38B-304 28 FAIRVIEW AVE BP-2018-1138
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B-304 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: Door Replacement BUILDING PERMIT
Permit# BP-2018-1138
Proiect# JS-2018-002046
Est Cost: $300.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use Groap: Homeowner as Contractor
Lot Size(sq. ft.): 11412.72 Owner. OLSZEWSKI WILLIAM S JR& PATRICIA E LYMAN
Zoning: URB(100)/ Applicant: OLSZEWSKI WILLIAM S JR & PATRICIA E LYMAN
AT. 28 FAIRVIEW AVE
Applicant Address: Phone: Insurance:
28 FAIRVIEW AVE
NORTHAMPTONMA01060 ISSUED ON.5/3/2018 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE FRONT DOOR OF HOUSE
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 5/32018 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Northampton Status of permit
Building Department Curb CuIlDriveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 :--C tans
phone 413-587-1240 Fax 413-56 -12BEC
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR,R NO TEWDEM91-@M6 ON OR IWO FAMILY DOWELLING O
SECTION 7 -SITE INFORMATION DEPT OF v–
7.1 Prooertv AddressNORTHAMPTOMMIN Nbn to completed by office
: Nd�/ L,
Zp FAIRVf6Lt1 AVE, Map 3d 6 Lot x7 Unit
9ORFRAMill Zone Overlay District
Elm St.District GB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
WILLIAM QL 7EWSKI
Name(Print) Current Mailing Address'.
Telephone
Signature ✓U 7 ~
2.2 Authorized Adam.
Name(Print) Current Mailing Address'.
Signature Telephone
SECTION 3.ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permitapplicant
1. BuildingQ J (a) Building Permit Fee
2. Electrical a (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 Number: Date
ssued.
Signature hoI` �t—
Building Commis - onspector of Buildings D e V C
M0 NOCK MR AI Ge COMt S-r Ne-r- MAY - 1 2018
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONT A F DUll DING INSPECTIONS
NORTHAMPTON.MA 01060
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Req aired by Zoning
This calume te be filed in by
Building Department
Lot Size
Frontage
Setbacks Front 7
Side G R: R:
Rear
Building Height
Bldg. Square Footage its
Open Space Footage %
(Lot area mime bldg&paved
done)
#ofParking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DON'T KNOW 0 YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW 0 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 V NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions o'signs intended for the property? YES Q NO O
IF YES, describe size, type and location:
E. Wil the construction activity disturb(clearing, grad ng, excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO (D
IF YES, then a Northampton Storm Water Managenen: Permit from the DPW is required.
l
SECTION 6-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[0] Other[Oj
Brief Description of Proposed
Work: REPLACE FEoNT AooE eF F/ouE Dcde — L JFAtTX , 30
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 housina, complete the following:
a. Use of building: OneFari 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_
It. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
1. Is construction within 100 ftof 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_ CitySewer Private well City water Supply_
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. , 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 Data
(LLIA14 S. 6"Z Eu1SK a as Owner/Authorized
Agent hereby declare that the statements and in rmation on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
ll)!LL/AA S OL 5 zEwswl��m
Print Name
Signature of Ownere gent Iate
4
SECTION 8-CONSTRUCTION SERVICES
81 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder.
License Number
Address Expiration Date
Signature -Telephone -
9.Reaistai Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25Ci
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
� Massachusetts 3"
F
DEPARTMENT OF BUILDING INSPECTIONS T
212 Hain Street Municipal Building Jr
Northampton, MA 01060 hp' S�cm
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
perforating 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:
Date of Permit Application:
I hereby certify that
Registration is not required for the following reason(s):
_Work excluded by law(explain):
Job under S 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 penury:
I hereby apply for a building permit as the agent of 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:
y5o I f d 71LQ0 L OLL,t,.=', 4
Date Owner Name and Signature �r
City of Northampton
✓(( Massachusetts = r'
" ( DEPARTMENT OF BUILDING INSPECTIONS x
212 Main Street • Municipal Building Cb
Northampton, MA 01060
Massachusetts Residential Building Code
Section I I O R5.12
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 o:-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 binding permit is required shall be exempt from
the licensing provisions of 780 CMR 110.85, provided that if a homeowner engages a person(s)
for hire to do such work, then such homeowner stall 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 inju:-ies 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
s �
Massachusetts 4
y DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street 4 t nicipal Building v n
Nartha ton, MA 01060 srYW 3" �l
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:
Ar FAity(Eu7 AVfi
(Please print house number and trees name)
Is to be disposed of at: II
&P(5NP(ELD I-R ANSrf-r— S'MrjoN
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
I .n(Company Name and Addregsss)
Signature of Permit Applicyt or OWneY 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
a Department of fndustrial Accidents
1 Congress Street,Suite 100
7
Boston,M,A 02114-1017
orww.mass.gov/dia
Workers'Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING ALTHORITV.
Applicant Information Please Print Legibly
Business/Organization Name:
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Business Type(required):
i
1.0 I am a employer with employees(full and j 5� E]Retail
or part-time).* i
1 6. ❑Restauravt/Bar/Enting Establishment
2.0 I am a sole proprietor or partnership and have no y. ❑Office and/or Sales(incl.real estate,auto,etc)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right ofexemption per c. 152,¢1(4),and we has e 10.F]Manufacturing-
no employees.[No workers'comp. insurance required]*
4.❑ We are a non-profit organization,naffed by volunteers, 11. Health Care
with no employees. [No workers'comp. insurance req.] 12.❑Other
`My applicant thatchecks box al nom,a also filleut the secnonbelow shewirg emosvirkm omismetion policy lnfmmation
"9f the mrpmm officers Iwve exanpted themselves.but the corporation hachow employees,a workercompenstrom policy is requved and such an
organcearon should check box#1.
Iam an employer that is providing workers'compensation issurmtce for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lie.# Expiration Date:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ofidG1 a 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well ac civ,I penalties in the form of a STOP WORK ORDER and a fine
of up In$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 thepains and penalties ofperjury that the information provided above is true and correct.
Signature: Date:
Phone#:
Official use only. Do not write in this are,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/Tmrn Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.ria „n�taia
The Commonwealth of Massachusetts
Department of Industrial Accidents
7 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/ilia
\N others Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #:
Are you an employer?Check the appropriate box:
Type of project(required):
It am a employer with cmployws(full amVorpan time)`
7. ❑New construction
2. l am a sole pmpriemr or partnership and have no employees working forme m S, ❑Remodeling
swpadty.[No werkerscomp_influence required-]
3%am a homeowner doing all work myself[Nowarkers'comp.insuraneercquiredl' 9. El Demolition
4ate'�f1am a homeowner and will be hiring contractors to conduct all work on my property- 1-11 10 El Building addition
re that an cancers either have workerscompcnsawa insurance or are sole II.❑Electrical repairs or additions
",,rants with no employees. 12.❑Plumbing repairs or additions
5r I am age neral eomaciaraad l have hired the flub-contractor,listed on the attached sheer ]3.�ROOf repairs
These subeontmmon have employees and have workers comp.insurance
6.❑We arc a correlation and as officers haveexercised thorn€ht ofexamption per MGL c 14,[]Other
IS°f 1(4),and we us,v no employees.Mo workers comp_insurance pa,en L]
*Aso applicant that checks box BI most also fill mut the section below showing their workers compensation policy information.
I Homeownus who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit contends such
in onnactors that check this box must attached an additional sheet showing the nave of the subeentrzctors and state whether or not those entities have
enployecs_ If the subcontractors have employees.they must provide their workers'comp_policy number.
7 am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lin.k: 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 5250.00 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.
7 do hereby certify under thepains anal pey^nalties of perjury that the information provided above is true and correct
Signalum 7w�.YQL4* @ (/e�.� -.�/,'/ � Date Y-13
Phone a: t—i hF--13.5.3
Official use only. Do not write in this area,to be completed by city or town ojficialt
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#:
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"...eve-y p( son in the service of another unit,,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 a deceased employer,or the
receiver or trustee ofan individual,partnership,association or ther legal entity,employing employees. Howeverthe
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 mil 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 at 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•meanonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public wmkuntil 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 comp late y,by checking the boxes that apply to your situation and,if
necessary,supply sub-eontmclons)name(s),addresses)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limitrd Liability Partnerships(LLP)with no employees ether than the
members or partners,are not required to carry workerscomfensation insumnce. If an GLC or LLP does have
employees,a policy is required. Be advised that this affi Javir maybe 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 ifyou are required to obtain a workers'
compensation policy,please call the Department at the n umber 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 Lgibly. 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 my given year,need only submit one affidavit indicating current
policy information(ifnecessary)and under"Job Site Address"the applicant should write"all locations in_(city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proofthat 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 licnme 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 Commonw.alth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, 14A 02114-2017
Tel. #617-727-4900 est. 7,406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia