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38B-213 (7)
18 FAIRVIEW AVE BP-2021-0002 GIs#: COMMONWEALTH OF MASSACHUSETTS Ma :Block: 38B-213 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2021-0002 Proiect# JS-2021-000003 Est.Cost: $30000.00 Fee: $143.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: MATTHEW KOZUCH 106644 Lot Size(sq ft.): 4486.68 Owner: FOELSTER MARK Zoning: URB(100Applicant: MATTHEW KOZUCH AT. 18 FAI RVI EW AVE Applicant Address: Phone: Insitrance: 6 HIGH ST (413)570-3279 0 FLORENCEMA01062 ISSUED ON.7/112020 0:00:00 TO PERFORM THE FOLLOWING WORK.-BATHROOM & OFFICE RENO 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 7/1/2020 0:00:00 $143.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner '� I (� J Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans • Other Specify N 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 A)oG Map 0 Lot '�_0 Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: v I w M� Avg.f� �e Name(Print) Current Mailing Address: /L 2�S= Telephone SignatureP 2.2 Authorized Aaen1t: \c_N+ Name(Print) Current Mailing dress: W L-_� �f13- 3V_TT 13 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 2-2— (a)Building Permit Fee 2. Electrical 3 (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4 /43 43 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) 0 Check Number TO This Section For Official Use Only 2(� Date Building Permit Number: Issued: Signature: uv i Building Commissioner/Inspector of Buildings Date ,VIII �ty@ I ,l, C� 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 C' f e Frontage ��r Setbacks Front z� Side L: �S R L: R: Rear Z6 Building Height i S,` Bldg.Square Footage i S�tJ X O % Open Space Footage _ % (Lot area minus bldg&paved parking) #of Parkin S aces C� Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO �DDTVT KN �j YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? 0-AQ-1 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 on the property? YES NO IF YES, describe size, type and location: 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,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O 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 Or Doors Accessory Bldg. Demolition New Signs [ ] Decks [ ] Siding[ ] Other[V-1 Brief Description of Proposed ( Work: Qc�l�l foQM � ICP (-eY�0�L1' � : �AI�C� Iti(�t�dw( (3) -:�"/ Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes 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. 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 1, Aa( ` S F L(` as Owner of the subject property q hereby authorize to act on m behalf,in allmatt rela' to work authorized by this building permit application. Signature of Owft 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 theains end penalties of perjury. /t`C7Z c Print Name �L Signature of Owner,Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction /Supervisor: L Not Applicable ❑ -J Name of License Holder: 1'�� \ �,'k." L — 10( License Number Address Expiration Date Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ <, CN- I -4qL07 Company Name Registration Number I1-ULA Address Expiration Date Telephone 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 SSS .- SSC •'' Massachusetts I� f A DSPARTIMT OF BUILDING INSPECTIONS z 212 Main Street • Municipal Building 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: [3o. �n('O©m 0_tl'&ct)Q 1 Est.Cost: 3e.oC) Address of Work: [CG Cc,:`�_V,e A,)e, Date of Permit Application:IF /ZO 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 t,^he agent Iof 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: Date Owner Name and Signature City of Northampton S S`5 S/ •' Massachusetts l A c N s DEPARTMS[VT OF BUILDING INSPECTIONS y M 212 Main Street •Municipal Building J6 CD u. Northampton, MA 01060 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: F'C�=,\r Ij t (Ple se print house number and street name) Is to be disposed of at: �C� l,0— 1 f-C c\� (PI print name and locatiob of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) -Im /.3 e, z� 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 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. Avolicant Information Please Print Legibly Name (Business/Organization/Individual): Address: Gj City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): LZI am a employer with Z employees(full and/or part-time).* 7. ❑New construction 2.a I am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers comp.insurance required.] 9. El Demolition 3.[:]i am a homeowner doing all work myself.[No workers comp.insurance required.]' 10❑Building addition 4.n 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.[:]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 subcontractors have employees and have workers'corrgr.insurance? 6Q 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#I 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 subcontractors 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. j f Insurance Company Name: Policy#or Self-ins.Lic.#: Lf lh-(01 0/Q Expiration Date: 1 L Job Site Address: i 0 A J e , City/State/Zip: Mo r hS NL f [CIA /v 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 verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. 11i Si nature: �4 < Date: &Z-C, Phone#: LI 3 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#: — —•- . ..••• —I.Ir w ICMO LIH[SILI I T INSURANCE POLICY Liberty Mutual. AR INFORMATION PAGE 10 INSURANCE 175 Berkeley Street Boston, MA 02116 Issued by LIBERTY MUTUAL FIRE INSURANCE 16586 Policy Number WC2-31S-624269-010 Issuing Office 016C NEW BUSINESS NEW Issue Date 05-22-20 Account Number 1-624269 Sub Account 0000 1. Insured and Mailing Address MILL RIVER DESIGN BUILD LLC RISK ID 001175125 6 HIGH ST FLORENCE, MA 01062 Status 46 - LIMITED LIABILITY CO Other workplaces not shown above: SEE ITEM 4. PREMIUM- EXTENSION OF INFORMATION PAGE 2. Policy Period: The policy period is from 05-16-2020 to 05-16-2021 12:01 A.M. standard time at the insured's mailing address. 3. Coverage t One of the policy applies to the Workers Compensation Law of the states A. Workers Compensation Insurance: Par listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100 ,000 each accident Bodily Injury by Disease $ 500 , 000 policy limit Bodily Injury by Disease $ 100 ,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE END WC 20 03 06B D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate per $100 Estimated Annual Classifications Number Estimated Annual Remuneration of Remuneration Premium See Extension of Information Page Total Estimated Annual Premium $ 2 , 552 552 Minimum Premium $ 500 (MA) Premium will be billed ANNUAL Producer 0004-132151 WEBBER & GRINNELL INSURANCE AGENCY INC EIGHT NORTH KING STREET SUITE 1 WC 00 00 01 A © 1987 National Council on Compensation Insurance,Inc. WC 00 00 01 B (CA) Ed. 07/01/2011 All Rights Reserved Page 1 of 1 711fir ; Ll t t ------r-6 mr Con , it , I II ' I levc Pion 2 T1 m m 10 REMAIN r N r V r - a = Z D REA TALL - LINEN IIIAN 11 REANSTALL 1N^r 2' 6 1/Z' 4'-11 3/16' �a✓Y z Z rn -- - l 1 (j O m V> y 211481)1-1 211480H