18C-020 (4) BP- 022-0846
285 HATFIELD ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
18C-020-001 CITY OF NORTHAMPTON
Permit: Exterior Res
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2022-0846 PERMISSIONIS HEREBY GRANTED TO:
Project# ROOF Contractor: License:
Est.Cost: 8000 JAMES ROBERTS 099404
Const.Class: Exp.Date:01/21/2024
Use Group: Owner: CZARNECKI STANLEY J & DAVID J ZARNECKI
Lot Size (sq.ft.)
Zoning: SR Applicant: JAMES ROBERTS
Applicant Address Phone: Insurance:
30 Edwards Rd (413)527-6078
WESTHAMPTON, MA 01027
ISSUED ON:07/20/2022
TO PERFORM THE FOLLO WING WORK:
STRIP AND RE-SHINGLE
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOL. TION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: A g
i k ''
I
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
AP
RECEIVED
The Commonwealth of Massachuse is Jtit 1 9 2022
Board of Building Regulations and Sta dards 'OR
MUNI IPA ITY
, , Massachusetts State Building Code,781 CM PT.OF BUILDING IN�PECTIO SE
NORTHA pie MA aA6fked Mar 2011
Building Permit Application To Construct,Repair,Renovate i
One-or Two-Family Dwelling 1
� This Section For Official Use Only
2
Building Permit Number: c�` 3`" gc#9_ Date Applied:
�. i�• j. X► 7 0/Ag.
Building Official(Print Name) Signature '0 /D e
SECTION 1:SITE INFORMATION
1.1 Pro e A dres : 1.2 Assessors Map& Parcel Numbers
1.1. a is this an accepted sh et?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own '.. -Record: ,.
Name( nnt) City.State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg.0 Number of Units _ Other 0 Specify:
Brief Description of Proposed Work:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(L 'or and Materials)
1.Building eCC Building Permit Fee: S Indicate how fee is determined:
2.Electrical � x ❑Standard City/Town Application Fee
0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) Total All Few^At
Check No. V Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
ti
SECTION 5: CONSTRUCTION SERVICES
5.1 Co ruction Supervisor i nse( SL) y� n
License N`utttnOi 4 if Expiration Date
Name Nolde 1-" (
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35.000 cu.ft.)
Restricted l&2 Famil) Dwelling
City/Town.State.ZIP Mason*
ry
flRoofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 insulation
Telephone Email address D Demolition
5.2 Registered me Improvement Contractor(HIC) 1/7/5
IC Registration Number xpiration Date
HIC Con Na c IC: . t. t N e
No.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6: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 Cl No .❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S 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 auth t e by this but d e n application.
Writ Uvvrter's ame(Qatfrt1'
Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
—7—(Cr—0',
Print is or Authorized Ag nt s Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home.Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
t,‘8 w.ma s.,oN uc t Information on the Construction Supervisor License can be found at w .mu :.coa'tips
2. When substantial work is planned,provide the information below:
Total floor area(sq.IL) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system _ Number of decks/porches
Type of cooling system___ Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
•
` The Commonwealth of Massachusetts
IIIMINNIMMO
z Wilik. If.; Department of Industrial Accidents
' — 1 Congress Street,Suite 100
As S
Boston,MA 02114-2017
4��. www mass.govidia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leaibiv
•
Business/Organization Name:
Address: t? 6 coce gf?
City/State/Zip: 0 / v p/� ��/ / ¶ Phone#: 73 ii�!✓— \5(j
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I a a employer with employees(full and/ 5. ❑ Retail
r part-time).* 6. El Restaurant/Bar/Eating Establishment
2. I ama sole proprietor or partnership and have no 7, ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp. insurance required] 8. ❑Noti-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing
no employees.[No workers'comp.insurance required]** I l.❑ Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees.[No workers'comp.insurance req.] 12.0 Other —
*Any applicant that checks box#I must also till out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves.but the corporation has other employees.a workers'compensation policy is required and such an
oreamzatron should check box#I
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic.# Expiration Date: /—3( --
-
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiratio date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DR for insurance coverage verification.
I do hereby certify,under the pains an enalties of perjury that the information provided above is true and correct.
Sienature: Date: / L t
Phone#:
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.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
wwU mass.gov!dia
ti
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership.association or other legal entity,employing employees. However,the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply your insurance company's name,address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members
or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy
is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested.not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers'compensation policy,please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that
must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this
affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02 1 1 4-20 1 7
Tel. #617-727-4900 ext. 7406 or I-877-MASSAFE
Fax#617-727-7749
www.mass.gov/dia
Form Revised 02-23-15