11C-067 (3) 87 FLORENCE ST BP-2019-1379
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao-BI k: IIC-067 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category:replacement windows/siding BUILDING PERMIT
Permit# BP-2019-1379
Project# JS-2019-002219
Est.Cost•.$19450.00
Fee:$123.50 PERMISSION IS HEREBY GRANTED TO:
Const.Class Contractor: License:
Use Group: DAVE MINER 99953
Lot Size(sa.ft.): 20908.80 Owner: PALMER DONALD R&BONNIE C
Zoning:URA(100 Applicant: DAVE MINER
AT. 87 FLORENCE ST
Applicant Address: Phone: Insurance:
347 NEWTON ST (413) 533-0481 WC
SOUTH HADLEYMA01075 ISSUED ON:6/3/2079 0:00:00
TO PERFORM THE FOLLOWING WORK.SIDING/REPLACEMENT WINDOWS -2ND
FLOOR GABLE END/ ENTRY DOOR
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:
FeeTyoe: Date Paid: Amount:
Building 6/320190:00:00 $123.50
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck-Building Commissioner
g p�O/-� 37� s ioiniG/cv�ivtaocvsj
Aoo,e.
Department use only
City of Northampton Stetue of Pemnd:
.+ Building Department CUM Cwonvewey Permit
212 Main Street SewedSepbc AvailabilRy
Room 100 Water=**Availability
Northampton, MA 01060 Two Sets of St umnal Plane
phone 413-587-1240 Fax 413-587-1272 Pl.VSife Plan.
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOV O DEMOLISH A ONE OR FA LY DWELLING
SECTION 1 -SITE INFORMATION NAY 3 7019 ((Cl— (�C07
1.1 ProoarN Addrra:
Thte aeetbn to pet d by o/Ree
A P DEPTOCTMO
. AMPTINdIMOCOfA S Uric
L` 7 i'�♦O ft orf f'1' Zone _ Owley District
�crlS Elm at Dal CS QI.Uwt
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2..111 Ownr of Record:
Name(Prlyd) Curet Maung Adtlrar:
T8 L-1Ftf
G.n}f..} TaMphoro
Sgrture
2.2 Authorized Acem:
Mrnri 3`1eyr-4..- Sl- js � H.YkT ot6 d—
Nima(Kiri)U Cumem7 Nang Adtrra:
77 f/^ D? 2 e
Signature T.wahore
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be 001=1 Use Only
wrn leted by Permit applicant
1. Budding (5, S O (a)Building Permit Fee
ir
2. Electrical (b)Estimated Total Coat of
Cons'hucton from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5,Fina Protection
B. Total= 1 +2+3+4+5 tQ 145-0 Check Number y
This Section For OMk:lnl Use Only
Date
Pomo N Issued:
Signet e: 5-31•Zolq
Well g Cp."ioner/Irepa t M Buikigs Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
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Section4. ZONING Al Information Must Be Completed.Permit Can Be Dente!Due To lmomplete Infatuation
Existing Proposed Required by Zoning
This cslums w be Ned ie by
BuddhilM anmest
Ll Si.
Frontage
Setbacks Front
Side L R L: R—
Rear
Building Height
Bldg. Square Footage
Open Space Footage °b
(Id arta mis®bldg&"ed
art's
#of Parking Spaces
Fill.
rdumc&Inca400
A. Has a Special Perrdt/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the pervdt 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 charajes to or additions of signs intended for the property? YES O NO O
IF YES,describe size, type and location:
E. Ng the construction acfivdy disturb(clearing,grading,excawaon,or filling)ooar 1 acre or is it pad of a rnmmon plan
thatwirdisasbowriacre? YU0 NO O
IF YES,then a Norlhamptun Sam Nater Management Permit from the DPW is required.
N&DESCRIPTION OF PROPOSED WORK(.hKk all appik,able
New Nouse EF] Addition ❑ RepYcamard windows Alteration(.) Roofing ❑
or Doors ❑
Aeemeary eltlg. ❑ Demolttbn ❑ New Signs r]] Decks ® Siding pl Other EM
Brief Description of ProposedV I ^ // 1 I-
Mrk I er it r]tke/1 & Ct4Lem,l1, 4tnd&4/ 4rrr duz✓
i r ra as t
ANeration of existing bedroom_Vea_No Add'ng Towba6ourn Ves No
Adached Namative Rsrovstirg ufiinlahed basement _Yes No
Plans Attached Roll -Sheet
Be 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 More a garage attached?
d. Proposed Square footage of naw construction. Dimensions
a. Number of stories?
C Method of hoofing? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
F. Type of wrretruction
i. Is wnstuction within 10D It W wetlands?—Yes —No. Is construction within 100 yr. floodplain_Ves_No
j. Depth of basement or cellar floor below finished grade
k Will building conform to the Building and Zoning regulations? Vas_No.
I. Septic Tank_ CitySewer_ PnwW well City water Supply_
SECTION]a-OWNE R AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMR
I UCb A.t Pq INrl as Owner of the subject
property �1
hereby authorl O 4-,- /'n1Mel -
to act on my behalf,in all matters relative to work aut onzed by this building permit application.
Siprtuns el W1mar Data
In 1141-/'
,as Owner/Authorized
Agent hereq dadare that tha statements and irfomation on the foregoing application are true and accumM.ta the beat of my knowledge
and belief.
Signed under the pans and penalties of perjury.
'}-kyC ✓off n r/
Print Name
nature of Canw/Aywd Das
_ _
4y
.0 f ..'� � i ,!i4�' !f}i... r
SECTION s•CONSTRUCTION SERVICES
8.1 Licensed Cormtruetlon Srnarvlaar: Not Applicable ❑
Name of Llcenee Holder: Dr r- ✓h iA'A
lJcrnue Nurrtrr
3H -7 t �- -k— AL So. l`t'/Le?- ✓sem /o%-All
AdErns ExpinrWn Oats
O-� 37Y -o7 > e
Signature T-WOM
B.Reablered Nome lmmovemmd Contractor: Not Applicable ❑
m Repetrabon NuT
z/ ! /�/
Address // Expiration Date
Telephone
SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.1S2,§25C(8))
Workers Compensation Insurance affidavit must he completed and submitled with this application.Failure to provide this aftwit will msWt
in the denial of the issuance of the building mtit.
S- ed Affidavit Attached Yes2r-- No...... ❑
City of Northampton
_.
Massachusetts <<
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AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Once of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on derached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction,a teration, renovation,repair,modemization, conversion,
improvement removal, demolition, or construction of an addition to any pre-existing ownwoocupied building containing
at least one but not in"than few dwelling unfis.—or to structures which are adjacent to such residence wbuilding'be
done by ROsterfd contractors.
Note:JJ 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 RESPONSIBILITIES 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 pwner:
uP P tR( n55Z.-
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the abo%c propertm
Daze Owner Name and Sigmhrre
City of Northampton
Massachusetts
D8PM1Tffi1T O BUILDING WS CTIONS 1�tj��pvpJ,�1 ti^
312 Main stxaat 6 lNn 010 Buildl,g
NC
artTYq,[a,. MA OSO60
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 110.85.1.3.1
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 thejob 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
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Da S Mw�G
OF BUILDING INSPFC1Z q
212 lhln _
212 et • clyal Bu11Ein9 i
CT
NorUspGon, nw 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, 554, 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:
V�/oirAc- fel/oir c- fJ"
(Please print house number and street name)
Is to be disposed of at:
1/c l Ir
fit</
(Please print name and .cation of facilely)
Or will be disposed of in a dumpster onsde rented or leased from:
(Company Name and 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.
r . . . , . ,,
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 01114-1017
wwsamass g"Idin
VII.ekers'Compensation,Imuraom Affidavit:8uildeNContmc rs/Eleclricions/Plumben.
TO BE FILED WrFH THE PERMITTING AOTHORITY.
Annlicantlnformation Please Print Usably
Name(BusmsstOvganvationslndivldusi: PAuc t'77tae•1 (f-Yferce.- ALte ;-Z--,c LCG
Address: 3 4 '7 two ,4-, S 1
City/State/Zip: So 14cAcj ^.V- ylo;,f-Phone#: 7Y - 0710
Arcym sae spbJer±Cn,e i sk eppropriae bos
'feA
Type of ro P l (re9uiradl:
l employawah�wnploywa(fan enNm paaahne).• 7. nNew :Ziction
2�Iam•solepmpriaarmpvtewehipmdlweno rnployceaworking fwmeio g edeling
mye,paeity.[Nowodm'amp.wumwe regaircdl
3�Imahaneawmr Ming as work myxr[No wwkve'mmp.wummwgairm.lt 9. ff=olifiaxt
ed mn•hmmwwoa aM wdl bchmvg mnasaon to conduct all workmmy ProPmY. twin 10 O^Building addition
me da illmmaam.titins tress w„hav'campemanon mewmremae wle I I L Electrical repairs or additions
Pamieom win as mpuyxs. 12.]Plumbing repairs or additions
dOl tan zameral rvMnmr.vd r hive shed de a,brantraclora lhtcd an fle auachd sheet 1301loafreparis
Ttceae.uhemuaama haw,mnployem and have wodme'comp.inns J
6❑We arca cmporatim and as of.hares,®cuedtheir rant ofexrnption pa MGLc 14,[]Oa r
Isp,Fl(a),andwehavcm•mPloww.INowmkme'comp.wamnw m,aoxl.I
•Myapplirm ant eherb sox a mmr ahofillons de aactim salt ahowmg den wohms k W aia,politylomatins.
tHmmownemwhoaIs nus diva u. tindicating dayarc Ming all work and denhireo-1--na,vartnmoneahmitanew alndavii iodiow,hw.
-pl,emrc da snack tins colt mus�aldenW an addaimal sM1 lslwwina de...of dcassshs—arnom mdsu�e whanermn�a d�.e rnlitia naw
cm,p�oyRa. udcaabaonaem,snn.o�,nM��.rca.des ma.t prmiae den, workem'eamp pone.nam6w.
I am an employer that it providing,ns rken'compensation insurance fin my employees. Neloo h die poGry andjob xite
lnformatfon.
Insurance Company Name.
Policy#or Self-ins.Lic.#: 4 7 Z O 0 ft Y Sl 13 b I t Expiration Date: /o �as X19
Job Site Address: L 7 City/SmNlLip: Lo -4% /4rJ
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to smtre coverage as required water MGL c. 152,§25A is a criminal violation psnwsheble by a fire up to$1,500.00
and/or ore-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up m 5250.00 a
day against the violator A copy of this statement may be forwarded to the Office of tmestigatiom of the DIA for insurance
coverage verification.
I do hereby certify mderthe palm and penalties offs dun'that the information provided above is true and correct.
$Jgganw. n
Phone# T7] —e'710
Official ore only. Do no,surae in this area,to he completed by chr or tion 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 Insluc for
6. Other
Contact Person: Phone#:
Information and Instructions
Massachusens General Laws chapter 152 requires all employers to provide workers'compensation for their employces.
Pursuant to this stature,an emplane is defined as"...every person in the service ofanother 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 often individual,parhnershi ,associationor other legal entity,employing employees. However the
owner of a dwelling house having not more it=three aperients and who resides therein,in the occupant of the
dwelling house of anorer who employs persons to do maintenance,construction or repair work on such dwelling hoose
or on the grounds or building appurermmn 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 busincis or to construct buildings in the commonwealth for any
applicant who hes not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)sures-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
roquirements of this chapter have been presented t the contracting authonty"
Applicants
Please fillout the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(.),address(es)and phone numbers)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with an employees other than the
members o paters,are motrequired w cmry workers'compensation hutD , if an LLC ocLLP docs have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidems forconfirmation of inmsum xe coverage. Alga be sure to sign and data the oflldavit. The affidavit should
be retumed t the city or Wort 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 ure required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-imancd companies should ewer their
self-insurance license number on the appropriate lire.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provideda space at the bottom
of the affidavit far you to fill out in the even the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pemmit/liomse number which will be used as a reference number. In addition,an applicant
that most submit multiple permit/license applications in any giver year,iced omy 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 must be filledout each
year Where a home owner or citizen is obtaining a license or permit not related to any busicess or commercial venue
(i.e.a dog license or permit to bum leaves eta.)said person is NOT required to complete its 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 est.7406 or 1-877-MASSAFE
Fax#617-727-7749
Revisal 02-23-15 www.mass.gov/dia
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SIDING PROPOSAL
HAMMINER.
Estarler Homs Improramenes Date: 3
(413) 533-0481
www.DuveNlineritoofing.com
347 Newton Street,South Hadley,MA 01075
MA Registration 4106552
Customer Name: Telephone Number
Address,City/Town,State:
Siding: Recover over existing siding _Strip off existing siding
Reside house using Lifetime Premium Siding
Install House wrap or insulation backerboard:
Tyvek House Wrap _3/S"Backerboard,approximate R Value I
_1/2'Backerboard,approximate R Value 3 —1/4"House Wrap R Value 4.17
Trim: Color:
—Wrap all wooden trim with aluminum coil
Door and Window Trim: Standard Bend - Built in J-Channels
Corner Posts: _Matching corners _Other
Soffits: Color
Cut open soffits ad use vented material
Use Soffit material on all ceilings and overhangs
AssOries: (Those checked will be needed)
Gable Vents _Exhaust Vents _Light Blocks _Split Blocks
_Siding Accents
Other:
Shutters: _Pairs _Louvered Raised Panel Other
Gutters: *Install new gutters and downspouts Complete _Partial
7_, Gutter Guard Protection
All Workmanship is guaranteed for 10 years unless otherwise specified
All debris removed from work site
Magnet ground for loose nails
See below for any additional work or comments '
Oth-
er:
Con ork starts
We Propose hereby to furnish material and labor-complete in accordance with the above specifications for the sum of:
dollarsls
A deposit of I/3,S + is to be paid before materials are ordered.
A Payment of S . - is due at the halfway point,and the balance of S '_maid upon completion.
All material is guaranteed to be as specified.All work to be completed in a workmanlike manner according to standard practices.
Any alteration or deviation from the above specifications involving extra costs will be executed upon written orders,and will
become an extra charge over and above the estimate.Our workers are fully covered by Workmen's Compensation Insurance and
Liability Insurance.
Authorized Signature: --- Note: This Proposal my be withdrawn
Acceptance of ProposatiThe above prices,specifications and conditions are satisfactory and we hereby accepted.
You are authorized to do the work as specified. Payment will be made as outlined above.
Signature: Signature:
Date of Acceptance: (//,1/jI
This agreement may be cancelled by Customer within 3 days of acceptance for any reason as detailed in the accompanying Notice
of Cancellation Customer's Initials