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31B-044 (5) 21 SUMMER ST BP-2018-1214 GIS 4: COMMONWEALTH OF MASSACHUSETTS Map.Block:3 1 B-044 CITY OF NORTHAMPTON Lot .001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: REPAIR BUILDING PERMIT Permit 4 BP-2018-1214 Proiect4 JS-2018-002168 Est.cost:$8000.00 Fee,$65.00 PERMISSION IS HEREBY GRANTED TO. Const.Class: Contractor: License: Use croup: Homeowner as Contractor_ Lot Size(sp.ft.): 7100.28 Owner. WALSH ROBERT E JR&MARY ELLEN TRUSTEES Zoning: URC(100)/ Applicant. WALSH ROBERT E JR & MARY ELLEN TRUSTEES AT. 21 SUMMER ST ApplicantAddress: Phone: Insurance: 21 SUMMER ST NORTHAMPTONMA01060 ISSUED ON.5/1812018 0.00.00 TO PERFORM THE FOLLOWING WORIGREPAIR LOWER DECK WITH NEW FLOOR BOARDS, REPLACE UPPER DECK WITH NEW FLOOR BOARDS, RAILINGS AND STAIRS - NO CHANGE TO FOOTPRINT 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 5/1820180:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2018-1214 APPLICANT/CONTACT PERSON WALSH ROBER E 1R&MARY ELLEN TRUSTEES ADDRESS/PHONE 21 SUMMER ST NORTHAMI 'ON PROPERTY LOCATION 21 SUMMER ST MAP 31B PARCEL 044 001 ZONE URCII00)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT A TION CHECKLIST ZONING FORM FILLED OUT NCLOSED REQUIRED DATE Fee Paid Buildin Permi[Filled out Fee Paid TweofConstruC REPAIR LOWER DECK WITH NEW FLOOR BOARDSREPLACEUPPER DECK WITH NEW FLOOR BOARDS,RAILINGS AND STAIRS-NO CHANGE TO FOOTPRINT_ New Consimcdon Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO,4MATION PRESENTED: pproved_Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major ProjecC Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance" Received&Recorded at Registry of Deeds Proof Enclosed _Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability _Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CF1 Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management emolmon Delay e o mI ficial Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. RECEIVED Department use only s ypY 1dty�Nort am ton Status of Pernl� Building De art ant Curb GutDrnvalvap Perrnit tre t Sevinso Uc Availability, En OF BUILDING INSBECTION&. NORTHAMPTONU Water/Well Availability C ,MAAWW66�BaA�I �� \ on, 1060 Tent Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 PFatlShe Plana Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property AddressThis section to be completed by office �r Som voc-er ST , Map a3� Lot 0 Unit 7-one Overlay District Elm St.District CB Distinct— SECTION istddSECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �o ewer t �rEN u�,�[ C7 a l ur4 we - S% Name(Print) �,f„/s�r— �/ /L/(„ Current Ma In ddmss' Telephon Sig afore 2.2 Authori ed Agent: Name(Print) Cunent Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bpermit applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) r� J 5. Fire Protection 6. Total- (1 +2+3+4+ 5) Check Number T is Section For Official Use Only Date Building Permit Numbe ' Issued: Signator . Building missioner/Inspector of Buildings Data EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) A 1f Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To larmir late InlDrmation Existing Proposed Required by Zoning This column robe filled in by building Desnanem Lot Size Frontage Setbacks Front Side C _.. R L... R ...... _-. Rear Building Heigh[ Bldg. Square Footage """ % — -- Open Space Footagete (Lo,arca m nus bldg&purred ,kin ) 4o Puking Spaces .--I -- - Fill: vommc&Loaadon) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW © YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT 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 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 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 activitydlsturb(clearing,grading,excavation,or Nling)over i 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. 1 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Atltlilion ❑ Replacement Windows Alteration(s) Roofing ❑ 0r Doors Accessory Bldg. ❑ Demolition ❑ New Signs [Ol Decks [0 Siding[O[ Other[a Brief De;�riplior)of Work.��?CC_�, Y �/11 /P�. 7c C.(' /�T( H 1 }yOel/ dC �dS 12Piti� 4K wr Al Alteration of existing bedroom_Yes No Adding new bedroom Yes No X hYW 1i Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet $/Lrdy CIN7 Its.If Newhouse and or addition existing housing..complete the following. T(r/'//J/lpn' M a. Use of building OneFani Two Fari Other J/ ' wr r 2P 4L d.b. Number of rooms in each family unit: Number of Bathrooms /n - /„�I, c. Is there a garage attached? -rV'FV�'+/�,/�/j�//LA+��I I d. Proposed Square footage of new construction. DimensionsC TlAL�!/t'— `rf e. Number of stories? I " 41-17 I. 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 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, 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. SignaWre o'f/O/wneyr/ N,^ '^ ,( �A Date �T)- -�/"✓ "� /!�V�"g/ ,` e -' n �r^ '9 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 Name 1 �Qlbz'7LT E G!/A-GS'17� ..