17A-298 (6) 148 HILLCREST DR BP-2019-0044
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mam lock: 17A-298 CITY OF NORTHAMPTON
Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateaory:ROOFING/REPLACE WINDOWS BUILDING PERMIT
Permit 4 BP-2019-0044
Project# JS-2019-000059
Est.Cost: $15000.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License:
Use croup: Homeowner as Contractor_
Lot Size(sq. ft.): 20342.52 Owner: BACH NEIL D&JOAN E
zoning?URA(100)/URB(0)/ Applicant: BACH NEIL D & JOAN E
AT: 148 HILLCREST DR
ApplicantAddress: Phone: Insurance:
148 HILLCREST DR
FLORENCEMA01062 ISSUED ON.711012018 0:00:00
TO PERFORM THE FOLLOWING WORKSTRIP & SHINGLE ROOF & INSTALL 20 NEW
WINDOWS
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$0 Foundation:
Driveway Final:
Final Final:
Rough Frame:
Gas: Fire Deoartment Fircplace/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 Occuoancv Signature:
FeeTvpe: Date Paid: Amount:
Building 7/10/20180:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
bi-19�'1y 9,0z -- * cvIl✓oocuJ
Department use only
City of Northampton Status of Permit..
Building Department Curb Cutmriv y Permit
/ a - 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets ofStructural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/ its P Lt��tC D
Other CVCIVC
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEM SH O R O FAMILY WE LING
SECTION I -SITE INFORMATION
is
1.1 Proo/e,M Address: /� --�—
1 7 n� HIIIG °t'ST,�1 O{K
Map
ITA' Lot a`'f d una
1 0 ke. v G e / ` .' ` . Ol O 6 Zone Overlay District
Elm St Diemct CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 OWner of Record:
N F i L l y8 i FI 0/2 Al Cle
Name(Print) Current Mailing Address:
hone I O
Signature
2.2 Authorized Agent:
EC<c 13ou 1 ,--(4 3 rhflple, 5� R G2en)Ge�
Name(P CuneM Mailing areas:
�t/3 - 5 - x/933
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION CQM
Item Estimated Cost(Dollars)to be Official Use Only
MCA
completed b rmIt a licant
1. Building 6J� r MCA6141 / 5 060 oR (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=fl +2+3+4+5) 1 Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued: )
Signature:
Building Comm inner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Or
SECTION S DESCRIPTION OF PROPOSED WORK(check all applicablel
New House ❑ Addition ❑ Replacement Windows Alterations) Roofing
Or Doors 13
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[[:3]
Brief Description of Proposed /�77 (� 0 ei
Work: Rr (✓10V2 1000C' RGtNsvfl1-1 e/✓r�('P wiudoWs Ne
Alteration of existing bedroom_Yes No Adding new bedroom Yes '✓ No'/
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Its.If New house and or addition to existing housi complete the folJowing:
a. Use of building : One Family Two Famity 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 stones?
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 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 .
1. Septic Tank_ CirySewer 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 Date
I, 0�6 L RfiLH ,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 threr pains and penalties of perjury.
AliL 64CH
Print Name ,,' �
o-71,a�la'
Signature of OwnerlAge Df.
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9.Registered Home Improvement CoMmctor. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
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....... ID No...... ❑
ti (�
The Commonwealth of Massachusetts
Department ol"Industrial Accidents
I Congress Street,Suite
Boston,MA 02114-2017
wa mmass.gov/dia
VIA-orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE ITLED WITH THE PER.NHTTING AUTHORITY.
Applicant Information L Please Print Leeibly
P n
Na1ne(Business/OrgmaatioNladividual): /V [1 l s7
Address: I u Sr $4 111 f n ! ,j; D►2 r I a12[ A/C to,
City/State/Zip: ObaPhDDeu: y13--5A0-! 6GS
Are you an employer?Check the appropriate box: Type of project(required):
LE]I an a employer with employees("I ml/or pan-time)" 7. ❑New construction
2Ulamusote propriermorparmerstip mhavc no employeeswo�kivg formem g_ ❑Remodeling
my cepa ay.[No workers'mon, mounter required.]
3 I am a homeowner doing all work myself Mwor
o kers'comp.smmce wonted.] 9. El Demolition
4.�1 aa homeowner and will be hong contactors to contact all work on my property. I wtl 10 E] Building addition
m
me that all contractors enter have worwrs'compeasaoon mamm=e or are sole 11.E]Electrical repairs or additions
proprietors wit no employees. 12.❑Plumbing repairs or additions
5l am ageveral conaactr and l have hired the sub-contmemrs local on the amched sheet 13.❑Roof repairs
These sub�wwwoon have employees and have workeri comp.examence t
6.❑We are a corpvmtiou and ifs offrcas have exercised rev right of exemption per MGL c. 14. Other
152,§107,and we have no employees.Mo workers'comp.-•`mince n luiredl
"Any appiema that checks box%1 must also fill out to section below show.,twitworkers'compeusation policy.formation.
'Hom wbo submit this affidavit.dlma try are doing all work and ten hire oumlde co.o-G me must submit a new affidavit.dicating such.
ICuatraaonthatchecktisboxmustattachedmad tonalsheettow.gto Dameoftosub-mnhaclonandstatewhetherornottoleentitieshave
employees. Ifte sub-wvnmmrs have employees,try must provide rev workers'comp-pohq number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site
information.
Insurance Company Name:
Policy 4 or Self-ins.Lia M Expiration Date:
Jab 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$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 der the
pains andpenaldes of perjury that the information provided above is bar and correct
1/ e t ' / ,,LDate 07/10 01�
Phone q: 4-13 320 1 6 6 J — 7
Official use only. Do not write in this area,to be completed by city or toren offrclal.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityaown 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 ofan 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 nates 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, §25 C(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 sub-contractur(s)name(s),addresses)and phone number(s)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 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 ur ifyou are required to cbtaia a .vcrksrs'
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 permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)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
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
City of Northampton
Massachusetts Ae=
r]TPAR�T OF BUSLDIHO IHSFBCTIoffS
212 nein Street • Municipal Budging
Northampton, M 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 mom than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note.If the homeowner bas contracted with a corporation or LLC,that entity must be registered
Type of Work: RxF;N� /WiVdolAj RePIP<p Ae In Est.Coat: l'Sj 000 0a
Address of Work: lye HI JC,1Ze.$T PR Fl02ewC,,e- MA - 016 Ll
Date of Permit Application: 7/3/4
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):-CI-//U e,/Z 7.0 OUe�- 6t!4 Gt/O/Ze1`
_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:
7/3/j g 45/ZPc 13ou (2 i!
Date Contractor Name' HIC Registration No.
OR:
Notwithstanding the above
notice,I hereby apply for a building permit as the owner of the above properly:
NFilt, Anil X( 6L o ��L/a0/g
Date Owner Name and-Signature ��
r --_ City of Northampton
Massachusetts ,e2s�6 J�c4
I ➢EPARTlSBT 08 BUILDING INSPECTIONS
212 Hain street •Municipal auil&ng
NortEa Wn, M 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:
/'/? N�11 cn ✓s r p2
(Please print house number and street name) /7
Is to be disposed of at: C Z--
(Please
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
y/3 - 5£7-11oo5 s7
A /feo,kn ATiVP, R81gJ1 Q 77W�
(Company Name and Address
X� YAr
Signature of Applicant or
" er 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.