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10D-021 159 MAIN ST,LEEDS BP-2019-1420 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: IOD-021 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Egress Stairs BUILDING PERMIT Permit# BP-2019-1420 Proiect# JS-2019-002295 Est.Cost:$5500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: TOSHI KASHIMA 060134 Lot Size(sg. ft.): 87120.00 Owner: LANGHELD JENNIFER Zoning:URB(125)/WP(95)/URA(0)/ Applicant: TOSHI KASHIMA AT: 159 MAIN ST, LEEDS Applicant Address: Phone: Insurance: 15 UNION ST (413) 774-5402 WC GREENFIELDMA01301 ISSUED ON:10/4/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-BUILD SECOND EGRESS DECK; 4X4 WITH PIERS &ALSO A T DOOR 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 SiLynarure: FeeType: Date Paid: Amount: Building 10/4/2019 0:00:00 $55.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2019-1420 APPLICANT/CONTACT PERSON TOSHI KASHIMA I ADDRESS/PHONE 15 UNION ST GREENFIELD (413)774-5402 PROPERTY LOCATION 159 MAIN ST, LEEDS MAP IOD PARCEL 021 001 ZONE URB(125)/WP(95)/URA(0) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OU Fee Paid OU Building Permit Filled ou Fee Paid Typeof Construction: BUILD SECOND EGRESS DECK;4X4 WITH PIERS&ALSO A Y DOOR New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 060134 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO MATION PRESENTED: proved Additional permits required(see below) '�l 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 rERMIT REQUIRED UNDER: § II FindiAng- * d ng Special Permit Variance Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability �Sept' Approval Board of Health Well Water Potability Board of Health t from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay 10 3 L 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. Department use only 13rr_r�rjr City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit e, y �1 212 Main Street Sewer/Septic Availability b Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax - EI t fest cify APPLICATION TO CONSTRUCT, ALTER, RE AIR, ENOVATE OR DEMOLIS A O E OR TWO FAMILY DWELLING ------ -- JUN 12 2019 ------ SECTION 1 -SITE INFORMATION Property Address: S ectio to be completed by office 1.1 Pro DEPT.OF BUILION,DING IN NOt C/� 159 .1� 1A`omh �+ �c NORT +++ 1�� Unit Zone Overlay District Elm St. District CB District SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT V — - -- 2.1 Owner of Record: UF-AIN iFEr- L AA.I bN F� 159 miliAI S-1 temps, AAA pivS3 Name(Print) Current MaijngAddress: L2 Telephone Signature 2.2 Authorized Agent: Name(� Current Mailing Address: sot h— 24 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS 1 2 C-7 t Item Estimated Cost(Dollars)to be Official Use Only completed by permit ap licant 1. Building j� (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee �j 4. Mechanical(HVAC) v 5. Fire Protection 6. Total = 0 +2 +3+4 +5) � Check Number O(J� This Section For Official Use Only Building Permit Number: DateIssued: Signature: Building Commissioner/Inspector of Buildings Date VA EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) KA ! fA IMA 1341onjt/7 Cd `1 A Ha 0 , cA-w-� Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DON'T KNOW O YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW O YES 0 IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained O Date Issued: C. Do any signs exist on the property? YES Q 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 0 NO 0 IF YES, describe size, type and location: E. Will 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 Q NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK check all applicable) New House House ❑ Addition ❑ Replacement*Ddws Alterations) a Roofing Q Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[ Siding[0] Other[O] Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll Sheet 6a. If New house and or addition to existing housing, complete the following: 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 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 j. 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, TE Al Al rF�P La 616 dj-- f� as Owner of the subject property ,` hereby authorize 0 �-" �S - OVA, to act on my behalf, in WLnuidlQrs relative to work authorized by this building permit application. Signat e of Ow er Date 15 ��m 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. Print Name Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: \ Not Applicable ❑ Name of License Holder � � � 06 0 H4- License Number ew di 3c) Address Expiration Date Signature T� 1 Telephone 9. Reaistered Home Improvement Contractor: Not Applicable ❑ � y C-� s`1�= nn C", Company Name Registration Number t Q6 Address Expiration Date Telephone V7 6(1c) SECTION 10-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...... ❑ City of Northampton "q' s Massachusetts i DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building p�,, •� Northampton, MA 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 must 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 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 has contracted with a corporation or LLC,that entity must be registered. �-� ol9a� Type of Work: v'y /'C>�,w `�,` 4�' Est. Cost: Address of Work: e1Xbk,&tk S 1:7--, Date of Permit Application: I&AA. 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): Building not owner-occupied Other(specify):Q�� �(��.�y s� OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTEktD 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 RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: hereby apply for a building permit as the agent of the owner: SSL,: V �5 g' 6 7� 7 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 DEPARTMENT OF BUILDING INSPECTIONS Z x a 212 Main Street •Municipal Building -' Northampton, MA 01060 SS'N�y •�,�} 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: (Please print house number and street name) Is to be disposed of at: C�A_(tg, G l (Please print nWne and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) � © Ct J�Q ��P�1(�• 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. MASSACHUSETTS DRIVER'S LICENSE � r:- .ia ISs lER a 11106/2016 ��S216d3991 M 11/0412021 11/04/1951 4-cuss 12 REST 3a END c D NOT NONE KASHIMA TOSNIHARU iJ a 15 UNION ST GREENFIELD,MA 01301.2917 DD 10bHOT 5' 7/L716 Rev 021/2016 11/04/51 Commonwealth of Massachusetts Division of Professional Licensure ' Board of Building Regulations and Standards Constr,QctiL6n`SUpefvisor CS-060134 Upires: 1110412020 TOSHI KASHIMA , 15 UNION ST GREENFIELD MA 01301 Commissioner v"" Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE: Individual Registration Expiration 186757 01/09/2021 TOSHI KASHIMA TOSHI KASHIMA 15 UNION STREET , GREENFIELD,MA 01301 Undersecretary 06/12/2019 11:22 14138639658 RIST PAGE 02/03 '4 CERTIFICATE OF LIABILITY INSURANCE DATE(MM— THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER./T 182019 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIzED REPRESENTATIVE OR PRODUCER,AND THE CERTIF=ICATE HOLDER. IMPORTANT: If I certificate holder Is an ADbETIONAL INSURED,the p011cy(iee)must be endorsed. if SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endoraement. A statement on th certificate holder in Ileu of such endorsement(a). is certificate does not confer rights to the PRODUCER A.H. Rist Insura.ACa A ri N ME: Traaray Kuklowiaz cYr Ins- PHONE F 159 Avenue A (Q13)863-d373NO c,No: Isis>ecy-Base P.O, Box 391 ADDRESS: Turners Falle MA 01376 I-------- AFFORDING COVERAGE NAIC f INSURED INSURER A:PhOeniX Insurance Comnaxly 5623 Toshiharu Xashima INSURER B: 15 UNION STREET INSURER C: INSURER n: GREENFIELD INSURER 2: 0x301 COVERAGESINyURER F: CERTII=ICATE NUMBER:2018 CERT REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEb BELOW HAVE BEEN ISSUED TO THE INSURED NAMEb ABOVE FOR THE Ppi ICY PE INDICATED. NOTWITHSTANDING ANY REQUIRE=MENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT 717 WHICH THIS RIOD CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE;TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, IN R LTR TYPE OF INSURANCE DOL P EFF LICY POLICY NU MM M IDDLIC LIMIT'$ GENERAL LIABILITY X COMMERCIALCENERAL.UABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE FX1 OCCUR 807042C340 /=0/2018 /20/2019 PREM SES Ea a frence $ 300,000 MED EXP(Any One person) $ s'000 PERSONAL t AOV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMY APPLIBS PER: POLICY PRO, F I LOC PRODUCTS-OOMP)OPAGG S 2,000,000 AUTOMOBILE LIABILITY S AN Ea EEDtSI LIMIT YAUTO ALL OWNED r SCHEDULED BODILY INJURY(par pe/a°n) f AUTOS NON-OWNED BODILY INJURY(Per accident) $ WED AUTOS AUTOS PROP DAMA Per pent $ UMBRELLA LAB OCCUR $ EXCE&S NAB CLAIMU-MADE EACH OCCURRENCE