25C-147 (4) 27 ORCHARD ST BP-2020-0896
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C- 147 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Pennit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Bath reno BUILDING PERMIT
Permit# BP-2020-0896
Project# JS-2020-001530
Est.Cost: $15400.00
Fee:$100.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: KUEL MCQUAID 051394
Lot Size(sq.ft.): 4007.52 Owner: ZEMELSKY RYE
Zoning: URB(100)/ Applicant: KUEL MCQUAID
AT. 27 ORCHARD ST
Applicant Address: Phone: Insurance:
131 FERRY ST (413) 537-5063 Q
EASTHAMPTONMAO 1027 ISSUED ON:2/7/2020 0:00.00
TO PERFORM THE FOLLOWING WORK.-RENO BATH
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 Sip-nature:
FeeTyue: Date Paid: Amount:
Building 2/7/2020 0:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-11272
Louis Hasbrouck—Building Commissioner
L77
�—�--`--�� Department use only
!` City of Northa ptoof rmit:
Building Depa meCurb ut/Dfiveway Permit
212 Main Str etewe/Sep c Availability
i Room 100 ' ' ate ell vailabilitNorthampton., MA 01Two is of Structural Plans
phone 413-587-1240 Fax41G IN iL�L Plas
NORTHAMT'TON. i pecify
�-- --
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 7 -SITE INFORMATION
. Tchi-sem section to be completed by office
1 Property Address:
Z4 6 CAuv`. S_"rju+ Map J� Lot Unit
G�PV 1 v Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Q Zj n,4_ Ll d- L_0_l/re�- � n n
Name(Print) Current Mailing Address:
Telephone
sidnafure
2.2 Authorized Agent:
oil, 414
Name(Print) Current Mailing AddressL--
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing -� C; Building Permit Fee OO
4. Mechanical(HVAC) �O!
5. Fire Protection
. Total = (1 +2+3 +4+5) S, 0 0 Check Number oZy
This Section For Official Use Only
Building Permit Number: Date
i nature: v"
g � a
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
'
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
Frontage
Setbacks Front I
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has aSpecial Pemnit/Vnriunce/Finding ever been issued for/on the site?
NO ����/ DONT KNOW �~��� YES �~��
�
|FYES, date issue&
IF YES: Was the permit recorded at the Registry of Deeds?
NO �� DON'T un / nnuvv 0 ,ES
IF YES: enter Book
Page and/or Dncument#
�� ��
��
B. Does the site contain a brook, body ofvvaterorwetlands? NO ��� DON'T KNOW �_� YES �~�
IF YES, has permit been orneed to beobtained from the Conservation Commission?
Needs tobeobtained �^� Obtained »�� Date Issued: � --
�~� «~~� ' . J.
Do YES �-� NO «��
���
C. v��
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO0
IF YES, describe size, type and location: =77777:=�
E. Will the construction activity disturb(clearing,gradingexcavation, orfilling)over 1 acre nrioitpart nfacommon plan
that will disturb over 1acre? YES � � NO n�� NU
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 F7Addition E] Replacement W" doves Alterations) Roofing
Or Doors EZ
ff
Accessory Bldg. ❑ Demolition New Signs [p] Decks [0 Siding [[:3] Other[O]
Brief Descriptio,p of Proppsed
Work: 11 I1 CJ C-CPovv\, s e—` O
Alteration of existing bedroom Yes L/No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.ff 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
�QWNERS AGENT
nORnCONTRACTOR APPLIES FOR BUILDING PERMIT
I, �w" r �" � n , as Owner of the subject
property / �1 l
hereby authorize �ve / M L c/el",0
to act on my ehalf, in all matters relative to work authorized by this building permit app Iition.
21671'2020
Signat f Owner Date
I, ku 'e- ( /"l C Q J G� 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 Na e
Z G ZoZo
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
o
Name of License Holder: K L/ C ?y CA- 6-P—0] '3 T
License Number
AA C� (vZ7 �2 �i 2oZo
Ad5ress!!�4
Expir tion ate
3 37
'Signature Telephone
9.Registered Home Improvement Contractor. Not Applicable ❑
�,J e- ( AC a, . ioC-7o co
Company Name Registration Number
AA 0 021 0-7 123 12-oZD
Address Expir on Date
Telephone( 3"S37
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 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: 27 0<-Gko-v-d C,4— Acl s
The debris will be transported by: /'eve-( Me aj��
The debris will be received by: \1ec Ctl-
Building permit number:
Name of Permit Applicant Kcr M C a'�"
Date Signature of Permit Applicant
' The Commonwealth of Massachusetts
x Department of Industrial Accidents
0
I Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individua]): r[V /1'tC' �/ct r
Address: 1 31 (- e S C J
City/State/Zip: MA G b2 7 Phone#: `� 3 , d�O
Are you an employer?Check the appropriate box:
Type of project(required):
L I am a employer with employees(full and/or part-time).*
7. ❑❑/New construction
2.�am a sole proprietor or partnership and have no employees working for me in $. I y�jtemodeling
any capacity.[No workers'comp.insurance required.] u
9. Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
❑4.FJ 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.dElectrical repairs or additions
proprietors with no employees.
12. Plumbing repairs or additions
5.r7I 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.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeownerswho 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: 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 andpenaltie ofperjury that the information provided 9bovejs abovetrue and correct
Signature: 7 Date: A v 2o2nd
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 agencyshall 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.haye 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 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