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25C-007 (21) 142 NORTH ST BP-2018-1192 GIS#: COMMONWEALTH OF MASSACHUSETTS MW.Block:25C-007 CITY OF NORTHAMPTON Lot,-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category,ROOF BUILDING PERMIT Permit# BP-2018-1192 Project# JS-2018-002137 Est.Cost:$16000.00 Fee'$40.0 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: CLAUDIO GARRIDO 89458 Lot Size(sq.ft.): 44431.20 Owner: BRANDES AARON Zoning URB(1001/ Applicant: CLAUDIO GARRIDO AT. 142 NORTH ST Applicant Address: Phone: Insurance: 140 NASH HILL RD (413)268-9052 HAYDENVILLEMA01039 ISSUED ON:5/1612018 0:00:00 TO PERFORM THE FOLLOWING WORK STRIP & SHINGLE ROOF 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 Occuimey Signature: FeeTvne: Date Paid: Amount: Building 5/16/20180:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner (L crp F Department use only i City of Northampton Status of Permit ' ,. ` Building Department Curb CuVDnveway Permit 212 Main Street Sewer/Septic Availability -'. (� Room 100 WaterlWell Availability Northampton, MA 01060 Two Sets of Structural Plans .,.. phone 413-587-1240 Fax 413-587-1272 Plot/Stte Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 6 to a- 72, This section to be completed by office 1.1 Property Address: 112 Nor1 , 9fffit Map Lgt Od ? Unit tic'( lU.tq��Gl� iMN 010 (uG Zone Overlay District Elm St.District C8 District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: AAron '[>r6" (d,S '4 Z' Norkl.ri }cls Nlva nlrU� Name(Print) Current Mailing Address'. lkaYCl� ratltle5 r. o rico Telephone Signature p 2.2 Authorized Agent. R?f JJ �n M �lAiSsl � !�6'1 lir`« ✓yl�� Name(Print _ ! Current Mailing Address: � T q � - TZ4, l�— 9�n s2 Signature Te ephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit ap licant 1. Building (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 Onl Date Building Permit Number Issued: Sign re: lv Building C manner/Inspector,of Buildings Data 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 tilled in by Building Deyanmcnl Lot Size Frontage Setbacks Front Side L.'. R'.._.. L. R. _. Rear _.. Building Height Bldg. Square Footage Open Space Footage (Lot arca minus bldg&paved parking) #off'arking Spaces --- Fill: ._...... ..._.. ivalumc&Location)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 DON'T KNOW © 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 © Obtained O , Date Issued: C. Do any signs exist on the property? YES © NO O 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© NO O IF YES,then a Northampton Ste"Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Akeration(s) ❑ Roofing Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding [0] Other[O] Brief Description of Proposed n 4 Work: Alteration of existing bedroom_Yes_X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes X_No Plans Attached Roll -Sheet Be.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 farm attached? In. 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 I, >4&ay\.� as Owner of the subject property (� l hereby authorize 0UJ IC ISIa Yr 1L'U to act on y behalf, in all matters relative to work authorized by this building permit application. ignature of/Owner 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 the pains and penalties of perjury. Print Nam. Signature of Win #�� Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervviis'orNot Applicable EI Name of License Holder:(/,/,A y:� /y�F License Nu be _ NO Atltlress/ i Expiration pate Sigrs,IWe Telephone 9.Registered Home Improvement Contractor,. Not Applicable ❑l .pr b / ;,,q -fit :�C> Company Name I Registration Number Address / Expiration Date /6' Telepho e — 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 Massachusetts x DEPARTMENT OF BUILDING INSPECTIONS i A 212 Main Stied • Municipal Building Northampton, N8 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 preexisting 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: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 reasonts): _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 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: Date Owner Name and Signature City of Northampton „wfMassachusetts (ri ' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Stteat * Municipal Building `., Northampton, MA 01060 �lttu Massachusetts Residential Building Code Section I I O R5.1.2 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 85.1.3.1 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 ' I DEPARTpENT OF BUILDING INSPECTIONS � m m 212 Main Street •Municipal Building a Northampton, kA 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: I Ill yek rrl - (Please print house number and street name) Is to be disposed of at: � Fm - ( nt te (tion of facility) Or will be disposed of in a dumpsler onsite rented or leased from: (Company Name and Address) Signajlrzof 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 ug,e Department oflndustrialAccidents l Congress Street,Suite 700 Boston,MA 027rialAc7 L01www.mass.gav/tire IN orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Nate(Business/OrganizafioMndividual): � y19t� Address: City/State/Zip: hone #: Are you an employer'Cheri the appropriate box Type of project(required): I-E]1 am a employer with employees(Cull and/or par-lime)1 7. ❑New construction 201am a sole proprietor or partnership and have no employees working for me in ES. ❑Remodeling anyorpscrty.IN.workers comp.insurance required.] 3._ I am a homeowner doingdworkm if [No workerscom .insurance r 9- ❑Demolition ra yae p ,yriirea I 10❑ Building addition a.❑ensure ama homeowner and will be hiring wnnanorsmconductall sukce or are y- Twill w rcmat an contractors ennerhave.vorked w�npcnsmion mammncc or ea snlc I-❑Electrical repairs or additions proprietor,x;th no employee.. 12. Plumbing repairs or additions 5I am a general commemr and l have hired the sub contractors listed on the attached sheep 13. Roof repairs Thosesub-contmemrs ha.,e employees and have workers'wmp.insurance: 6 Wd.c,a eoryoml-andse,officers have exercised their right of exemption per MGL,. 14.❑Other 152,y leo,and we have no anployces.[No workerswmp.Insurance required] 'Any applicant that chwks box#1 must also fill out the section below showing their workers compensation policy information. t Homeowucrs who motor this affidavit indicating they are desire all work and then hire outside core wines must submit a new affidavit uar.......rich. !conumtors forelock this box must..,had an additional sheet showing the name or the suh-rontrnevers and state whether or rat those entities have on,foyees tribe sruembacmrs have emdd,as.they must provide their workers dump 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: Policy#or Self ins.Lic.N: 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 crinunal violation punishable by a fine up to$1,500.00 and/or one-yen imprisonment,as well as civil penalties in the from of a STOP WORK ORDER and a fine of up to S250.00 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 thepuf. and a ties ofperjury that the information provided above is true and correct Si nature: ��� Date: / Phone# I Official use only. Do not write in this area,to be completed by city or town Oficial. 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"...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 therein 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 not any of in 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 sub-contractor(s)name(s),addresses)and phone number(s)along with their con ificate(s)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. ifan LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Indosmal Accidents for confirmation of insurance coverage. Also he 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 number listed below. Self-insured companies should enter their self-insurance license number on the appropriate fine. 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 permiNlicense number which will be used as a reference number. In addition,an applicant that most submit multiple permitlicense applications in any 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 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, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia 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 htre, 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 ofthe foregoing engaged in ajoint enterprise,and including the legal representatives ofa'deceased employer,or the receiver or trustee of un 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 ofthe dwelling house of another who employs persons to do maintenance,construction orrepair 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 ofits political subdivisions shall enter into any contract for the performance ofpubhc 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 bonom ofthe 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 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 a license or permit not related to any business or commercial venture(i.e.a dog license or permit to bum leaves em.)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 I Congress Street Boston, MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 www.mass.gov/din Form Revised 02-2J-15