S DED RETENTION S AGGREGATE $ WORKERS COMPENSATION $ AND EMPLOYERS'LIAMiTYWC S TH- ANY PROPRIETorvPARTNrWE)KECUTIVE Y f N LIMITS OFFICERIMEMBER EXCLUDED7 � NIA E.L.EACH ACCIDENT $ IMAndatory In NHI If yea,d-w lbe under E.L.DISEASE-EA EMPLOY OESCRIPTiON OF OPERATIONS below EE S E.L.piSEASE-POLICY LIMIT S bESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLEu(Attach ACORD fat,Additional Claeai�ication: Caspent%y 'narlcsSetlpdule,Iimo(Bepa°cl8roqufnaa) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRA11ON DATE THEREOF,NOTICE WILL 131E DELIVERED IN City Of Northampton ACCORDANCE NTH TME POLICY PROVI$IONS, 210 Main street NOrthampt,pn„ MA 01060 AUMORMI;DRPPRESENTA'1 I Tracey KUklewiaz/Mn P. INS026(z01 � ACORD (2010105) Cd 1886-2010 ACORD CORPORATION. All rights reserved. (201005)01 The ACORD name and 1090 are registered marks of ACORD 06/12/2019 11:22 14138639658 RIST PAGE 03/03 AC � CERTIFICATE OF LIABILITY INSURANCE OATB(MMrDDrY- [CERT'THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLD RiTHIS iFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder Is an ADDITIONAL INSURED,the pollCy(€es)must be ender0e0. If SU6ROGAT►ON IS WAIVED,sebject to the terms and conditions Of the Policy,Certain policies may require an endorsement. A statement On this certificate does not confer rights to the FINSURED tifate holder in Ileo of such endorsement s). T INSURANCE AGENCY INC CT NAME: Michelle Bettencourt PHONE : (413)863-4373 F C o: 391 Aea s: mlchelle@lahrist.corrl FALLS INSURER(SIAFFORpINO COVSRgGE NgIG 7M MA 01376 INSURERA: LIBERTY MUTUAL FIRE INS C23035 ARU KASHIMA pe;INSURERC: STREET INSURERD:ELD INSURER E COVERAGES MA 01301 INsuRER K CERTIFICATE NUMBER: 413390 THIS IS TO VISION NUMBER: CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED ENAM D ABOVE OR THF_POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCR€BED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, L R TYPE OF INSURANCE ° POLMYNUMBI?R PO JEFF PPLID XP 'GOMMERCrAE GJ: i MIDD NERAL LIABILITY LIMITS CLAIMS-MADE Ell OCCUR I I EACHOCCURRENCE q PR SES CCLerrc $ N/A MI DEXP Anyone erson $ GEN'LAGGREGATELIMIT APPLIES PQR: PERSONAL&ADVINJURY $ POLICY 1:1JECY LOC GENERAL AGGREGATE $ OTHER: PRODUCTS-COMP/07 AGG $ AUTOMOUILEUABILITY $ COM NEDSI LE LIMI ANYAUTO Es ent S ALL OWNED ASOHOS ULED N/A BODILY INJURY(Per person) s AUTOS HiREDAUTOS NON-OWNED BODILY INJURY(Por acciderg) $ OS P ERTY Pe dent AGS $ UMBRHELALIA9 OCCUR $ EXCESS UAB CLA1MS,MA0E N/A EACHOCCURRENCE. $ DEO RETENTION AGGRE)aATE $ WORKERS COMP@NBATION $ AND EMPLOYERS'LJADILITY TH- A YIN X PEATUT A ,ANYPROPRIETOR/PARTNER/O anclat ty in N REXOLUDEOy Niq NIA NIA VVC2318376057029 E.L.EACH ACCIDENT $ 100,000 (Mengatory Ire NH) D3/2312019 03/23/2020 If IPTI N Under E-L,DISEA9E-EA EMPLOYEE $ 100,000 DES RIPTION OF OPERgTION below E.L.DISEASE-POLICYI..IMrr a 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Addn7onei Remwrha SnhYQule,mqy be,Kaohed M more spa"Is required) Workers'Compensation benefits will he paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay clalma for benefits to employers in states other than Massachusetts if the Insured hires,or has hired those employees outside of Massachusetts. This C6rtf lcate of Insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the Issue data of this Cartificate of insurance)_ The status of this coverage can be monitored dally by access- www-mass www.massgovllwdlworkers-mmpensaton/investgations/. ng the Proof of Coverage-coverage Verification Search tool at . Sole proprietor has not elected coverage, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLIC�18EANCELLED BEFORETME EXPIRATION DATE THEREOF, NOTICEE DELIVERED IN City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS_ 210 Main St AUTHORUED REPRESENTATIVE Northampton MA 01080 ' y;ytSt ,CPCU,Vice President—Residual Market—WCRIBMA ACORD 26(2014/01) 01968-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia NVorkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are u an employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with D--employees(full and/or part-time).* 7. ❑New construction 2.[:]1 am a sole proprietor or partnership and have no employees working for me in $, ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.[J 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]f 10❑Building addition 4.[:]l am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole 1 I.[:]Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑1 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.[:]We are a corporation and its officers have exercised their right of exemption per MGL c. �e"�d 152,§1(4),and we have no employees.[No workers'comp.insurance required.] Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy inTo—rr6ation. , t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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:_ 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,§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 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 true and correct. Sip-nature: Date: Phone#: 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#: r � I l 1 ` 1 � w c Q> Cr ► I � ► I C �1 l �,��-,gip �9x-� �d Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Form 2 — Determination of Applicability 1 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 A. General Information Important: When filling out From: forms on the Northampton computer, use Conservation Commission only the tab key to move To: Applicant Property Owner(if different from applicant): your cursor- do not use the Toshi Kashima Jennifer Langheld return key. Name Name 15 Union Street 159 Main Street r� Mailing Address Mailing Address Greenfield MA 01301 Leeds MA 01053 City/Town State Zip Code City/Town State Zip Code 1. Title and Date(or Revised Date if applicable)of Final Plans and Other Documents: Request for Determination Packet, including property sketch June 24 2019 Title Date Title Date Title Date 2. Date Request Filed: June 24, 2019 B. Determination Pursuant to the authority of M.G.L. c. 131, §40, the Conservation Commission considered your Request for Determination of Applicability, with its supporting documentation, and made the following Determination. Project Description (if applicable): Construction of a 4'x4' deck set on concrete piers with stairs, within riverfront area to the Mill River. Project Location: 159 Main Street Northampton (Leeds) Street Address City/Town 10D 021 Assessors Map/Plat Number Parcel/Lot Number wpaform2.doc•Determination of Applicability•rev.12114 Page 1 of 5 • Massachusetts Department of Environmental Protection -- Bureau of Resource Protection - Wetlands WPA Form 2 — Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 B. Determination (cont.) The following Determination(s)is/are applicable to the proposed site and/or project relative to the Wetlands Protection Act and regulations: Positive Determination Note: No work within the jurisdiction of the Wetlands Protection Act may proceed until a final Order of Conditions(issued following submittal of a Notice of Intent or Abbreviated Notice of Intent)or Order of Resource Area Delineation(issued following submittal of Simplified Review ANRAD)has been received from the issuing authority(i.e., Conservation Commission or the Department of Environmental Protection). ❑ 1. The area described on the referenced plan(s)is an area subject to protection under the Act. Removing,filling,dredging, or altering of the area requires the filing of a Notice of Intent. ❑ 2a.The boundary delineations of the following resource areas described on the referenced plan(s)are confirmed as accurate.Therefore, the resource area boundaries confirmed in this Determination are binding as to all decisions rendered pursuant to the Wetlands Protection Act and its regulations regarding such boundaries for as long as this Determination is valid. ❑ 2b. The boundaries of resource areas listed below are not confirmed by this Determination, regardless of whether such boundaries are contained on the plans attached to this Determination or to the Request for Determination. ❑ 3.The work described on referenced plan(s)and document(s) is within an area subject to protection under the Act and will remove, fill, dredge, or alter that area. Therefore, said work requires the filing of a Notice of Intent. ❑ 4. The work described on referenced plan(s)and document(s) is within the Buffer Zone and will alter an Area subject to protection under the Act. Therefore, said work requires the filing of a Notice of Intent or ANRAD Simplified Review(if work is limited to the Buffer Zone). ❑ 5. The area and/or work described on referenced plan(s) and document(s) is subject to review and approval by: Name of Municipality