29-297 (8) 120 BROOKSIDE CIR BP-2019.1325
GIs a: COMMONWEALTH OF MASSACHUSETTS
Map:B1ock:29-297 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Pertntt: Buildinc DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv,REPAIR BUILDING PERMIT
Permit a BP-2019-1325
Proiect4 JS-2019-002138
Est.cost $4275.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class, Contractor: License,
Use Group: MR HOME 103401
Lot Size(sp.it.): 14287.88 Owner: ANDREWS BEVERLY R&RANDY K&RICHARD A&KENNETH D&
KELLY V&SUSAN B DOYLE
Zoning: Aggg ant: MR HOME
AT: 120 BROOKSIDE CIR
AaalteantAdAress: Phone: Insurance,
74 CISLAK DR (4131222-5368 WC
LUDLOWMA01056 ISSUED ON:5/2112019 0:00:00
TO PERFORM THE FOLLOWING WORKINSTALL 130 FT OF 4" PVC PIPE INTO SUMP
PUMP
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: t>L Insulation:
Final: Xe; Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy slenature:
FeeTYDe: Date Paid: Amount:
Building 5/21/20190:00:00 565.00
212 Main Street, Phone(413)587.1240,Fax:(413)587.1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
` 212 Main Street Sewer/Septic Availability
Room 100 WaterM/ell Availability
Northampton, MA 01060 Two Sets of Structural Plana
phone 413-587-1240 Fax 413587-1272 Plot/Site Plans
.Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address. This section to be completed by office
/a wnogefice L/nt/e Map Lot cn7 Unit
,A AIM, Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
/emgxiiT' �` 1?&AI /#/I. t
Name(Prim) Current Mailing Address:S
� , 22 L
Z
Signalur /JCv � Telephone
2.2 Authorized Agent:
-1h"�����
Name(Print) Current Mailing Morass:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permita licant
1. Building3/2,LI" (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Permit Fee _
4. Mechanical(HVAC)
5. Fire Protectign
6. TOWL(2 +2+3+4+5) Check Number !(p `� 3O
This Section For Official Use Only
Building Permit Number: Data
Issued'
Signature: S�z 1 19
Building Commissioner/Inspector of Buildings Dale
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
a
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 filled m by
Building De .m '
Lot Size
Frontage
Setbacks Front
Side L R: L R: --�-
Rear _.
Building Height
Bldg.Square Footage %
Open Space Footage
(Lw arca minis bldg a percd .o .. _..
k of Puking Spaces
Fill:
volume a Location
A. Has a Special Permit/Variance/Finin ever been issued for/on the site?
NO O DONT KNOW 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 Doclanent p
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW 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
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. WIII the construction actmty disturb(clearing,grading, ation,or filling)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 Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK Ichil all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) Roofing O
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [[:I] Decks [D Siding[O] Other IQ
Brief Description of Proposed
Wo* r✓
y1rz P,�� iQ�NA�d ;nlD .�4r�b Pyr
Alteration of wasting bedroom_Yes No f Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the following
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 stones?
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 ft. of wetlands?_Yes _No. Is construction within 100 yr. floodplain_Yes_Nu
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 7a-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 matters relative to work authorized by this building permit application.
Signature of Om�eerte / J Date
%/'L .b'1/�//'2 as Owner/Authorized
Agent hereby eciare that the s temente and information on the foregoing application are true and accurate,to the beat of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name e2i�� //
Signature of Owner/Agdin V Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:/ Not Applicable 13Nem.of Licenx Holder ,/YJ//Y/M/
lkeme Number
1 elfIA/r /D 3 VkW
Address Expiration Dae
Signature Tolson 2
8.Registered Norm Improvement Contractor Not Applicable/❑
Company Name Registra'on Number
Address bryiration.D�atta 7
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C.132,§2SC(6))
Workers Compensation su
Inrance aMdavd must be completed and submitted with this application. Failure to provide This alfidavd will resu8
in the denial of the issuance of the buildin pennd.
Signed Affidavit Attached Yes....... ❑ No...... ❑
City of Northampton
r
Massachusetts
c
\ 0a'PMSIffi!1' OF BDILDZNG ZnaPFCTIOna 2, w
212 Min tr • auax 01l Building T�
aorNupCon, b 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
perforating work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconshuction, alteration.renovation,repair,modemization, 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 buihlitg"be
done by registered contractors.
Note:If the homeowner has contracted with D corporation or LLC,that entity must be registered.