�y��n/vt/�/ r/l/Lli/ Signature of OwnerlAgent Date - - / 1 SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder'. License Number Address Expiration Date Signature Telephone 9. Re tiatered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Atld cess Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C.152,§25C(6)) Workers Compensation Insurance affWavit 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 s, � Massachusetts sr � DEPARTMENT OF BUILDING INSPECTIONS 2 212 Main Street a Municipal Building LC Morthang,ton, Me 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. 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$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.C.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: f l / T -fit (� ^-,4 , Rdh r W )5 D to I Owner Name and Signature City of Northampton Massachusetts h {. D212 Main OF Ha LDINGMunicipal INSPECTIONS t V m 212 Hain Street • Nunicvpal Hmlding Northampton, MA 01060 sW-�vha Massachusetts Residential Building Code Section 1 IO.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 1 I O.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 c l G DEPANTMENT OF BUILDING INSPECTIONS 2 212 Main Strcet aMm¢cipal Building Nort]umpton, MA 01060Yµ. Y„dC 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 performed at: (\� r a1,- -c— CC J rk Nr l'_a� ', ! 7T ((tease print house number a street q e)7 4 J Is to be disposed of at: V �7 (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature of 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. k The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02174-20177 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMUTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate tons: Type of project(required): L❑l am a employer with employms(bill and/or par-time)." 7- ❑New construction 2.❑Iamasolcproprietororparzvaship and hove no employecsworkivg formciv S. Remodeling any capacity.Ivor workers comp.insurance required.] 3 lamahomcowoes doing all work myself.INoorkchs comp.insuranvorequircd_l' 9. Demolition w 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my churches. I will 10❑ Building addition ensure that all contractors either have workers'eompevsationinsmance or are sole 11.❑Electrical repairs or additions pmpricems with no employees. 12.❑Plumbing recons or additions S.[]Tama gmerelcontracmf eelhavehired have workeo'cos listedonthennacned sheet 13. Roof repairs These aobeomncmrs have employees mdhava workeu'comp.ivsurance.t ❑ P fi We are a co tion and its officers have exercised their right ofexem tion 14.00ther ❑ anon g p per MGL c. 152 31(4),and we M1ave no employees_[No workers'rotor_insurance required,] -Any applicant that checks box#I mart also fill on,the section below showing their workers'compensation policy intbrmation. t Homeowners who submit this andevit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such. :Contactors that check this box must attached an additional sheet showing the name of the sub-eontraoters and state whether or not dose couties have enployces. If sub-contractor have employees,they must provide their workers 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: Policy#or Self-ins.Lid.#: Expiration Dale: Job Site Address: City/SMte/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$250.00 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 the pain�/ // ss/sfa'nd pen��Jalt�iies ofperfury, da that the information provided above is true a rnee!. Phone g: y 39- —3-11(, 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.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massaehaseus Geneml 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 m individual,paruretship, 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 afpublic work until acceptable evidence ofcompliance 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-contractors)name(s),address(es)and phone numbers)along with their certificates)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 Deparuncin of htdustrial 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 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 permiNicense 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(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 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 I 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 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 of an individual,partnership,association or other legal entity,employing employees. However,the owner ofa 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 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 authonly." Applicants Please till 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. [fan LLC or LLP does have employees,a policy is required.Be advised that this affidavit 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 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 permidlicense applications in any given year,need only submit one affidavit indicating current policy information(ifnecessary). 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 yew. 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 ronin xev,:ea 02-23-15