10D-011 139 WATER ST BP-2020-1183
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: IOD-011 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPAIR BUILDING PERMIT
Permit# BP-2020-1183
Project# JS-2020-001987
Est.Cost: $27500.00
Fee:$179.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DOMAIN MASONRY LLC 106096
Lot Size(sq. ft.): 10628.64 Owner: AHEARN BARBARA A&LAWRENCE B SMITH
Zoning: URB(100)/ Applicant: DOMAIN MASONRY LLC
AT. 139 WATER ST
Applicant Address: Phone: Insurance:
86 KELLOGG AVE (413)687-2866 SOLE PROPRIETOR
AMHER5TMA01002 ISSUED ON:5/29/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR OF BRICK FOUNDATION
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:
Bough: 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 5/29/2020 0:00:00 $179.00
212 MainStreet, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Northampt6n rmit:
Building DepariFhent *qy Cum tD vewa�,Pemait�
Y 212 Main Street SFA 9 errrer/Se is Availability
1(
Room 100 tioq°�� ''`'ter ell Avpffability_
Northampton, tVMA 01060 qM°��i�; Two is of Structural Plans
1 /n
phone 413-587-1240 Fax 413-5s7-1 �;qAF tf ite Pns _
oho
a f%r Sp cify__ _—
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEItiOI.SH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: �1This section to be completed by office
Map U Lot—SL_._' Unit
139 Water Street, Leeds Zane Overlay i2istrict___.
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Lawrence B. Smith 139 Water St.,Leeds, MA 01053
Name(P nt) Current Mailing Address:
4133-727-4097�-727-4097
Telephone
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 $27,500 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 17q
5.Fire Protection
6. Total = (1 +2+3+4+5) $27,500 Check Number
This Section For Official Use Only
3
Building Permit Number: �
_ / Date' Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
larrysmith139 @ yahoo.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 14,1b7sf"--'77"",' 14.107sf
Frontage 104' 104'
Setbacks Front '20i 20'
Side L:`8' R:'30' L:8' R:30'
Rear 87' 87'
Building Height 35' 35'
Bldg. Square Footage 270sf 20 .270sf 2(}
Open Space Footage °o
(Lot area minus bldg&paged 10,71 76 10,71 76
-parking)
#of Parking Spaces
`2 �
Fill: 0
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO (�) DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES Q NO
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
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 0 NO
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 F–] Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 1`7
Accessory Bldg. ❑ Demolition ❑ New Signs [[:3] Decks [Q Siding[0] Other[M
Brief Description of Proposed Repairing 15'ofbrick foundation at SW comer oFbuilding(crawl space)
Work:
Alteration of existing bedroom Yes X ,_W No Adding new bedroom Yes x No
Attached Narrative Renovating unfinished basement Yes x No
Plans Attached Rall -Sheet
sa.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.
1. 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
I, /a1.,�, sq G.c /•s Owner/ horized
Ag661:ftereby declare that the statements and information on the foregoing application are true and accurate,to my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print me
Signature er ent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor., Not Applicable ❑
Name of license Holder: tT 1Ll S 'iF'1 It t
License Number
Address Expiration Date
Signature Telephone 5/�-9?/Ze
9.Registered Home Improvement Contractor. Not Applicable ❑
Company Name Registration Number
_ l4�ed qk Ave A,�-ersf _ J'�� 179483
Address Expiration Date
TelephoneLl/9.687-2.866 (9
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....... 'i- No...... ❑
City of Northampton
tiSa. `s,
Massachusetts
z -A �.• �
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building �v .
Y Northampton, MA 01060sk :
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:
Lo Pt't E
(Please print house number and street name)
Is to be disposed of at:
US15A 0U
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signat of Permit Applicant or caner 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
r
DEPARTMENT OF BUILDING INSPECTIONS r
212 Main Street • Municipal Buildingk�,
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, r»odemization, 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.
-Vote:If the homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: "F-C)LU1%-PF4-Tt o ru ?-.E-:P t(?- Est. Cost: -'4-1-3 , .�-0 6
Address of Work: �3 R ( f3T�r2 _l _L J_S P,4 C�/ b
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): ,�' c.�_/!hr,e l
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 OR NIERS 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.
4R:
Notwithstanding the above notice;I hereby apply for a building permit as owner of the above pro rty:
Date Owner Name and Signature
The Commonwealth of Massachusetts
Department of Industrial Accidents
ai I Congress Street,Suite 100
Boston,MA 02114-2017
/Y www massgov/dia
NVorkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED RTTII THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Crscanization,'Individual):Lawrence B. Smith
Address:139 Water Street
City/`State/Zip:Leeds, MA 01053 Phone#;::413-727-4097
Are you an employer?Check the appropriate box: Type of project(required):
Z.. a
emp oyer WI employees(full and/or part-time').* 7. E] New construction
sole proprietor or ria ership and have no employees working for me in $. E] Remodeling
pacity.[No w comp.insurance required-1
9. ❑Demolition
omcowncr doingall work myself.[No workers'comp.insurance required.]
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 I I.E]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.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance
14.E]Otherbrickfoundation repair
6.E]We are a corporation and its officers have exercised their right of exemption per MCA.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.
f 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 no: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.
Ido hereby cera under the pains and penalti erjury that the information provided above is true and correct.
Si tore: ,dz--- e--5�7 Date:
Phone#:413-72i-_4097
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#: