28-004 (4) 396 SYLVESTER RD BP-2019-1457
GIS a: COMMONWEALTH OF MASSACHUSETTS
Mau,131 ck:28-004 CITY OF NORTHAMPTON
Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Catcgorv�window replaced BUILDING PERMIT
Permit# BP-2019-1457
Project# JS-2019-002365
Est.Cost: 8500.00
Fee S40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License.
Use Group: WILLIAM FULLER 111440
Lot size(sa. fol 22064.92 Owner: HURLBURT JOSEPH
Zoning: Applicant: WILLIAM FULLER
AT. 396 SYLVESTER RD
Applicant Address: Phone: Insurance:
26 MAPLE ST (413)345-0864 SOLE PROPRIETOR
SOUTHAMPTONMA01073 ISSUED ON.6121/1019 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 1 REPLACEMENT WINDOW
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 N 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:
FeeTVpe: Date Paid: Amount:
Building 6/21/20190:00:00 540.00
212 Main Strcet,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
�v�NrJ0�
Department use only
City of Nort :am El CEI VE Permit
/ Building De art ro C Driveway Permit
212 Main Stre t r/ ptic Availability
Room 100 2 0 2019 ter ell AvailabilNorthampton MA 1 7 o Se of Structural Plans
phone 413-587-1240 Fa�C 72 P veil Plans
EFT OF WIIDINC INSPECTI er etiy
NORTHAMF
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOL SH A ON/E�OR TWO FAMILY DWELLING pp
SECTION I-SITE INFORMATION Q� 9- /--4
1.1 Property Address:�,� �,,/ This section to be completed
��to office
06 S�/!K/��r 161 Map Lot -Unit
Zone Owrlay District
Elm at District CS District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name(Pard) , / ' Current Mailing Address'
Telephone
Signature
2.2 Authorized Anent:
7oS �//� b��icn� 34� s✓/r er�Tt ,Qd ^u /vo ,
NameName(� Cu
Mallin ess: Ya�T
.5115 f/—6766
Sign re Telephone
TION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
wm leted by permitapplicant
1. Building j p6, (a) Building Permit Fee
lv�+
2. Electrical (b) Estimated Total Cost of
Construction from 8
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number b
This Section For Official Use Only
Building Permit Nlmben Date
Issued:
Signature:
Building Commissloner/Inspector of Buildings r� Date
V
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied!Due To Incomplete Information
Existing Proposed Required by Zoning
This c.IBuan m be flld in by
Budding DeFamnrni
Lot Size
Frontage
Setbacks Front --"
Side L:- R:—_. Lo.__"_ R:_....."_
Rear _. '_........_.
Building Height -
Bldg.Square Footage
Open Space Footage
dm vra mina,Wig&pavd
#of Puking Spaces
Fill:
volume&Lacalionl
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O .,...DONT Kf OW 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. NAZI 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,then a Northampton Sion Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK Icheck all applicable)
New House ❑ Addition ❑ FReplacement.Windows Alterations) O RoofingrsAccessory Bldg. ❑ Demolition ❑ igns [01 Decks lM Siding(0] Other lfDl
Brief Desadption of Proposed
Work: ZYr cF�Lr »sr�
Alteration of existing bedroom_Yes_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _Yes No
Plans Attached Roll -Sheet
Ga.If New horse and or addition to existing housi complete the followina:
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 cimstwetion. Dimensions
e. Number of stores?
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_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 Cry water Supply
SECTION 7a-OWNER AUTHORVATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, lT0 IL�,IxAI�� as Owner of the subject
prop
hereby authorize .\> a FILA, SOnS ferc�f-
to a on my behal in matters relative to work authorized by this building permit application.
AVatdFe La/2^%9
of oWher
q Date
/1
I, h) to 1�r 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.
d ! r
Hint Name -
1J / a
Signature of OenerlAgent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder: W11 .ow. A 1 ) fyyD
Ucense Number
Z L. M Cpl„ Sa rje 1rb.y,o/d. MA . -Je'13 11 . P7 -zczo
Address \� Etpkaaon Date
Signature Telephone
9 Reolstered Home Improvement Contractor: Not Applicable ❑
W;I1:o — P r—/L.� !9!134
Company Name Registration Number
'2 L. ✓'Torts S+ :!;- mA -173 4/2✓Zioe o
Add.. Expiration Date
Telephonegl 31 ;y'-'au,y
SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c,152,f 25C(8))
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 ofthe building permit.
Signed Affidavit Attached Yes.......bo No...... ❑
City of Northampton
Massachusetts
4�
� a a
212 Hain S 08 B. LDINGnunici al Building
212 Hain Btraat Munielpal Building .C1
NertLaapten, Mx 01060 �e
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, alteration,renovation,repair, modemimfion, 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.If the homeowner hss contracted with a corporation or LLC,that entity must
t be registered
Type of Work:�?lw, / W.,^ioo,.J ry
Est.Cost: � 40�
Address of Work: 391, 514� Kgr- S-J
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law(explain):
Sob under S 1,000.00
_Owner obtaining own permit(explain):
owner-occupied
not ownerccupied
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:
%-.1-7c j/4 %,Y.)1:4„, A F-1 LAr 191231
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
PT '
// Massachusetts
A. m
D212 MTIn S ee BUILDING al SQ ,uW
212 [Nin Strut • �, ee 020 Buildup
xancn.eq,ton, ew 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 I O R5.L3.1
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
TS
Massachusetts L 'p
� c
F
DEPaA1ffi'NT
OF BDILDING INSPPCTIONS
212 Nain Strut aeanicipal BuilA nq y C�
NoSt anpton, M 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:
34c. ' 1I!"'M
"' cs�.� 2
(Please print house number and street name)
Is to be disposed of at:
Jo-)it 'i�acia e��'L,.�
(P ease print n me an tion of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Permit Applicant or Owner Dafte
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 ofMassaehuselts
Department of IndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www,massgov/dia
VNNorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Native(Business/Organ¢atioNhid...dust): F—x.''
Address: Pt. of ei.. sb
City/State/Zip: Se..j-1....,„P+.— n,X Phone#: 1/0- 3K- GUO
Me you m employer?Cheok me appropriate box:
Type of proJeM(required):
Il am a employer with Ioc<s not motor lmn-truel' 7. ❑New construction
2�Iamamk pmprietmmpamenhip mdhave no employees wodwg forme. S. 0Remodeling
my cutesy,[No weirkm'eump.inswanc< r<anh 1.]
J�1 rat a hommwmrdoiug all work myselr INo workers'cmnp..surmu requimd.j' q. Delllplltlpn
4 1 am a homeowner and will be hiring wooamors an conduct all work em my pmpmy. twill 10 Building addition
more met an Contraction either have workers mmcemation insurance or are sole I IQ Electrical repairs or additions
popiiterswith m employees. 12.❑Plumbing repairs or additions
501 ran u general contractor and 1 have hired me sWrwnaacmrs acted on now munched sheet 13.❑Roof repairs
These sub conmemrs have employees and have workers comp.imumnee.
6.[]Kb me a corporation and in.afrmm have exemisNth<w right of<n<mpdov per MGL e. 14. Other
152,00,and we have no employees.[No womens comp..sutmce required.]
"Any applicant mut checks box#I most also Ill out the section below showing their workers enmpensmion policy.f ernamn.
I
Homeowners who submit this aaidpvit indicating they arc doing all work and than hire outside contactors must submit o new affidavit indicating mill,
TC.00rs mm check mil box must mltached mWar..]sheet showing me name of the sub-cennacters and stale whether err,net those entities have
employees. If the sub-comctors be,,employees,they must provide mew workers'comp. rch,numher.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
Information.
Insurance Company Name:
Policy#or Self-ins.Lia #: 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 DLA for insurance
coverage verification.
I do hereby certify under thepoins and penalties`ofrj
�pe 'uy that the information provided above is nue and cot
rrec
Signature: C-o���-a..�. (S._ �} v Date-
Phone#:
ate-Phone#: H735 74<i - -q4y
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Perecit/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 M
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-contractors)name(s),address(es)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,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 resumed 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 permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicense 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 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 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. #617-7274900 ext. 7406 or I-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.rtrass.gov/dia