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16D-021 (6) 147 NORTH MAIN ST BP-2020-0949 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 16D-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: REPLACEMENT WINDOWS/DOORS BUILDING PERMIT Permit# BP-2020-0949 L Proiect# JS-2020-001611/ Est.Cost:$4000.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq.ft.): 24262.92 Owner. BLAIR DANIEL Zoning URB(,100)/ Applicant: BLAIR DANIEL AT. 147 NORTH MAIN ST Applicant Address: Phone: Insnrnnce: 147 NORTH MAIN ST FLORENCEMA01062 ISSUED ON:2/24/2020 0:00:00 TO PERFORM THE FALLOWING WORK.-REPLACE WINDOWS AND EXTERIOR DOOR POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspecor of Wiring D.P.W. Building Inspector Underground: Servic : Meter: Footings: Rough: Rough House# Foundation: Driveway.Final: Final: Final: Rough frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smokes Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. I Certificate of Occupancy signature: FeeType: Date Paid: Amount: Building 2/24/ 020 0:00:00 $40.00 12 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton Status of Permit: ✓� Building Department Curb Cut/Drivew y Per -A Ir 212 Main Street Sewer/Septic Av Na '�. Room 100 Water/Well Avail bility. > ' ' Northampton, MA 01060 Two Sets of Stru tura) land Pq 21 E� phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ON OR r�►Ri'ilfl'PrbWEfL'L���IG __ SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office IV.Me,( A S+ Map DLot _Unit �)`7y-\ ©I06Q Zone Overlay District Elm St.District CB District SECTION 2 -PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record:: UCNv,\it\ S+ Fl0re✓I�P Name(Print) r Current Mailing Address: u 13 S'S a 113 Telephone 1 Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: 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 L/Jy 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) Check Number This Section For Official Use Only (jJ P� ay �C / Date Building Permit Number. Issued: Signature: MMoZ Building Commissioner/Inspector of Buildings Date -taw 13 @ 66VIA ,c�� EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement wiDdicrws Alteration(s) ❑ Roofing ❑ Or Doors Er Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[0] Other[p] Brief Descriptio of Proposed Work: Weed W+^a�S.S t t AV eX�1�'ul' oof Alteration of existing bedroom Yes `� No Adding new bedroom Yes t�l No Attached Narrative Renovating unfinished basement Yes t/ 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: Js 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 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 c 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. 0 CC V1 I-t- � e 1c), r Print Name Signature of Owner/Agent Date City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS S 212 Main Street • Municipal Building Jti ca \, 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 Type of Work: �f Q�41ce rt?_"4 W)-040uX + do n rg Est. Cost: a 16 D. D a Address of Work: y Al•Mc r Q iyi S+ in C P. 4A O )O CR Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): ,,,ob under$1,000.00 Owner obtaining own permit(explain): � �' ^ "� �`�"�'�S Lk rs 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 agent of the owner: 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: ndill')-e-1 4r V4� Date Owner Name and Signature City of Northampton Massachusetts `�• At DEPARTMENT OF BUILDING INSPECTIONS a+ r �J a� 212 Main Street *Municipal Building _ C Northampton, MA 01060 i4. �1� 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: 10Y1 n (Please print house number and street name) Is to be disposed of at: (4CA C -c k ,jn d NoAclylID-1011 /M� (Plea a print n4ne andAocation of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) 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. '\ The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. AAoolicant Information yy. ) Please Print Legibly Name (Business/Organization/Individual): f l ri l d 6/ci) f Address: me,,-A S4 City/State/Zip:T/6"l1 f,g MA 0106_,2 Phone #: 1413 S '5 '� ',f/33 Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with 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. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.®I am a homeowner doing all work myself.[No workers'comp.insurance required.]f 10 Building addition 4.0 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 11.Q 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.❑ repairs Roof i airs These sub-contractors have employees and have workers'comp.insurance.t 6.[:]We are a corporation and its officers have exercised their right of exemption per MGL c. l 4. Other 01 // Wj✓1 � 152,§1(4),and we have no employees.[No workers'comp.insurance required.] �4 oo r_v *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: 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 certif y under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: d ho13 Oa Phone#• 911 SJ a 6133 Ojjicial 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#: City of Northampton Massachusetts �-A DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 JPspy�...... INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two- year period shall not be considered a home owner." The building department for the City of Northampton wants any person(s)who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed). insulation inspection (if required) and a final building inspection The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas)the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made () r understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date a\ao\'aoa b Address of work location / N• ih S