Pursuant to the following municipal wetland ordinance or bylaw: Name Ordinance or Bylaw Citation wpaform2.doc•Determination of Applicability•rev.12/14 Page 2 of 5 w Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Form 2 — Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 B. Determination (cont.) ❑ 6. The following area and/or work, if any, is subject to a municipal ordinance or bylaw but not subject to the Massachusetts Wetlands Protection Act: ❑ 7. If a Notice of Intent is filed for the work in the Riverfront Area described on referenced plan(s) and document(s), which includes all or part of the work described in the Request, the applicant must consider the following alternatives. (Refer to the wetland regulations at 10.58(4)c.for more information about the scope of alternatives requirements): ❑ Alternatives limited to the lot on which the project is located. ❑ Alternatives limited to the lot on which the project is located, the subdivided lots, and any adjacent lots formerly or presently owned by the same owner. ❑ Alternatives limited to the original parcel on which the project is located, the subdivided parcels, any adjacent parcels, and any other land which can reasonably be obtained within the municipality. ❑ Alternatives extend to any sites which can reasonably be obtained within the appropriate region of the state. Negative Determination Note: No further action under the Wetlands Protection Act is required by the applicant. However, if the Department is requested to issue a Superseding Determination of Applicability, work may not proceed on this project unless the Department fails to act on such request within 35 days of the date the request is post-marked for certified mail or hand delivered to the Department. Work may then proceed at the owner's risk only upon notice to the Department and to the Conservation Commission. Requirements for requests for Superseding Determinations are listed at the end of this document. ❑ 1. The area described in the Request is not an area subject to protection under the Act or the Buffer Zone. ® 2. The work described in the Request is within an area subject to protection under the Northampton Wetlands Ordinance, but will not remove, fill, dredge, or alter that area. Therefore, said work does not require the filing of a Notice of Intent. The applicant shall notify the Commission 48 hours prior to work, and again when work is complete. ❑ 3. The work described in the Request is within the Buffer Zone, as defined in the regulations, but will not alter an Area subject to protection under the Act. Therefore, said work does not require ❑ 4. The work described in the Request is not within an Area subject to protection under the Act (including the Buffer Zone). Therefore, said work does not require the filing of a Notice of Intent, unless and until said work alters an Area subject to protection under the Act. wpaform2.doc•Determination of Applicability•rev.12/14 Page 3 of 5 Massachusetts Department of Environmental Protection �<-- Bureau of Resource Protection - Wetlands WPA Form 2 — Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 B. Determination (cont.) 5. The area described in the Request is subject to protection under the Act. Since the work described therein meets the requirements for the following exemption, as specified in the Act and the regulations, no Notice of Intent is re uired: - �! Sio+� S Gt�CesS�► �pSt' '� Exempt Ate app ica le statuatory/regulatory p visions) ❑ 6. The area and/or work described in the Request is not subject to review and approval by: Name of Municipality Pursuant to a municipal wetlands ordinance or bylaw. Name Ordinance or Bylaw citation C. Authorization This Determination is issued to the applicant and delivered as follows: ❑ by hand delivery on by certified mail, return receipt requested on f Date Da This Determination is valid for three years from the date of issuance (except Determinations for Vegetation Management Plans which are valid for the duration of the Plan). This Determination does not relieve the applicant from complying with all other applicable federal, state, or local statutes, ordinances, bylaws, or regulations. This Determination must be signed by a majority of the Conservation Commission. A copy must be sent to the appropriate DEP Regional Office(see http://www.mass.gov/dep/abouthttp://www.mass.gov/dep/about/region.findyour.htm)and the property owner(if different from the applicant). Signa D to wpaform2.doc•Determination of Applicability•rev.10/6/04 Page 4 of 5 ( 0 4 C/( Massachusetts Department of Environmental Protection �-- Bureau of Resource Protection - Wetlands WPA Form 2 — Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 B. Determination (cont.) ❑ 6. The following area and/or work, if any, is subject to a municipal ordinance or bylaw but not subject to the Massachusetts Wetlands Protection Act: ❑ 7. If a Notice of Intent is filed for the work in the Riverfront Area described on referenced plan(s) and document(s), which includes all or part of the work described in the Request, the applicant must consider the following alternatives. (Refer to the wetland regulations t 10.58(4)c. for more information about the scope of alternatives requirements): ❑ Alternatives lim' ed to the lot on which the project is locate ❑ Alternatives limite to the lot on which the project is I ated, the subdivided lots, and any adjacent lots former or presently owned by the s e owner. ❑ Alternatives limited to t e original parcel on w ch the project is located, the subdivided parcels, any adjacent pa els, and any othe and which can reasonably be obtained within the municipality. ❑ Alternatives extend to any sit whic can reasonably be obtained within the appropriate region of the state. Negative Determination Note: No further action under the We nds rotection Act is required by the applicant. However, if the Department is requested to issue auperse g Determination of Applicability, work may not proceed on this project unless the Depart nt fails to a t on such request within 35 days of the date the request is post-marked for certif' d mail or hand elivered to the Department. Work may then proceed at the owner's risk only upon tice to the Depart ent and to the Conservation Commission. Requirements for requests f Superseding Deter 'nations are listed at the end of this document. ❑ 1. The area describe in the Request is not an ar a subject to protection under the Act or the Buffer Zone. ❑ 2. The work des ribed in the Request is within an are subject to protection under the Act, but will not remove, fill dredge, or alter that area. Therefore, s id work does not require the filing of a Notice of Int t. ❑ 3. The wor described in the Request is within the Buffer one, as defined in the regulations, but will not a er an Area subject to protection under the Act. T refore, said work does not require the filin of a Notice of Intent, subject to the following conditi ,s (if any). ❑ 4. The work described in the Request is not within an Area subject to protection under the Act (including the Buffer Zone). Therefore, said work does not require the filing of a Notice of Intent, unless and until said work alters an Area subject to protection under the Act. wpaform2.doc•Determination of Applicability•rev.10/6/04 Page 3 of 5 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Form 2 — Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 D. Appeals The applicant, owner, any person aggrieved by this Determination, any owner of land abutting the land upon which the proposed work is to be done, or any ten residents of the city or town in which such land is located, are hereby notified of their right to request the appropriate Department of Environmental Protection Regional Office (see http://www.mass.gov/eea/agencies/massdep/about/contacts/)to issue a Superseding Determination of Applicability. The request must be made by certified mail or hand delivery to the Department, with the appropriate filing fee and Fee Transmittal Form (see Request for Departmental Action Fee Transmittal Form)as provided in 310 CMR 10.03(7)within ten business days from the date of issuance of this Determination. A copy of the request shall at the same time be sent by certified mail or hand delivery to the Conservation Commission and to the applicant if he/she is not the appellant. The request shall state clearly and concisely the objections to the Determination which is being appealed. To the extent that the Determination is based on a municipal ordinance or bylaw and not on the Massachusetts Wetlands Protection Act or regulations, the Department of Environmental Protection has no appellate jurisdiction. wpaform2.doc•Determination of Applicability•rev.12/14 Page 5 of 5