OccuoancY signature:
FeeTYDe: Date Paid: Amount:
Building 5/2/20190:00:00 5106.00
212 Main Street,Phone(413)587.1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Pile p BP-2019.1212
APPLICANT/CONTACT PERSON JEFFREY MORIN
ADDRESS/PHONE 29 GRANT AVE NORTHAMPTON (413)374-7799()
PROPERTY LOCATION 70 CHESTNUT AV EXT
MAP 06 PARCEL 064 000 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ZONING E OSE REQUIRED DATE
F FILLEDOUT
Fee Paid
Building Permit Filled out
Fee Pa'
Tvre*f Construction, ADD 2 AR DETACHED
Now Construction
Non Stmctuml interior renovations
Addition to Existine
Accessory Structure
Building Plans Included:
Owner/Statement or License 97133
3 sets of Plans/Plot Plan
THAELLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
NATION PRESENTED:
_ roved_Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§ ~
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Sim Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Findings 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 Conservmion Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
_Demolition Delay
at� `414- 0 set
Signature of Building Official Dam
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 mom information.
f
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
j 212 Main Street Sewer/Septic Availability
Room 100 WateoWell Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 7-SITE INFORMATION
1.1 ProoeM/Address: This section to be completed by o
�FJ �lte$.�,I✓a' 7"q � 1^S r'M�/ Map�� LM f 6/Cl _Unit
✓l S �1.1� Zone Overlay Dlstrct
Elm St.DisWfc Ca Dfsblct
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZE D AGENT
2.1 Owner of Record:
L e 1 �2 Gsti1 ,f / G�f
Na Ptlm) Cumm Maill Address:
lis 1S�bI
(�. al�Te1..111.L
Telephone a
Sig a1u e
2.2 Authorized Aaent:
J iz�tt'tF y MeR , ✓ 2a C,� 4-ve /V.17^/ 010t,
Name(Peon Current Mailing Address:
y12, —
Signstu TNephone
SECTION 3-ESTIMATED CONSTRUCTION COM
Item Estimated Cost(Dollars)to be Official Use Only
completed by permitapplicant
1. Building U� d U v (a)Building Permit Fee
2. Electrical (2 d O D (b)Estimated Total Cost of
i Construction frau 8
3. Plumbing Building Permit Fes 0
o
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) D.40 Check Number 2
This Section For Official Use Only
Date
Building Permit Number Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
C
Section 4.jSide
All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Tins column to be Mail in by
Building De mnmr
Lot Size
Frontagea S
Setbacks
L R: L14 R:�
Rear
Building Height
Bldg.Square Footage rZ
Open Space Footage % /
tot am minus bldg&paved
#ol'Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO I& 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 0 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 AIN
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 X18/
IF YES,describe size, type and location:
E. Will the construction activity disturb(clearing,grading,pexc�avation,or filling)over i acre or is it part of a common plan
that will disturb over lam? YES O NO C&
IF YES,then a Northampton Store Water Management Permit from the DPW is required.
SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors O
Accessory Bldg. Demolition ❑ New Signs [01 Decks (O Siding(01 Other[f]j
Brief Description of Proposed
WorkZ 014,1
: �
Alteration of existing bedroom_Yes---&_No Adding new bedroom_Ves 1 No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Sit If New house and or addition to existing housing, complete the following
a. Use of building One Family K Two Family Other
b. Number of rooms in each family unit Number of Bathrooms
c. Is Mere a garage attached? Alp
r �
d. Proposed Square footage of new construction. 4i 7 c7 Dimensions 7-
e.
e. Number of stories? 1
C Method of heating? AI ZA Fireplaces or Woodstoves /V o Number of each
g. Energy Conservation Compliance. W�4 Masscheck Energy Compliance form attached?
h. Type of construction
I. Is construction within 100 R. of wetlands?—Yes -X-No. Is construction within 100 yr. floodplain—Yes-!!L-Np
,r
I. Depth of basement or cellar floor below finished grade 19
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank_ City Sewer Ge- Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION•TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, +i
nAto. . 1 mIrL_ ,as Owner of the subject
proPeny
hereby authome J�-? A ,1 Zi A/
to act my behalf,in all afters lab to work authonzed by this building permit application.
3 .2"F prt � �A19
Signature (Owner /I /�� Date
I, d C ::P- t C- -z ^'/O/Ly A .as Owner/Authorized
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.
1 —F '7. MoIt'/A /
Print Name
Signature of Own ge Date
SECTION e-CONSTRUCTION SERVICES
8.1 Licensed Construction SupeMsw: Not Applicable ❑
Name of License Holder: d 1�7 w/ CS - O C/ /3
license Number
2—Gl [TY/A'�/ �'✓f� �Z /Z/ /2-'d
Atltlress E>tpkation Date '
SignatureTek hone
9.Registered Home Improvement Contractor. Not Applicable ❑
Compamv Name Registration Number
�(!�-v'r /a'(iP .v, f2.✓ O/dG0 IO �24 �Z-d
Address Expiration Da
Telephone y/ �
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e.152,1 25C(S))
Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide Mis afidavd vdll resu0
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No...... Cl
City of Northampton _
Massachusetts
PLPAATr6Al OF HUIIOIIr6 ZASPHCTZO(rS
-0 212 Nain Str t • Mnicipal Building h.
v Northanmten, Mx 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, afteretlon, 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 contractors.
Note:Lf the homeowner has contracted with u corporation or LLC,that entity must be registered
Type of Work ",9 6-14- _21I'C-�//' Est.Cost:q y}i,, ,,o
Address of Work: q2— Ut4 Mr1-
Date of Permit Application: '/ 2-9 • /r1
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 RESPONSIBHATES 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 permit as the agent of the owner:
Y, Zy • 1 Q -l v �t-� r9 i
Date Contractor Name H C Registration No.
OR:
Notwithstanding the above notice,l hereby apply for a building permit as the owner of the above property:
q,4 . u *; I aO lel
Date Ot a Na a and Signature
a
City of Northampton
r
Massachusetts
DBPB1tT1ffiiT OF BUILDING INSPECTIONS \
fie ' 212 min sezaat • mnicipal luildinq Y
Nn[tLa .., !0i 01060
Massachusetts Residential Building Code
Section 110.85.1.2
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 I I O.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
DSFART Wr OF aUZLDZNO ZNSFECTZONS
+ sis Z. sch«c .xu..01 s,.+iei�w
.ep
_ xo:cecoo, ew ooso
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:
E��/,..A � E',�r
(Please pont house number and street name)
Is to be disposed of at:
V A-L r.1 �C7c�fA�J—
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
J / J a4 se-. 4,.a,,v
(Company Name and Address)
` . Zy •/ cr
Si at a of Penn' pl nt or OwnelkDate,
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.
PIN
The Commonwealth of Massachusetts
Department of IndusirialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.massgov/dia
Workers'Compensation Insurance ARdavin Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/OrgmuatioNlndividual): J �� "LfI
Address: -2-°( '^•�
City/State/Zip: /Y . A,r l /V* d/ddd Phonek Lf/7 •��-y• ��-4s
Are you as emPbYer?Check me aPpeopriale has: Type of project(required):
I.C]I an a employer win employee(tWl atWmpmt-dm).* 7. New construction
2,r Ll am a ole pmpnetor or puewisltip=it neve n,a,ployeea waking for me in g. Remodeling
addy capmdy.[No workers com,insurance regmovd.l
3T11 am a hommwnerdaing all work myself.(No workers'comp.inure ee requined.]' 9. Demolition
4.Fl1 w a homcownn std will ba hhhlg cunaamors to cm =ttll work oo my pmpety. I will 10 Building addition
ure dm an corldid.either have wmkm'cmnpemation ipsurame or are sok 11.0 Electrical repairs or additions
proprietors wid no employee'.
12.❑Plumbing repairs or additions
Sj]I am a,—]emand.mail
grbmd I have hood the,�tid-,maracuvry lsed an
theesuh-e,muddddvnave emploeam nave wodkers the a mrh d Sh n.
crimp.insmauce.: 13.E]Roof repairs
6,❑We arc a cmpormum and in officers have exercised their right ofexempown per MGL c. 14. Other
152,11141,and we love on employee.(No workers'camp,insurance nyuimd.]
•Any applicant Wt checks hox#1 must also fill out the inion bebw stowing their workers'comprnsetion policy iobrmmamo
'Homeuwnen who submit this affidavit indicating they art doing all work and drn hire ourside condemn,must submit a new affidavit indcating such.
.,,that cheek dis box must marched an additional sheet showing the name orde subcontmcmrs and stmt whedwr or not those entities have
employees. Ifdn:ub-cmvaemrs have.mtployeea.auy must povih deu workers'comp.pokey numlzr.
I and an employer that is providing workers'compensation insurance for 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.
I do hereby cerdfy under the pains andpeneddes oirprierjury that the information provided above is true and correct
Sixn•tture: ADate 2t1
4!e • at Gi
Phone#: ,5 2:Z ?-" at
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License 4-
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspeclnr
6.Other
Contact Person: Phone N:
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 m"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,contraction 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)morsels),addresses)and phone number(s)along with their certificates)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 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 pernitAtemse 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 future permits or licenses. A new affidavit mus[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 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
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