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23D-017 542 ELM ST BP-2020-0204 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23D-017 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Stair BUILDING P E RM I T Permit# BP-2020-0204 Proiect# JS-2020-000345 Est.Cost: $1400.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: GREY GOAT BUILDERS - DBA JOHN DEMERSKI 108772 Lot Size(sa.ft.): 7143.84 Owner: HAYDEN NANCY L Zoning:URB(100)/WP(29)/ Applicant. GREY GOAT BUILDERS - DBA JOHN DEMERSKI AT. 542 ELM ST Applicant Address: Phone: Insurance: 72 DUNPHY DR (413) 588-2232 SOLE PROPRIETOR FLORENCEMA01062 ISSUED ON.811912019 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMOVE STAIRS AND INSTALL NEW WITH RAILINGS 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: FeeType: Date Paid: Amount: Building 8/19/2019 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2020-0204 APPLICANT/CONTACT PERSON GREY GOAT BUILDERS-DBA JOHN DEMERSKI ADDRESS/PHONE 72 DUNPHY DR FLORENCE (413)588-2232 PROPERTY LOCATION 542 ELM ST MAP 23D PARCEL 017 001 ZONE URB(100)/WP(29)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ZONING FORM FILLED OUT OSED REQUIRED DATE Fee Paid Buildinp,Permit Filled out Fee Paid TypeofConstruction: REMOVE STAIRS AND INEW WITH RAILINGS New Construction Non Structural interior renovations Addition to Existing_ Accessory Structure Building Plans Included: Owner/Statement or License 108772 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay //- 9 P9-&)q Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. 51 k U The Commonwealth of Massachusetts AU1 2019 FO Board of Building Regulations and Stan ds MUNIC ALIT Massachusetts State Building Code,780 C DEPT OF GUILDIh1G N U Building Permit Application To Construct,Repair,Renova a BION. 1060 &r 2 11 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Da!p Applied: Ev►iy asp -19 ZON Building Official(Print Name) Signa a Date SECTION 1:SITE INFORMATION 1. 'r;o,pperty Address: 1.2 Assessors Map&Parcel Numbe�rg, 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private❑ Zone: _ Outside FI ne? Municipal On site disposal system ❑ Check if ye SECTION 2: PROPERTY OWNERSHIP' wner'of4Re�cord:� d(9!'► Name(Print) City,State,ZIP C5t� -e 66'3 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORD(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) KI Alteration(s)KIAddition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: AMW Description of Proposed Work': SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1OWBuilding $ t ©b 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total Al es Check Nil Check Amount:_ �Cash Amount: 6.Total Project Cost: $ `�- � aU ❑Paid in Full ❑Outstanding Balance Due: aeloAL e-4_5 �{ ls dao to03q -� SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) -71.21 � CS c Jcbn enk ( License Number Expii-atioA D to Name of CSL Holder 1 7A �Uh�V' Dr. List CSL Type(see below) C/ No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft. UI C.i 61�C tY R Restricted 1&2 Family Dwelling City/To ,State,Z M Masonry L RC Roofing Covering WS Window and Siding l '���� �// I SF Solid Fuel Burning Appliances (� I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 119 Li N t 30 � *ButUais HIC Registration Number Expiration Date HC Co y Name or HIC Registrant Name U No,a4d Street ��� may">� �� Email address re"A- of Ci /Town,State,21P Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) 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? Yes.......... No...........O SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize 6101 >�'f e �k4, to act on my behalf,in all matters relative to work authorized by this building permit application. .25 / Print Owner's Name(Electronic Signature) I Dafe SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application isHeand accu te to the best of my knowledge and understanding. I ✓ Print Owner s or�Aut horized Agen's ame(Electronic Signature) Datvr NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass. og v/dns 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" tt ,t .. � r;v.;r tt,• :r .. ., � '� t �.• _ ... ' a3 el-' 't7'( it�'�. � !F 1 ? 10 .. .'•.a.• 0+" v.. _ I The Commonwealth of Massachusetts -- - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information �j�], Please Print Le 'bl Name(Business/OrganizatiorOndividual): -Joh n Te e � —k l�► Vim+ 'V5 I ` 5 _ r Address: "�� DUYIPhy bel b/4(,P D— City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I (full and/or part-time).* have hired the sub-contractors6. ❑New construction 2X,6nm'ployees 1 am a sole proprietor or partner- listed on the attached sheet. 7. JWRemodeling ship and have no employees These sub-contractors have g. ❑ Demolition workingfor me in an capacity. employees and have workers' Y P tY- 9. E]Building addition [No workers'comp.insurance comp.insurance.: 10. Electrical repairs or additions required.] 5. ❑ We are a corporation and its ❑ P 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: e& q Policy#or Self-ins.Lie.#: o �� �Q-L 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce ify under pains and penalties ofperjury that the information provided above is true and correct Signature: _ Date: �� Phone#: 43 r 5-9v ;9-5)L— Official use only. Do not write in this area,to be completed by city or town 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 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 a joint 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-contractor(s)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,are 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 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 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 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 www.mass.gov/dia ,{ r' .. Yi".,,+�'..(,•:. !Yf�e . . !t:>i' ,,,":'f. - 7f,r � ,. ff. !:" .. , ..f'( ';r-.,'(�:�J .(C• - "{ .;f' of nit r`. At ... yet: � •S�� 'f; , "a3:.. �' . - tY , f 3G: „",' sa' . �,i . ._ .. , .. ,: .-.t'E'S'�i�,:fi1l� t ,' .-[• .... 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'I r j11 y1mr' S a, 0 Not, 03 4 t{1P v u r i{..r. ,i, r .r. ,._, - 1Ff6-`.•9$ti� � � '? .'93; !, :M.°,.:'ri: r''ri;', tY.)�.•. ,r{r''� .. .r S! �l ,ji ,...if i Massachusetts Department of Public Safety Board-of Buildiny Regulations and Stancia;js Lidense: CS408772 Construction Supervisor JOHN DEMERSKI 72 DUNPHY DRIVE ':m FLORENCE MA 01062 Expiration: Uommissioner 07/21/2019 Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual Registration: 194397 JOHN DEMERSKI Expiration: 01/30/2021 D/B/A GREY GOAT BUIDERS 72 DUNPHY DR FLORENCE, MA 01062 Update Address and Return Card. SCA 1 E3 20M-05/17 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 194397 01/30/2021 1000 Washington Street-Suite 710 JOHN DEMERSKI Boston,MA 02118 D/B/A GREY GOAT BUIDERS JOHN DEMERSKI 72 C' Not valid without signature DUNPHY DR Undersecretary FLORENCE,MA 01062 Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction"Supervisor CS-108772 Expires: 07/2112021 JOHN DEMERSKI 72 DUNPHY DRIVE FLORENCE MA 01062 Commissioner City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste 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. Address of the work: 15-9a ���/`l 57- lJy/L;-J21-elt, /n The debris will be transported by: t ie I-, -- The debris will be received by: Building permit number: Name of Permit Applicants Date Signature of Permit Applicant