Type of Work: &eeA /O,6L� Wl/n��t� rEat.Cost: yz z)
Address of Work: Jo�p
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 owneroccupied
_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 permit as the agent of the owner:
Date Contractor Name HIC e�stration 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 � c4
i
D212 B n S 08 BOZMunici al Building `11
212 IYin Bt *x,, Mu.01l Building i
XorNwpCon, XR 01060
Massachusetts Residential Building Code
Section 110.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.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.
l
City of Northampton
( Massachusetts L a�
1, S
I DEPARTMENT OF BNIIDINO INSNS
212 Hin Street • Wnicipml Buildxng
Norlhpton, ,F
t pCn
MA 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:
z aAw A-0�mG,�'6,f
(Please pont name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Permit Applicant or O rdr 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.
y�
i"\ The Commonwealth of Massachusetts
wil.rkers'CompensationlusurmeeAfrdavit;
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
riww.mass.gov/dia
Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information /n,'- Please Print Legibly
Narne(Business/OrganizatioNlndividual): /'r
Address: q
City/State/Zip: dAj 14 Phone#: J
Are you an employer?Check We appropriate box:
,J Type of project(required):
L—lam aemplorerwilh_ A a wtoyees(rullamd/orpmt-mact. 7. E]New construction
2.❑lamasolepropdmmorpm .Wpmdhavew mployeeswmkivg fmanciv 8. []Remodeling
any calecity.[No workers'comp.insurance natural]
3❑1 am a hommwomdowg all work myxlf.[No workers'com,iasurancerequired]t 9. El Demolition
4.❑I am a hom mumor and will be having conbacmrs m mvduct all work on my property. I will 10❑Building addition
um Wal all cnnoactors chum have workercnmpmsation insamvoc m are ante 11.❑Electrical repays or additions
proprietors wiW no cmploycas.
12.❑Plumbing repairs or additions
xrl I c,a aftconwnhamorand Ihave hiredthesubcwha'voip.inovtheatucbedsheet.
These subcovtracton have employees and have workers'comp.imumnce[ 13.ERoof repairs
6.❑We are acia,uro mond its oflmas hoveexercieMNernghtofexcamonFar MGL c. 14.❑Other
152,§I(4),and we have no employees.[No workers'comp.imutmme required.]
.Any applicant that checks box#1 anus[also fill out he xclion bclow shnwiug Weir workers'compevmtwv policy Nf tion.
,Homeowners who submit Wis affidavit indicant,Way me doing all work and Wen hire outside covtmcmrs must submit a new affidavit wdimting such.
TCmanortma do,check Wis box must attached at additional sheer showing We aame of We sub-conoacmrs and state whether or not mow entities have
emptoyces. If the subcoayacmrs have canployees,Wey must provide Wer workers como policy vombar.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. /q
Insurance Company Name: lwertC q `�,f
Policy#or Self-ins.L�irc,.�A#: p / nl/ Expiration Date: ?,IA
2%
lob Site Address: /,L/J / f�zQa4s! 'L 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 a 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.
I do hereby cerdfy under the pains and penaldes ofperjuy that the information provided above is nue and correct
Signature: D t
Phone#:
Official use only. Do not write in this area,to be completed by city or town officio(
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#:
r
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 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)morels),addresses)and phone number(s)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 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 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 permiNicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permi0icense 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. Anew 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 bum leaves cteJ said person is NOT required to complete this affidavit.
The Departments address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA O2114-2017
Tel. #617.727.4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
PROPOSAL/AGREEMENT
MA Lic. # 147560 Moro ROME, Ina. www.mr-home.net
CT Lic # 613751 6 Dumaine Street, Wilbraham, MA 01095 office.mchome@gmaii.com
(413) 222-5368 .+
(86o) 627.5610
DatePmpoaea To ee unae
Ej Windsor Locks, CT
Submitted To: n /, Phone Numbers•
C r J �
Street: Call:
C
City,State and Zip Code: Q e Email:
Notes:
WORK TO BE DONE
COLOR-.
GUTTERS:
DOWNSPOUTS: fbl,4rAg,IP '''
MITERS: ea
HANDOUT MITERS: J
RIP/REMOVE:
GUTTER GUARD: 41 f ti' e
z�VA/WCP.✓/ / .
r ,
Please Check Diagram Carefully and Sign Below
Total Cost For Above Specified Work Includes Material And Labor: S
1/3 Down Required to Bank Work and Balance Is Due Upon Completion
Acceptance of Proposal-The above prices,specifications and conditions are satisfactory and hereby accepted.
You are authorized to do the work as specified. Payment will be made as outline above.
You maycancelthis transaction without penalty or obligation within three buismas days.
Date of Acceptance: d.- dgqO /41 — complatad By:
Customer Signatum: Amhudaad signature: