24A-130 (3) 33 PROSPECT AVE BP-2019-1479
GIs k: COMMONWEALTH OF MASSACHUSETTS
MarrBlock:24A- 130 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: KITCHEN RENO BUILDING PERMIT
Permitk BP-2019-1479
Proiecto JS-201M02394
Est.Cost.$56000.00
Fee:$364.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License:
Use croup: Homeowner as Contractor_
Lot Size(w.R.): 7143.84 Owner. BENJAMIN MARC
Zoning,URA(100V Applicant. BENJAMIN MARC
AT. 33 PROSPECT AVE
ApplicantAddress: Phone: Insurance:
33 PROSPECT AVE (212) 666-9232 0
NORTHAMPTONMA01060 ISSUED ON.612512019 0.00.00
TO PERFORM THE FOLLOWING WORK:REMOVE WALL AND RENO KITCHEN, NEW
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 if Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Cas: 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:
FeeTvne: Date Paid: Amount:
Building 6/25/20190:00:00 $364.00
212 Main Street.Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
i
)(ita- 16no
Department use only
City of North "r ECEI V mid:
.q BUildmig De rtm Cu meiiray Permit
1. 212 Main eeI r/Se lw Availability
Room 1 0 JUN 2 5 201 we r/w I Availability
Northampton, 0 060 T Sets i Structural Plans
phone 413-587-1240 az$ - 2 to ns
EPT RTaUnDING N9PF
NORTHgMPT
r COW
APPLICATION TO CONSTRUCT,ALTER,REPAIR RENOVATE OR DEMO A ONE OR TWO FAMILY DWELLING
SECTION 1.SITE IIFORMATNNt
1.1 Prooerhr Address: This section to be coinpleted by office
J77 Map r} tfq Lot 130 Unit
J �r'r_7 J�rc / /i Vf
Zone Owrley District
/ / Elm SL Disoirl CB getrkt
SECTION 2-PROPERTY OWNERSMMAUHIORIZED AGENT
2.1 Owner of Record:
Name(Prttl
TelephoneSgnawm
22 m:
Name(Prin) Current Mulling Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
hem Estimated Cost(Dollars)to be Official Use Only
complelad by Permitapplicant
1. Building J tJ U (a)Building Permit Fee
2. Electrical U (b)Estimated Cost of
ion from(61
3. Plumbing / t) Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
e. Total=(t +2+3+4+5) S-Z ejJ Chack Number /,25
TMs Section For OlNeisl Use Only
Date
Building Permit Num Issue&
Signature: "25-w19
Building
//Can/mYabnxlYmpects,of BuYOYgs Dide
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING AR In/ormenon IMrt Be Cmgleted.Pernik Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This cdwm m be filled in by
Building Depa t
Lot Sim
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(t4 cops minus bWg h pavd
n
IfofParking Spaces
volumeFill:
a Imam
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES Q
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 N
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. Will the construction activity dishob(clearing,grading,exrovalim,or filling)over 1 acre orm it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,than a Northampton Storm Water Management Per-nit from the DPW is required.
SECTION e-DESCRIPTION OF PROPOSED WORK(check all applicablel
New Nouse ❑ Addition ❑ Replacemen y(,.,(fmdows Akeration(s) Roofing ❑
Or Doors }SI
Accessory". ❑ Demolition ❑ New Signs [0] Decks [q Siding[[-I] Other[171
Brief Description of Proposed
Work: �,,J/ i./..// 1--/ / rryJrArl K. / ., i� incl✓./� t„i)n rAJ✓
Afteration of existing bedroom_Yes_No Adding new bedroom Yes No
Attached Narrative Remna&g unfinished basement Yes No
Plans Attached Roll -Sheat
Ga.If New house and or addition to existina housing, complete the following:
a. Use of building:One Family Two Famiy 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 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 fl.of wetlands? Yes No. Is construction within 100 yr. fioodplain 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 CitySemer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PfRA1R
I, ,as Owner of the subject
property
hereby ardfrorize
to am on my behalf,in all matters relative to work authorized by this building permit application.
m d Oww Data
1, r r /�. n t c r n ,as Owner/Authorized
Agent hereby declare that the sla and information on the foregoing application am true and accurate,tc the best of my knowledge
and belief.
Signed under the pains and penalges of perjury.
printNsrra
SignaW / Date
SECTION 8.CONSTRUCTION SERVICES
8.1 Cleansed Construction Suoerrfaor: Not Applicable ❑
Name of License HdM
License Numher
Adtlress F�iefbn Dale
SgneNm Teleph
9.Re iste d Home qn r man rNot Applicble ❑
Comu ? l R6
eg�a — y
.,�/, ff��� �� r✓ �
ice/ 0
Adtlress F�iretion Dete
/4 Tekplrme %13j2J-STI
SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.15Z S u'C(8))
Workers Compensation Insumnce alfideve must be wngleted and submdted with this application.Failure to provide this afraera will re8u8
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ NO...... ❑
City of Northampton
Massachusetts
OBPAR� OF ZN
BOILDZNG SPSCTZONS i
it 312 Nein street e amici al Bml1 1l(J
North, ton, 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 perforating improvements or renovations on detached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("I LIC").
