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36-232 (10) 12 DIAMOND CT BP-2019-1475 GIS 4: COMMONWEALTH OF MASSACHUSETTS M=Block:36-232 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Cateaorv:demolition BUILDING PERMIT Permit# BP-2019-1475 Proixt x JS-2019-002390 Est.Con:$5000.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor. License. Use Group: BRIAN CAMPEDELLI 082616 Lot Size(sa.ft.): 46609.20 Owner: DIPILLO BELINDA Zoning, Applicant: BRIAN CAMPEDELLI AT. 12 DIAMOND CT Applicant Address., Phone: Insurance: P O BOX 823 (413)539-3685 WC EASTHAMPTONMA01027 ISSUED ON.6125/2019 0:00:00 TO PERFORM THE FOLLOWING WORK REMOVE CONCRETE POOL AND FILL IN 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 k 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: FeeType: Date Paid: Amount: Building 62520190:00:00 $65.00 212 Main Street,Phone(413)587-1240,I=:(413)587-1272 Louis Hasbrouck—Building Commissioner �'--' City of No ha C E I V EU Permit Department use only ./' Building D part ant Dnveway Permit t. .. 212 Mai Slfet ptic Availability Roo 100 i JUN 24 2019 ell Availability Northampto , MAj01060 of Structural Plans phone 413587-124 Fax• :=n=r� Plans acafy APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION t-SITE INFORMATION 1.1 Property Address: This section to be completed by office I� 1 - Map aro Lot �_ � !g . Unit y IAUf 1 V!L zone Overlay District IElm SL District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT '��/ •���� 2.1 Owner af Record. Name(PrInt—b ; ` /� �C I Current Melling Address: SJ 1 I I I Telephone Signature 2. uMorized A ant: l & Covvwlo Na ) Current Were Address: y/ 3 �q Sign TelepMne SECTIO41--e$TIMATED CO Item Estimated Cost(Dollars)to be Official Use Only completed by permit So licarn I. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Coat of Construction from 6 3. Plumbing Building Permit Fee (/ 4. Mechanical(HVAC) l� S.Fire Protection 6. Total=(1 +2+3+4+6) Check Number This Section For Official Use Only Date Building Permit Numb r: Issued: I'I fn fp Signature: 6-4 Building Cornmissionenlnspector of Buildings pate EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incornplete Infarmation Existing Proposed Required by Zoning Thu wNmo to h filkd m by Badding Dcpxnmtnt Lot Size Frontage Setbacks Front Sl4a L: R: — L= It C Rear Building Height -- O Bldg,Square Footage Yo O Open Space Footage —_ % (Int w min.bldg At Pved q of Parking Spaces -� 0 Fill: volume&Caution A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DONT KNOW O YES O IF YES: enter Book I Page and/or Dotvment q 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 O IF YES, describe size, type and location: E— D. 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. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 arse or is B part of a common plan that,mill disturb over 1 acre? YES O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) Now House ❑ Addition E] Replacement Windows Alteration(s) Roofing Q Or Doors ❑ Accessory Bldg. ❑ Demolition New Signs [0] Decks [p Siding JE3] Other[111 Brief Description of Proposed �(,y\ar 4- /t,., _ C 1 _ ��„e t / _ -_I I / t' Work �-N Y1 '�Q (/P!'C OV`✓J1 1 Alteration of existing bedroom_Yes_No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Rall -Sheet ea. If New house and or addition to existina housina. 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 construction. Dimensions e. Number of stories? f. Method of healing? 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. Sepbc Tank_ City Sewer Private well_ City water Supply_ SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT O1R�CONTRACTOR �APPLIES FOR BUILDING PERMIT n�- I, Ll Y1/A{!y' r�� tl r 1/1I n asOwner of the subject property hereby authorize OL OAM by`lV ' ' to act on my behalf, In all matters relehva W work au oozed by this building permit eppll a'on. zlo Signature of Owner b 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 pans and penalties of perjury. Pmt Name Signature of OwnedAgem Deb SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construcilon Su arvisor: Not Applicable cO Name of Licaneaa Hdar: r Vh C5 L License Number C) Aaa Expiration late If Telephone 9.RTI ) O� 77='i Y 1 j CA Not �l able OL ber 2 Company Name I RegisGaBon Num Yr - DI - I °f Address Expiration Date Telephone SECTION 70.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M-O-L G 752,s25C(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 of me building permit Signed Affidavit Attached Yes....... O No...... 0 City of Northampton Massachusetts z napMAal11' or =Lmm rNSPr Tom 212 1 n atraat a Municipal auilainc NorNampton, M 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,alteration,renovation, repair, modernization,conversion, improvement,removal,demolition, or construction of an addition to any pne exlsbng owner-occupied building containing at least one but not more than few dwelling units....or to structures which are adjacent to such residence or building'be done by registered contractors. Note:If the homeownerhas contra M with a c ration or LLC,t at entity must be regissttered Type of Work: ��/ III) IZ �' Est. Cos�'7c:(�(, Address of Work: Date of Permit Application: 1 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 TINDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBELnES 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.- /7� a - C Date a 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 DEPARTIgNT OF BWWZEG INSPECTIONS 312 Mein st—t . qun...,.1 suild—, Nort mpton, M 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 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 11025, 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 DP@aB2f®T OP BOZDDZBO ZB8DBC4 Ms 212 l . 2< t •14 Ii P" Mul1da,, � ?� Mnrth pt n, 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 property licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from construction work being performed at: l a �,) I rwyvMN t Cf (Please print house number and street name) Is to be disposed of at1�b (Please print name and location of facility) "\ Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) v � 1 Sig Ir anit 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 02774-20/77 rvww.massgov/din TWorkers'Compensation Insurance Affidavit:Buflden/Contracton/Electricfam/Plumben. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Plem Print Le ibl Name(13usiness/OrganamioMndividua0: Address: City/State/Zip: Phone#: Are ..employer?Chec�kth(e appropriate boa: Type of project(required): I.z1macmployerwitha enWlorecslfwl aamm pmt-t®el' 7. []New construction 3�Imasole PmPictor or pmmmnip sod have no employs workiegf mm 8. Remodeling any mpaoty.[No wmken'compwormsee rexuud.l �a�-- ].�1 m a hrmownm doin8 ell work myself INo works'comb,buuravu yuhea.l' 9. �ea1101iIlOn e.nImahnmeowmvandwalxb�ramactonto�wtmlwm mmrmwmtr, twin 10 Building addition cmim mat all wnnamwseimcrheve wmkcrs'wmprnwiom immmwmmaok ll.[3 Electrical repairs or additions pmprietms with ma employees. 12.[]Plumbing repairs or additions 5f]1 run a general connector and 1 have herd me subeu temm s laud is do anachd sheer. mere sub-contactors have employees mW nave workers'wmp.timumnce t 13.E]Roof repairs 6.[]We mawma.tion and aatifficm have asercisd their right of exemption per MGL c 14.F]Othm 152,sr114b and we have m employers.(No workers'comp.imaemc retained.) 'Any appaemt met checks box#1 most euro no out the section below showing seer workers wmpemation In,information. I Hommweers whe submit runs aaidavit indicating the,we items all work and them hire remade contractors most submit a new atlidnvit indicating such. :Contractors now check this box most aaachd an additional sheet showing the mase of the nub-contractors and once whemm or not those entitcs have employees. If the stat muacmm have employees,they mustprovide their workers wmppolicy muni I am an employer that is providing workers'cos oration insurance for my employees Below is the policy and job site information. � ,t Insurance Company Name: U 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 oneyear 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 veriti n. Idohere cerun the pg t ins andpenalnes ofperjury that the informanonprovide�allo-ispveeandcorrect Signature: Date' J� 1 Phone#: OJf&fal use only. Do not write in this area.to be campleced by city or town officiaL City or Town: Permit/License# Issuing Authority(circle ane): 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 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,p25C(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,p25C(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-contracton(s)name(s),address(es)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 tu 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 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 permit/license number which will be used as a reference number. In addition,an applicant that most submit multiple permili icenie applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and order"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 net 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 Depamneat of lodustrial 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 w .mass.gov/dia NOTICEul NOTICE TO TO EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-7274900 As required by Massachusetts General law,Chapter 152,Sections 21,22, &30,this will give you notice that I(we)have provided payment to our injured employees under the above mentioned chapter by insuring with: A.I.M. Mutual Insurance Company NAME OF INSURANCE COMPANY P.O. Box 4070 Burington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY W MZ-800-8007239-2019A 03/15/2019-03/15/2020 POLICY NUMBER EFFECTIVE DATES 14 Bobala Road The Dowd Agencies LLC Holyoke,MA 01040 (413)538-7444 NAME OF INSURANCE AGENT ADDRESS PHONE Pioneer Landscapes Inc 15 Industrial Parkway Easthampton, MA 01027 EMPLOYER ADDRESS 02/01/2019 DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the mum of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, H the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that We Insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER i