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24D-088 (8) 60 NORTH ST BP-2018-1072 GIS a: COMMONWEALTH OF MASSACHUSETTS Map,Block:24D-088 CITY OF NORTHAMPTON Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category: Siding BUILDING PERMIT Permit« BP-2018-1072 Proiectk JS-2018-001935 Est. cost: $25000.00 Fee: 560.00 PERMISSION IS HEREBY GRANTED TO. Const.Class. Contractor: License: Use Grmmo MATTHEW T WILCOX 075440 Lot Size(sa. ft.): 8886.24 Owner: FREY JOBN D&JENNIFER K DIERINGER zuntue: URC000)/ Applicant: MATTHEW T WILCOX AT.* 60 NORTH ST Applicant Address: Phone: Insurance: 7 PORTER ST (413) 665-8269 SOUTH DEERFIELDMA01373ISSUEDON:4/19/20180:00:00 TO PERFORM THE FOLLOWING WORK:REMOVAL OF EXISTING SIDING AND TRIM AND INSTALLATION OF NEW HARDI PLANK CLAP SIDING 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 ft 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 Sienature: FeeTvoe: Date Paid: Amount: Building 4/19/2018 0:00:00 560.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner X I Department use only ty Northampton Status of Permit: ildi g Department Curb CWDriveway Permit_ -- Main Street SewedSeplic Availability :I Room 100 Water/WellAvailability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 PloVShe Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION i -SITE INFORMATION 81,9- 19- 10 '7x- 1.1 Property Address: This section to be completed by once '. Map c'(l/ Lot 59.- Unit 60 North Street Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZMAGENT 2.1 Owner of Record: JohnFrey 60 North Street Name(Fri Current Mailing Address: 413-320-1265 Telephone 4-1 Si t 2.2 Authorized Agent: Ma ewt�-leve la-Mingl7dog�rv . Nolan Gr, N Lc�field rvlk6 Name(Print) ueeM Mailing Atldress: '-113 52,Z— I Q 9 H Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 25000.00 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total-(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit NumbeDate Issued Signatur : / 2 Building C�, linspctr&oBuildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING Ah Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This columm to be Filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L R: Rear Building Height Bldg. Square Footage % Open Space Footage % (1,u9 area minus bldg&paved ad,im #of Parking Spaces Fill: volume&Lm ation A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O 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 O NO O 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 NO 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 Wiinpows Alterations) ❑ Roofing ❑ Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [q Siding[EI) Other[m Brief Description Of Proposed Removal of existing siding and an and installation of new Hardi Plank clap siding Work: Alteration of existing bedroom_Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet w. 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? J. 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? In Type of construction i. Is construction within 100 R. of wetlands? Yes No. Is construction within 100 yr. floodplain_Yes No I. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No- I. Septic Tank_ CdySewer 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 onze "^vvr/^PiG✓ "V t ( GFX to a n my beh f 11 matters relative to work authorized by this building per a Iiwtign_ L Sig • ,I Owner Date 1, M(.lT'f/ll��A� W1, `LOX as Owner/Authorized Agen hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Sighed under the pains and penalties of perjury. Pnnt N 'me (�I /7 Signature of Ownar/Agent Date / // SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor. Not Applicable ❑ Name of License Holder: MatthewTWilcox License Number 7 Nolan Circle CSFA-075440 Address Expiration Date Hatfield, MA 01038 6/20/2019 Signature Tele hone 413-522-1894 8.Realatenad Home Im'p�rovement Contractor: Not Applicable ❑ Wil Cox [aI lrinrs l r1c Company Name Registration Number 2 N0`6an Gr- 1'7624 (O Address Expiration Date �'Pr0 ' - olb�p Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§I6C(6)) 1 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 UDEPARTMENT y\5 3/n Idaaaachuaetts OF BDIDDINO INSPECTIONS 212 Main Street & Mwicipal auilding��\,.. Northampton, 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. Nate.Ljthe homeowner has contracted with a corporation or LLC,that entity mos(be registered Type of Work: gic4iirI5 Est.Cost%.1�(Ogo Address of Work: (/O N 0(-j-h $'!i�'"T,9,4ti— Date of Permit Application:_ L1/ 7)1 a 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 RESPONSUMLITES 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: /041 /W a4linj a) l co Dater C actor Na ne 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 Massachusetts DEPAE� OF BDILDiNG INSPECTIONS 1\ 212 Main Street • M cxpal Building Ju Cm Northampton, M 01060 Massachusetts Residential Building Code Section I IOX5.1.2 Homeowner: Person (s) who own a parcel of land on which he/she resides or intends to reside, on which there is, or is intended 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 homeowner. Section 110.R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. Such homeowner shall submit to the Building Official, on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. City of Northampton Massachusetts F25 - °4l DEPARI4�NT OF BUILDING INSPECTIOIPS 212 Main S=eet elWnicipal Building 22 �.n Northampton, nm 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: &0 No(+h are-e+ (Please re e+ (Please print house number and street name) Is to be disposed of at: Val,(t u (Please int name aPfd location tif facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) � 4 00717 Signature of Permit Applicant orpvfner 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 IndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 0211 4-2 01 7 www.mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMI'11 ING AUTHORITY. ADDlicant Information I ,.1aPlease Print Leeib W lv Business/Organization Name: 11C`m bl la Id � �, Address: 7 l j oiositn cr City/State/Zip: FLA±fi W MA a Phone#/: Are y�employer?Check the appropriate box: Business Type(required): L I am a employer with 10 employees(Poll and/ i ❑Retail orpart-time).' 6. ❑Restaurant Bar/Ealing Establishment 2.❑ I am a 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] S. ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152,§I(4),and we have 10.❑ Manufacturing no employees.[No workers'comp.insurance required]* 11 ❑Health Care ,LF We are a non-profit organization,staffed by volunteers, r��. l� with no employees.[No workers' comp.insurance req.] 12.❑Other Oms "All 'Any applicant that checks box pl must also fill out the section below showing their workers compensation polies information_ "Uthe corporate oRce>s have exempted themselves,but corporation has other employee,a workers'a mpensonch policy is mlwrad and such an organisation should check box N I. I am an employer that is providing worker 'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Qr'I� 4.CV r) Lmb" Insurer's Address:_ (Qa- IM-Ple L_ lu'M t r 2 1 1(p 2 City/State/zip p� 1 ' p� Policy#or Self ins. Lic.# XI a S 57S r��f 3r1(_)��� Expiration Date: I a 5 Attach a copy of the workers'compensation policy declaration page(showing the policy number and a piration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition ofctiminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of 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 DIA for insurance coverage verification. I do hereby certify, under th stns kr! enal8es of perjury that the information provided above is true and correct. Sim u>� Date' Photic#: '�{�`—� Oficial use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License it 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#: www.m tva— ur acoiro® CERTIFICATE OF LIABILITY INSURANCE Nn2/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEN D,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT. Nthe c Mfi aie holder he an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or INS endomed. H SUBROGATION IS WAIVED,subject to the terms and conditions of no policy,certain policks may require an endorsement A statemerd on this cerNBcaM dons net confer rights to the cerlfRcate holder in lieu of such endorsement(s). PRODUCER CONTACT Linda P.,S AME: WehherBGnnnell Ia�"ic°Nw EN. (413)586-0111 (413)58&8481 8 North King Street anNOAal�.ss: Ipowedy@AeeeemndgnRPUIl GO. INSUREmaI AFFORDING COVERAGE SAID. NOlthan-plon MA 01060 INSURER A: OHIO Seounty/Libedy 24082 INSURED INSURER B: W E,ox Builders,Inc INSURER c Alin Martin.MI. INSURER D 7 Nolan C,"D INSURER E: Hatfield MA 01038 INSURER E: COVERAGES CERTIFICATE NUMBER: Master Evp 11-2018 REVISION NUMBER: THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOIDNITHSTANDING ANY REQUIREMENT TERM OR CONDITION OFANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAV BE ISSUED OR MAY PERTAIN,THE INSURANCEAFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUW ECT TOALL THE TERMS, EYCLUSIONSANO CONDITIONS OF SUCH FOLIOSE LIMITS SHOWN MAY HAVE BEEN RE WCED BY PAID CLAIMS. / [—ADDLrUBRj PO ITR T,PED INAURaN, IMAD ANN PRUCY NUMBER vsaTOYEFF YPoDIVyTYP LICYOY IMITS X COMMERCNLGENERALUABIl1 TY EACHOCCURRENCE E 1,000,800 CUIMS UNDE O OCCUR FEMISES Ea oxurreI.I $ 100.000 mE.'(A „aPH.11 $ 1,006 A BKS57534380 11/01/2017 11101/2018 PERSONALa AUVINLURY E 1 000DOC GENLAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 3,000,000 X POLICY JE0 LOG PRODUCTS-COMPIOPAGG $ 3,000,W0 OTHER AUTOMOBILE LIABILITY LCCMBIINIO SINGLE LIMIT $ 1,000,000 ANYAUTO B0.111.11RY(I cas. I $ A OTESPED ONLv wHEWDULED BAS576343B0 111014D17 11/01/2018 FODILVIRUPI,nema.,,) E X AUT050n1Y X AUOTOS ONLYD LOPE. AMAGE E Medical payments $ 5,WO UMBRELLA WB OCCUR EACHOCCURRENCE $ CACEBBWB CIIIMSMADE AGGREGATE DED NTIUN E g WORNERS COMPENSATION ER OTH- ANDEMPLOYERS'LABILITY X STATUTE ER A OPYIC NA MBEF EsCLUDEo.EcurrvE YO x XW557534380INYR 12/154017 1211512018 eL.EACH accmenT S 500000 tM,na.l.ry In xm EL DISEASE.FA EMPLUYES S 500000 IO...RIION OF OPERATIONS be. EL DISEASE- 500,000 POLICY LIMIT } DESMG NWOPEMT SILOCA S/VEHICLES(ACORD 101,AEJNen.IR—MnS.MEUM.May MManl,eEr m.n yvs Is ry,nNH CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EX%RATION DATE THEREOF NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 5 AUTIORIZED--I-- 0 1938-2015 EPRESEHTAIIVE®1888-3015 ACORD CORPORATION. Ali rights reserved. ACORD 25(201611 The ACORD name and logo are regbtsr°d marks of ACORD 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 ajoint enterprise,and including the legal representatives of 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 heense 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,net 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 most 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 bum 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 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 www.mass.gov/dia Form Revised 02-23-15