30B-058 (6) 147 RIVERSIDE DR BP-2019-1388
GIS A: COMMONWEALTH OF MASSACHUSETTS
MamBlock:30B-058 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv: INSULATION BUILDING PERMIT
Permit N BP-2019-1388
Project p JS-2019-002230
Est.Cost:$500.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sp.ft.): 24742.08 Owner. DEMARIA SUSAN
Zoning: URB(100 Applicant: DEMARIA SUSAN
AT.- 147 RIVERSIDE DR
ApplicantAddress: Phone: Insurance:
147 RIVERSIDE DR
FLORENCEMA01062 ISSUED ON:614/2019 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE BRICKS ON BACK OF HOUSE AND
INSULATE PIPES "PRELIMINARY INSPECTION REQUIRED'
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 p 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:
FeeTvpe: Date Paid: Amount:
Building 6/420190:00:00 $65.00
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 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plays
phone 413-587-1240 Fax 413587-1272 Plot/Site Plans
Other Speciy
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION I-SITE INFORMATION P2,2 C I pn i Nf t Ztl Iiij5 p6 O N
.1Property AddressTh section to be completed by office
11Uy '.
1 \` �weRs fpr, Map Lot Unit
Zone Owday District
Elm SI.District CB District
SECTION 2.PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
IaASANI
Name(Prim) CurteM Mallin Atltlress:
�lt� S oSEi(� H7394R—Sci(n�1
—Ez:�Q,cs'-- ` Telephone
Signature
2.2 Authorized Agent:
Name(Print) Cunent Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permitapplicant
1. Building OO (a) Building Permit Fee
2 Electrical N Q (b)Estimated Total Cost of
Construction from 6
3. Plumbing N A Building Permit Fee
4. Mechanical(HVAC) N A
5, Fire Protection
6. Total=(1 +2+3+4+5) Check Number r�15
This Section For Official Use Only
Building Permit Number: Dare
Issued:
Signature: r.Z.- l��
Building Commissionedmispector of Buildings Date
@
EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
susctndecy\�aall e ' n" co c*
Section 4. ZONING Al Information IAet Be Completed. Permit Can Be Denied Due To Incomplete IMonnaboo
Existing Proposed Required by Zoning
This coMm m be filled in by
Building Depmnnem
Lot Size
Fmnwge
Setbacks Front
Side L: R: U R: .._.
Rear
Building Height
Bldg.Square Footage .
Open Space Footage %
ILat w minus bldg @paved
#of Parking Spaces
Fill:
volume&Lwatian
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 O
IF YES, describe size, type and location:
E. WIII the construction activity disturb(clearing, 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,men a Northampton Stone Water Management Permit from the DPW is required.
E T PR ORK a lice I
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doo s
Accessory Bldg. ❑ DamolHlon ❑ New Signs [0] Decks ID Siding[pj Other[OJ
Brief Descmpbon of Proposed
Werk: re f t�SU� t
Alteration of existing bedroom_Yes I No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes �No
Plans Attached Roll -Sheet �d. t�C'Sn, p�`�7��y p/a(sQ
rra N Newhouse and or addition to existing housing, complete the following NIA
a. Use of building One Family X Two Family Other
b. Number of rooms in each family unit: 7 Number of Bathrooms 2--
c. Is there a garage attached?-G..(—
d. Proposed Square footage of new construction. Z x S Dimensions
e. Number of stones? 2
f. Method of heating? b O S Fireplaces or Woodstoves N b 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 No
I. 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, C AN CDINI�'A as Owner of the subject
property
hereby authorize Jt+SAS-1 pMA
to act on my behalf,in all matters relative M work authorized by this building permit application.
S<�sz f�1 (�1 tq
Signature of Owner Date
I, 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.
Prim Name
Signature of OwnedAgent Date
SECTION 8.CONSTRUCTION SERVICES
8A Licensed Construction Supervisor: Not Applicable ❑
Name of License Halder:
License Number
Address Expkalion Date
Signature Telephone
9.Registered Home Improvement Contractor. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 70-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152.1251
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Ves....... ❑ No...... ❑
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City of Northampton
'^ Massachusetts
D212 i.NS 0I H. niD G .l bai TIONS
212 It�in ahewt • I, n 010 Building
NerGhampGen, Nx 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. Prim 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 pre-existing owneroccupied building containing
at least one but not more than low 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):}};�q�1Q>QS'
_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 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:
Date Owner Name and Signature
City of Northampton
Massachusetts
OEPBNI9ffiiT OF BUILDING INSPECTIONS -
212 Min St • Municipal Buildin,
MortB ton, Ma 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 110.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.
City of Northampton
•'f• Massachusetts
)822 N in iS 08 Bo ML ci ZNSuilZ NS
Zl] win BthM •wnicipal 9viltliw
aoecM1uipcon, to 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 property licensed solid waste disposal facility, as defined by MGI c 111, S 150A.
The debris from construction work being performed at:
MA
(Please print house number and street name)
Is to be disposed of at:
\F A►J4 A� veW ,Q1oa lA�icho -
(PI as print name and cation of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Compan
y 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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston, MA 01114-1017
www.mass.gov/dia
Vm.rlaurs'Compensation Insurance Affidavit:Builders/Coaftmton/Electriciana/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
)`lame IBusiness/Organizfatioombuividual)
Address: `l7�a R�Ve12S�['Q.R
City/State/Zip:F�c�CEr�9�.�P Ci JC � Phone#LW" > &A k-09qb
Are you an employer.^Cluck Ne appropriate this: Type of project(required):
I.E]I un a espbycr with employees than and/or part-track, 7. ❑New construction
2.❑l am a wde popnetor or partnership and have no employees working ft,me in 8. ❑Remodeling
y capacity.[No wmkm'comp.insamnee requaN.]
19"l m
a homeowner doing all work mp yself(No workers'comp,iiaumnc .]
e mquired ' 9. Demolition
4.❑I am a hommwner aM will be bang rnomctors m cavduct all work on mY laopeiw. lion 10❑Building addition
ore lhal all wntmcmrs nthnhave wmkers co�eoatine immaneemarm,sok I1.0 Electrical repairs or additions
protrusion with no employees. 12.❑Plumbing repairs or additions
5,r7 I am a general corammur and I have hired the sub-contecmrs listed on de attached anent, 13.❑Roof repairs
These sub-cono-ectors have emd he.employees anve workers'comp.insuruvice.
6.❑We area cowura4on arra as officers have eacreised thea right of cxcmptioo per MGL c. 14.❑Other
152.5H<I.aM we have no employees.Mo wokcrscamp.ilaumnce regnired.l
'Any applicant that checks bon#1 must also fill out the section below showing aeawoken'compesetion policy information.
t Homeowners who submit this affidavit indicating they art doing all work and then hire outside contractors must submit a new affidavit hmdicaaing such.
lCo tatemrs that check this Imo must matched an additional sheet showing the nameorthe,c1v tva,and state whether or act th®e entities have
ehourduyees. If the wbcuntracmrs have employees,they must provide thea workers comp.Whey number.
I am an employer that is providing workers'compensation insurance for my employers. Below is the policy and job 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,p25A 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 certify under the pains and penalties of perjury that the information provided above is nue and correct
S m 75-- tilrnl »
Phone M 'AN 3 -S-FSL4 -<-)Sq (o
Oficial use only. Do not write in this area,to be completed by city or town official.
City or Town: Per nit/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
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
reeeivef 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)name(s),address(es)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,arc 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 m 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 permit/license 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 an file for future permits or licenses. A new affidavit must be filled our 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
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel.#617-727-4900 ext.7406 or I-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia