36-186 (7) 878 BURTS PIT RD BP-2021-0096
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36- 186 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Deck BUILDING PERMIT
Permit# BP-2021-0096
Project# JS-2021-000148
Est.Cost: $12000.00
Fee:$78.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sg.ft.): 31232.52 Owner: OHOTNICKY JULIANNE D&JOHN R
Zoning: Applicant. VALLEY HOME IMPROVEMENT INC
AT. 878 BURTS PIT RD
Applicant Address: Phone: Insurance:
P O_BOX 60627 (413)584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.7/24/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.-RE-DECK EXISITNG 20X12 DECK, NEW
RAILINGS
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 7/24/2020 0:00:00 $78.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
r Department use only }
City of Northampto>� LC E I P It7Y
f ..'e7 Yr c"'qs r •sy}! a-;Yl f. a y�„
4 u� Building Department r..' way Perrruf J ,�_ 14_7
tea' .
212 Main Street
Room 100 JUL 2 4 l
y e �F � 4 v ,� •
a fIA al abtr t r a + z
� ,. .• ' / Y.S.5....'F 4gw...d 4 Z. S .sTi f-.a-'3'•i'
Northampton, MA 01060 o� oturaI pian � ; . W
phone 413-587-1240 Fax 41.3=58
Fuji Fir:C,Nr z x, z
,,,
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION f-SITE INFORMATION
1.1 Property Address:
Thus sectton tt}be comp( d by,oftice ,-
Ma Lat
_Un
p
Zone Overlay DEstitct
.Elm
Sf:t7istrict CB Dfstrtct. k:
SECTION 2:-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
to 4-,"V)hn (` yno- nIC.L.._,i ? 4S Pi 4 1?,1 -IUlez2cC Nd 0jU1u�
Name(Print) Current Mailing Address:
or 69.7- 2 2
� . Telephone
�5�fature
2.2 Authorized Agent:
I l ue r P c�.fix bGoao• i-lote�c_c� A- oI c)G
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 t I 00(7 (a)Building Permit Fee
2. Electrical f (b)Estimated Total Cost of
Gonstruction from(6),
3. Plumbing Building Permit Fee . n
4. Mechanical(HVAC)
5. Fire Protection
6. Total_0 +2+ 3+4+5) % Check Number
This Section For OfficialUse Only
Date
Building Permit Number: [7r" �� L `� Issued:
Signature: 2
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING AU Information Must Be Completed, Permit Can Be Denied Due To incomplete Information
Existing Proposed Required by Zoning
Tbis column to be filled in by
Building Department.
Lot Size
14
k.
Frontage
Setbacks Front
Side L:f § R:I�.V= L:! i R:' 1 I i
Rear f i
Building Height I l
Bldg. Square Footage
Open Space Footage
(Lot arca m us bldg&-paved
arkin )
r of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:i
IF YES: Was the permit recorded at the Registry f Deeds?
NO 0 DON'T KNOW ( YES 0
IF YES: enter Book Pagel and/or Document
B. Does the site contain a brook, body of wa r or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need tore obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
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 0
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 n NO 0 i
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 AIteration(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks-NZ Siding[01 Other[El
Brief Description of Proposed _ r J� d
Work: z �.- bE(--K ti15T)J6 U X II '-C* L
Alteration of existing bedroom Yes No Adding new bedroom Yes -rte No
Attached Narrative Renovating unfinished basement Yes ? No
Plans Attached Roll -Sheet
--
ra.1f Neihr.hoiise and' r ffion to.ezistfng�hbuslng comp lete:the'foltovvtne:
a. Use of building: One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathroom'`
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 fi ' hed grade
k. Will building conform to the Building d 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.APPOES FOR BUILDING PERMIT
I, ir1+n C)ht34-r!1 as Owner of the subject
property
hereby authorize }� ; c "e�sGr7 c7l>1VCr�rrriiCCr7
to act on my behalf,in all matters relative to work authorized by this building permit application.
Sign a of Owner Da e
I,_ A-3n 1 S1 I i1e4'rrOL2. V WT as OwneOuthorized
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.
,eve I u
Print Name
Signature of Owner/Agent Date
SECTtOtd 8-,ONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: �� - ry'iku-1 0-77a-29
License Number
1 C .
C-1( - - /ao
Address Expiration Date
///w X 59 9-,-1
Signature- phone
9 Reiestecedltome:linpraetrierrt:Gontractor:a Not Applicable ❑
Company Navhe Registration Number
Address pp Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§,25C(6)j
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...... ❑
i
City of Northampton
r/ r Massachusetts"
*` DEPARTMENT OF BUILDING INSPECTIONS �
212 Main Street • Municipal Building
'. Northampton, M3 01060
AFFIDAN'TT-
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 .... ' Est.Cost:
Address of'Work t1S
Date of Permit Application:
I hereby cerffy that:
Registration is not required for the following reason(-):
Work excluded by law(explain):
Job under$1,000.00
_Owner obtaining own permit(explain):
Building not comer-occupied
_Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE ROME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR M D DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GIIARAN-TY FUND
UNDER M.C.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILPTES FOR ALL WORK
PERFOR-N ED 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:
_TA- a7a-0-1:0 C iG�S y 3
Date Contract6r 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 _
� x r Massachusetts _
i
� t DEPARTt �1.T OF BUILDING SNSPcC2Z0:VS f a-
_ 212 Kaln Street •Municipal Build-'ng
Ncrthanmton, MA 01060
Debris Disposal Affidavit
In accordance of the provisions of IVIGL c 40, S54, I acknowledge that as a condtion 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:
(Please print house number and street name)
1s to be disposed of at:
(PIS ` e print nd. e and lac on of fa6lity)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company game and Address)
Signature of Permit Applicant or brvr er Dale
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
x 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 lnformation Please Print Lezibly
Name(Business/Organizationtlndividual): ffif In-1 `I?m n+
Address: ( ,.O.PbC>,4 boon ;- �NC� ��U2 u {-� ►y
City/State/Zip: Y\a(emic, c)kbb2- Phone#:
Are you an employer?Check the appropriate box:
Type of project(required):
i.gl am a employer with JB employees(full and/or part•time)* 7. ❑New construction
1[]1 am a sole proprietor or partnership and have no employees worlang for me in $, ®Remodeling
any'capacity.(No workers'comp.i* *ran.e required.]
3.❑lama homeowner doing aII work myself[No workers'comp.insurance required.]t 1• ❑Demolition
10 Q Building addition
41:1 lam a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have wod ors'compensation insurance or arc soler 11.0 Electrical repairs or additions
proprietors with no employees. 12.[]Plumbing repairs or additions
5.Q I am a general contractor and I have hired the sub-contractors listed on the attacbed sheet 13.QRoof repairs
These sub-contractors have employees andhave workers'comp,incinance.
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 511 out the section below showing their workcrs'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.
tContractors 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 sob-contractors have employees,they must provide their woxkers'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: !-y bif .1 bSU(-0_ Y C. 6 a
Policy#or Self-ins.Lic.#; C)01�—:,&D,J a'2.t S Expiration Date:
Job Site Addzess: st.13 ( �>+'� 0,=� City/State/Zip: Fjjorejne e 01 C3'z,
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 S 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 fom arded to the Office of Investigations of the DIA for insurance
coverage veriacaticr_.
I do hereby certify uunLder thepains andpenalties of erjury that the information provided above is true and correct.
Signature: /`/ �! Date:
!q� 1
Phone# "1 I,J'Std q��egg
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/Tovsn Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person:-- Phone
— f
®� Commonwealth of tAassachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Constr
pUpervisor
tJ
CS-077279 Wires:06/21/202
i � y Jam.
STEVEN A SIL-VERM A F.
268 FOMER R4�QD _
SOUTHAMPTOftilA.p1073,!
Commissioner l..IZ l Office of Consumer Affairs and Business Regulation
One Ashburton Place - Suite 1301
Boston, Massachusetts 02108
Home lmprovement Contractor Registration
�.
Type: Corporation
VALLEY HOME IMPROVEMENT INC }}' L � Registration: 105543
P.O.BOX 60627 NJ .,; �— Expiration: 07/16/2020
FLORENCE, MA 01062
��l\ � `f�•� Update Address and Return Card.
7 %r 20
M-o51
C1
p7
J/26 !:N71nZtlt[L'�'¢CLJL P��fJGr:J¢C/2elJLt�t
Office of Consumer Affairs k Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:Corporation Before the expiration xpiration data, If found return to:
Reoistratio i� Expiration Office of Consumer Affairs and Business Regulation
05543- 07/16/2020
One Ashburton Place-Suite 1301
VALLEY HOME tU(-GVEP7i�E�T�� Boston,MA 02106
STEVEN A.SILVER Tl—
540 RIVERSiDE:DR"=:����-
NORTHAMPTON,MA 01062 Undersecretary Not valid without signature