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31B-134 (2)
122 STATE ST-APT 2 BP-2018-1343 GIS#: COMMONWEALTH OF MASSACHUSETTS Mao:Block: 31B- 134 CITY OF NORTHAMPTON Lot:.001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category'renovation BUILDING PERMIT Permit# BP-2018-1343 Project JS-2018-002387 Est.Cost: $3000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group- MATTHEW KOZUCH 106644 Lot Size(sg ft.): 4007.52 Owner. KOZUCH MATTHEW Zoning: URC(100)/ APPEcant. MATTHEW KOZUCH AT. 122 STATE ST-APT 2 Applicant Address: Phone: Insurance: 6 HIGH ST (413) 570-3279 0 FLORENCEMA01062 ISSUED ON.6/18/2018 0.00:00 TO PERFORM THE FOLLOWING WORK 13' STRUCTUAL BEAM REPLACEMENT IN BASEMENT TO FRONT DECK 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 6/18/2018 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File k BP-2018-1343 APPLICANT/CONTACT PERSON MATTHEW KOZUCH ADDRESS/PHONE 6 HIGH ST FLORENCE (413)570-3279 O PROPERTY LOCATION 122 STATE ST-APT 2 MAP 3111 PARCEL 134 001 ZONE URC1000 THIS SECTION FOR OFFI—Q AL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildirez Permit Filled out Fee Paid Typeof Construction 13'STRUCTUAL M REPLACEMENT IN BASEMENT TO FRONT DECK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 106644 3 sets of Plans/Plot Plan THE�FFOO 'LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INT yrtMATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: §. - Finding Special Permit-1 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 CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management De olition Delay eof Bu ding ial Date Note: Issuance of a ning 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. Department use only City of Northampton Status of Permit ,a Building Department Curb CWI Driveway-Permit ,i 212 Main Street Sewat/Septic Availability Room 100 WaterNdell Availability 1, Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-567-1272 Plot/She Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Phain rtv Address: ` p This section to be completed by once .2. 1I-I- S'�rwnle r:'A, Al � Z Map �J f ✓lj Lot ( 3 L Unit c )U 6 O Zone Overlay District Elm St.District OB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: �a� 1,72 Name 'int) Current Mailing Address: Telephone 1 1 1 gnature 2.2 Authorized Agent: MIA 2V' 1 \ �n I�tn� Sk FW '& Ce W Name(Print) Current Mailing Ad ass'. �+I z -3y� _R Q 9 � M1kDZ�Y tia�D , f 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) S �� 5. Fire Protection 6, Total=(1 +2+3+4+5) 3 Check Number j This Section For Official Use Only Date Building Pennit Number: Issued'. Signature' Builtling Commi neninspector of Buildings Date 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 filled in by Building Department Lot Size 2 Frontage 5d Setbacks Front Ali �T n/ A Side L R .._ L R: Y xt Rear Building Height Bldg. Square Footage 32gL Open Space Footage IC (Lot area minus bldg&paved _. .... orlon ., #of Parking Spaces 7— Fill Filh vomma&Loemlon) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO © DONT KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T 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 DON'T 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 V 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 Q/ IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading, exca q or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO 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 Windows Alteration(s) Roofing ❑ Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[O� Siding [[[0]- I� Oglther[al Brief Description of Proposed \ a PkM PO1 AC-P 'JC 4 In I SC l'1YY\T ry Work \}` S�fLc C 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 housing, complete the following'. a. Use cf 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 form attached? h. Type of construction 1. 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 5I('ri S �C�01� , as Owner of the subject property hereby authorize 0.F- 2 to act on my beh II matters relative to work authorized by this building permit application. Signature Date ,��t ,as OwnerlAuthonzed Agent hbydeclare that the erestatements 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 �� Date Signature of Owner/Agentate SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed ConstructionppSup`erv�i ::/ Not Applicable ❑ Name of License Holder'. V°\w'L\ Il,J2�.�� i joii License Number h�l\ o( o6z 9/2 Address Expiration Date `")ti� �(�, SignatuTelephone gre 9.Registered Home Improvement Contractor Not Applicable ❑ Ijj7-0 Company Name Registration IN bar Address \\ Expiration Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.154i25C(e(( 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 C DEPARTMENT OF BUILDING INSPECTIONS i 212 Mom Street • .Municipal Bviltling �. Navthempton, !0 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 he 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. Note:If the homeowner has contracted with a corporation or LLC, that entity must be registered. Typeof Work: 51rJ t-�Jfa1 '�-,,ppo4 q Est. Cost: 4 � 1� Address of Work: 17--L S �1\\� S'F A) Date of Permit Application: eot� 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 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 Massachusetts i_ F DEPARTMENT OS BUILDING INSPECTIONS 5 212 Main Street • Municipal Building Jy, �.., Northampton, Nh 01060 fstiH:'y j{6J: 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.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 persons) 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 ® s DEPARTMENT OF BUILDING. INSPECTIONS 212 Win Sthe on, icipal Buil6ing C � Naithampton, MA 01 060 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: � 2z S\ -\ St (Please print house number and street name) Is to be disposed of at:/ 1 Vra t�'Q-ti I�ec,� �l�va\ (Please print name and to tion of fa 'lity) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature of Permit Applicant o Owl nerr Date I 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. y� , L''\ The Commonwealth of Massachusetts Department of Industrial Accidents 7 Congress Street,Suite 100 7 Boston,MA 02774-2077 www.mass.gov/dia US Workers'Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. ADDlicant Information ( Please Print Legibly Business/Organization (Name: I�j�0�-v Ch Address: w City/State/Zip: f— 61 CA Le A Phone#: yj 3 3 qj g p Q Are you an employer?Check the appropriate box: Business Type(required): L❑ I am a employer with employees(full and/ 5. ❑Retail or art-time).' 6. ❑Restaurant/Bar/Eating Establishment 2. 1 am a sole proprietor of 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 of exemption per c. 152,§I(4),and we have 10,F]Manufacturing no employees. [No workers'comp. insurance required]` I1 ❑H alth Care 4.E] We are a non-profit organization,staffed by volunteers, II L with no employees. [No workers comp.insurance req.] 12. Other Ne,F✓Pq V d/,/ "Any applicant that checks box#1 must also fill out the section below showNg thou workers'comporno i policy aampoi min '"If Ne eoryarem omcem have cxempmd Nemselves,bw Ne co,pomtion has olhea employee aworkees'cumpemmion policy is required andsuch an orgaaccuson should check box#]. 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.Lit.# 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 of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 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 ofthe DIA for insurance coverage verification. I do hereby certify, under thepains andpenalties of perjury that the information provided above is true and correct Somature' I_ ;deylvnsss' l DateSII ' Phone#� q1; ' 3C1( — ll 17 J 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#: waw mans govmia 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 ofthe 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 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, §2507)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 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 permiulicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary). A copy ofthe 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 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 Imm R—acd 02-23-15 "pi,w]fl� b+1aq tx"L ? r7V} ay1 W �pgw C�.,.ty All �Vig'w2 �rt.d� S�SeoS, n — V,4 �» v tea a� n� 071 �aar p5l, 1�wIN