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17C-218 (11) 29 NORTH MAPLE ST BP-2020-0650 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C-218 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category BUILDING PERMIT Permit# BP-2020-0650 Project# JS-2020-001107 Est. Cost: $800.00 Fee: $100.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group JAMES PETERSON 107525 Lot Size(sq.ft.): 6490.44 Owner: LAFRANCE SANDRA K Zoning: GB(100)/ Applicant: JAMES PETERSON AT: 29 NORTH MAPLE ST Applicant Address: Phone: Insurance: 1310 SOUTH MAIN ST (413) 68.9-8359 PALMERMA01069 ISSUED ON:11/20/2019 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE RAILING FOR ENTRY WAY 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 11/2d/2019 0:00:00 $100.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner I i Versionl.7 Commercial Building Permit May 15,2000 j �Departmnt use''"only e� City of NorthamptonStasis of Permit, Building Department Curo,Cut/Driveway Permit 212 Main Street SewerfSepticAvailability Room 100 Water1We11 Availability Northampton, MA 01060 T"'Sets of'Struetural Plans phone 413-587-1240 Fax 413-587-1272 PlottSlte Pians ; OtheraSpecif . ¢ �• APPLICATION TO CONSTRUCT,REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 ;SITE INFORMATION 1.1 Property Address: Thrs sectron to be completed by office- -m Xyk .Sf Mao'_ ay C` UnXq it 7/Gre A<7 a ,:Zoned Overlay D�stnctE � Elm StQrstnct CB�rstnct> SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Signature Telephone 2.2 Authorized Agent:^ Name(Print) Current M,,aaipiling Address: Signature Telephone el/3- 4 0 7—' je SE CTI J,KN-1-ESTIMATED CONS TRUCTION'COST$> Item Estimated Cost(Dollars)to be °Official Use Only- completed nly com leted by permit applicant _ 1. Building (a)%BuildindPermitFee i 4 2. Electrical b Csonst uction 6l Cost of` O m6 3. Plumbing `Buildmg Permit Fee 4. Mechanical(HVAC) s 140�O° 5. Fire Protection F 6.. Total=0 +2+3+4+5) .Check Number 64b .. This Section For Official Use Onl Building=Permit Number Date �SD Issued . .. 1 Signature., Building�Com ssioriedinspectocof.Build'ngs Date Versionl.7 Commercial Building Permit May 15,2000 SECTION 4-''CONSTRUCTION SERVICES OR PROJECTS°'LESS THAN 3 F5;000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other Brief Description Enter a b�ief descriptionhere. R!!? e L x te f+-�� JPa•�� y Of Proposed Work: mayI �T11�'g `«y "mo of Lex`/ vprIY1,E aIke or;.t7 fio emterea, ell flJA /o• /niY� fB over c� 00 � SECTION 5 ,USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 113 ❑ B .Business Ell, - 2A ❑ E Educational ❑ 213 I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ I 3A ❑ I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 313 ❑ M Mercantile ❑ 4 ❑, R Residential Q1" R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ . S-2 ❑ 513 0 U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS ADDITIONS AND/ORtGHANGEIN USE` Existing Use Group: --t Proposed Use Group: Existing Hazard Index 780 CMR 34): I Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY x Floor Area per Floor(sf) St s St � 1 nd L r t 2nd 2 3rd 3rd 4th 4� ,aY_ r Total Area(sf) Total Proposed New Construction r Total Height(ft) �s s Total Height ft � 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone E= Outside Flood Zone❑ Municipal ❑ On site disposal system❑ f r { Versionl.7 Commercial Building Permit May 15,2000 19-41--p-, P 7 HAMPT©N ZC IlYG �. ZZ77 . 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 l r Bldg.Square Footage % Open Space Footage i % (Lot area minus bldg&paved arkin #of Parking Spaces i 1 ti Fill: volume&Location A. Has a Special Permit/Variance/Finding er been issued for/on the site? NO _ DON'T KNOW YES , IF YES, date issued: IF YES: Was the permit recorded at the,Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book Page� and/or Document# B. Does the site contain abrook, body of water or wetlands? NO DON'T KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained. Obtained , Date Issued: C. Do any signs exist onj the property? YES NO i IF YES, describe size, type and location 14"X SBS' �r®wt r►c'T Covc►�/ D.' Are there any proposed changes to-or additions of signs intended for the property? YES NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading,excav n, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES NO In IF YES,then a Northampton Storm Water Management Permit from the DPW is required. i � , 0 Versionl.7 Commercial Building Permit May 15,2000 e SECTION 9-:PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES• FOR'BUILDIt!1GSRND STRUCTURES SUBJECT TO CONSTRUCTION'G,ONTROL.PURSUANT,TO 78Q,.CMR,116(CONTAINING`MORE THAN iS' C F„OF,'NCLO,SED SPACE) 9.1 Registered Architect: Not Applicable ❑ i - Name(Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address _ Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor � �a yds e Z� ro�� e1.t Not Applicable ❑ Company Name: Responsible In Charge of Construction Address nature Telephone Versionl.7 Commercial Building Permit May 15,2000 SECTION 10•-STRUCTURALPEER REVIEW(780 CMR 110:11) Independent Structural Engineering Structural Peer Review Required Yes No SECTION 11,-OWNER AUTHORIZATION TO BE COMPL=ETED'WHEN OWNERSAGENT OkCONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property i hereby authorize `'+�e I�7�e �"ti A� .� fid°�' ��s* �°vt'o�r e n f to , act on my b half, in all matters relative to work authorized by this building permit application. Signature of Owner \ Date 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 Deriury. Print Name Signature of Owner/Agent Date SECTION 12 _CONSTRUCTIbNrSERWICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: 9License Number S 1310 S. *k;.. f �AL- tr Address Expiration Date ignature Telephone SECTION 13=WORKERS'COMPENSATION INSURANCE AFFIDAVIT 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 0 No I ' I 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 ofthe work: 27 •v, /4ae/e T-/- The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of IndustrialAccidents p I Congress Street,Suite 100 Boston,MA 02114-2017 s� www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Annlicant Information A.A. ase Print Legibly. Name(Business/Organization/Individual): .j er�nt a /3/e-I<,soin �L lro/.t� .�M/���i^t a�cs� Address: 5,� W4 '54 City/State/Zip: c,1 er `�1 v�oG Phone#: �l 3-4 Are you an employer?Check the appropriate box: Type Of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.g?-.ma sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.,insurance required.] 9. El Demolition 3.F-1 I am a homeowner doing all work`myself.[No workers'comp.insurance required.]t 4.❑I am a homeowner and will be.hiring contractors to conduct all work on my property. I will 10 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. ! 12.❑Plumbing repairs or additions 5.711 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑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. 14..IJ Other tx f 152,§1(4),and we have no employees.[No workers'comp.insurance required.] /'C/ohX *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 thepolicy andjob 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 Si 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#: 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 LLCLor 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 compleie 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 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 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.mass.gov/dia . i I i • I . I I� I I 1 �I C Fo Zmu)JG I u S6'Ac1 MG, ON itALaUk-S - I