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38D-018 (8) 25 HAMPDEN ST BP-2020-0945 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:3$D-018 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Cate�,oa:renovation BUILDING PERMIT Permit# BP-2020-0945 Proiect# JS-2020-001607 Est. Cost: $25120.00 Fee: $163.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor., License: Use Group: ALLEN GUIEL 054248 Lot Size(sg. ft.): 11020.68 Owner: ROUNDS CALEB M Zoning: URB(100)/ Applicant: ALLEN GUIEL AT. 25 HAMPDEN ST Applicant Address: Phone: Insurance: 63 CHESTERFIELD RD (413)268-9200 0 WC WILLIAMSBURGMA01096 ISSUED ON:2/20/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-ROOFING, SIDING, WINDOWS AND DOORS 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 Si¢nature: FeeType: Date Paid: Amount: Building 2/20/2020 0:00:00 $163.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton Status of Permit y . ! Building Department Curb Cut/Drive y Pe 212 Main Street Sewer/SepticA ilabil y Room 100 Water/Well Avai ability F E B 2 o Pon :: , . Northampton, MA 01060 Two Sets of Str ctural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans ' £L'ILDING INSPECTIONS Other Specify�n,nRTHAMPTON.MIA 01060 APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Map O Lot Q 1 Unit 25 Hampden Street Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Caleb Rounds 25 Hampden Street Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Aent: Name(P Current Mailing Address: u13 oc) 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 ,rte (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 +2+ 3+4+ 5) (� Check Number This Section For Official Use Only �. Building Permit Number: Date Signature: 2-ZD ZOZI� Building Commissioner/Inspector of Buildings Date allen@guiel.com 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 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 O DONT KNOW O YES O 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# B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW © 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 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 Q 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 ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Rn Or Doors Accessory Bldg. Demolition ❑ New Signs [0] Decks [[] Siding Ni Other[0] Brief WorkDTZkkQ ['ygpose,� �Gd 1C.1 t VI C.� A 21A DO0 4 ��1 Q �l�t�/ Alteration `of existing 'bedroom Yes�No Adding new bedroom Yes No � wt�`^G� Attached Narrative Renovating unfinished basement Yes No 65CN— 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, &' IL �dv���1 as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, Iv 1 l as Own r/ ut prized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the bestmy knowledge and belief. Signed under the papenaltie perjury. Print Name Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su ervisor: Not Applicable(❑ Name of License old �'� 0/J c/ � ( GJ MA- License NP umber Address- f Expiration Date Signature Telephone 9. Re ist red Home Im rovem nt Contractor: Not Applicable ❑ /4 61 U 1 0—( I NNY Company Name I Registration Number l�\ IY4 00 ?6 o l • 17.;, - 20 Address' Expiration Date Telephone ;C4 20 co 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: 'rtCy,�pC�Qln The debris will be transported by: &C Lr`U G6� The debris will be received by: Building permit number: Name of Permit Applicant fiUoGL)I - v a Date Signature of Permit Applicant City of Northampton :rrrirV V f.' e 5 c Massachusetts r/ hr DEPARTMENT OF BUILDING INSPECTIONS 9 212 Main Street •Municipal Building ti � 1 Northampton, MA 01060 rs11h 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: ei& (Please print house number and street name) Is to be disposed of at: (Please print name and location of f cility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signafure 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. City of Northampton Massachusetts ��� A i s , DEPARTMMT OF BUILDING INSPECTIONS y 212 Main Street a Municipal Building Northampton, MA 01060 �s11 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 Type of Work: GAe'q6t&- P_te, ,(;l nF i �O i Wo l'�F Est.Cost: Address of Work: �S Date of Permit Application: 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): 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.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: I hereby apply for a building permit as the aagenf the owner:- 5-- � 4-o (-)qqq 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 The Commonwealth of Massachusetts Department of Industrial Accidents 1 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 Leeibly Name (Business/Organization/Individual):Allen Guiel Address:63 Chesterfield Road City/State/Zip:Williamsburg, MA 01096 Phone#:413 268 9200 Are you an employer?Check the appropriate box: Type of project(required): 1.E✓ I am a employer with 2 employees(full and/or part-time)." 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8, a Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.M I am a homeowner doing all work myself[No workers'comp.insurance required.]r 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.2]Roof repairs These sub-contractors have employees and have workers'comp.insurance.] 6. 14.�✓ Other Siding F1We are a corporation and its officers have exercised their right of exemption per MGL C. 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 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:Hartford Underwriters Insurance Company Policy#or Self-ins.Lic.#:6S60UB-9F66069-2-19 Expiration Date:04/27/20 Job Site Address:25 Hampden Street City/State/Zip:NorthamptonMA 01060 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 verifipation. I do hereby ceu der t pai nd penalties of perjury that the information provided above is true and correct Signature: Date: C) Phone#:413 268 9200 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#: My 1 JLJ� tow,i -w-4op (oral,,,!o" u; y r yy -au At m YTULP: , pphmm j-UnU44U6 111--f-hclou 11-f A. YA5 U, jovo. 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