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 omtaining
at least one but not more than/our dwelling units.—or to structures which are adjacent to such residence or building'be
done by registered contractors.
Not!:If she homeowner has contracted with a corporation or LLC,that entity must be regu1ered.
Type ofwmk: �r A�� EEet.Cost ST h o O
Address of Work: d i e o jt 2— AUC1/ � . .....o/ ll AA 0/060
Date of Permit Application: _/,,,.�, ,�,ni ..,2J/ 5
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
UNDER M.G.L.Cimpter 102A.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 Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
612-(4c) Nle 'b(m &v-o-- d A4-
DaOwner Name and ignature
City of Northampton
it Massachusetts
l seven or sazasrm rasescrrass
\
224 I n ST t . M icipa Building v Y C
,.� North,a n, M 01060
Massachusetts Residential Building Code
Section 110.115.1.2
Homeowner. Person(s)who own a parcel of land on which he/she resides or intends to reside,
on which these 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 110.115, 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
., s
-�°"r Massachusetts
�I. DSPAIt1fffi!T OF BOTCHING ZNSPBCTIONS
\ 212 Main St t •W .ip l Buil[l
MortLwptw, I 01060 1-M
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 150k
The debris from construction work being performed at:
(Please print se number andstteet name)
Is to be disposed of at:
( print naVle and location of facisty)�
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
q tv ,
Signature 7
Permi Appli nt or Owner Dale
If,for any reason, a 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
W
Department of'Industrial Accidents
1 Congress Scree/,Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
IN orken'Compensation Insurance Affidavit: Builders/Co•traeton/Eketricims/Plumben.
TO BE FILED WI"1'H 3'HE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Basipess/OrganimUon lndrvidml):
Add : 33
City/Statelzip: 0/0,W Phone#: o2/d -GGC'xW,�_
Amyaassernpla,0Ch«kourpyngbelasmmeet
'h'Da of P j (required):
I.[]I am.ere loy«wi+h_—mWym(fill maser panaainl' 7. ❑New construction
2.nlamawleprWrielormpmn ipaWhaverwc"Wymw«ting forme. g, Lremodefing
my ca mely.[No workers'can,.insumme required.]
3.Of ams honeowler demo all wmk -muumn 9. Demobtion
a myalr.Mo womkers'camp.� ce required.]'
�am a ho—ru,r and will he hhmg embwwn to eondecm all work nn my pmpehty. 1 will 10❑Building addition
suer lMt all cantna«s ciWer have w«kes'rannmatinn imwmcc«ar ark 11.,M Electrical repairs or additions
peo,m ss woh no empWy«a. 12.LPlumbing repays or additions
50 l am agerenl mmrxmor anal l havehimd oe sub<oneactan listed on the aaacld shed. 13. ROOf
Tteae aubeommaon teem erhnloyco end Mee weekaa'esm�.i., ❑ repaus
6,C]We a2acnryontim and itsofficer Mee eaenirN them right afcaomryhton par MGL.. ME]Oduer
152,§I(4),and we Met no employeca.pie w«kas'conn.mini requiad.l
•Any sWicamtut checks tom#1 most atm fill no the action Mlaw,showing their workerscoances" ipolicy in onamon.
t Homemi nen wlw submit Nis alfidavit indicaling they art Ming all work and then hire onside mmtmdotn most submit a new affidavit indicatng such.
tCenmaemn that check Win boa must amehed an adlhiorwl shret sthowwg We same of the subcodmnon and m..whelherar nal those amities home
m#toy . If the sub-emhael«sM.cml they must pmeide Weir worker'nth- now,mmhber.
lam an employer tlfmis providing workers'compensation insurance for my employees Below is the policy andjob site
inforwatiolk
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/Smne/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure W wane coverage as required under MGL c. 152,§25A 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 viulawn A copy of this statement may be forwarded W the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties ofperjmy that the information provided above is true and coarct
Sionature. Date:
Phone#: I I in 1,1V (v L 7/
OQicial use only. I
not write in this anal to be completed by city or town ofjwiaL
City or Town: Permit/License#
tuning Authority(circle one):
I.Board ofHean 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5. Plumbing Inspector
b.Other
Contact Person' Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers t provide workers'compensation for their employees.
Pursuant to this statute,an earployer 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
ofthe foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of m individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than Ihrce apartments and who resides therein,or the occupant of the
dwelling house ofaneWer who employs persons to do maintenance,concoction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be doomed 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—tractor(s)mantis),addness(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 to the Department of Industrial
Amidents for cmfinration of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be reamed m the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have my 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 a the appropriate line.
City or Town Officials
Please be sure that to affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill our in the event the Office of lovestigations has m contact you regarding the applicant.
Please be sure in fill in the permiNicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pemilt(license applications in my 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 furore 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 my business or commercial venture
(i.e.a dog license or pemmit to burn leaves etc.)said person is NOT required in complete this affidavit,
The Dcluu rent's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of tnthutnal 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 www.rrms.gov/dia
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