10B-092 (5) 191 MAIN ST-LEEDS BP-2018-1283
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Maly-.-Block: 1013-092 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit. Building DO NOT HAVE ACCESS 10 THE GUARANTY FUND (MGL c.142A)
Cateeorv:Deck BUILDING PERMIT
Permit# BP-2018-1283
Proiect# JS-2018-002284
Est.Cost: $2500.00
Fee: $65.00 PERMISSIONIS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: TIMOTHY SENEY 061088
Lot Size(sa.ft.): 89733.60 Owner: Cynthia Roberts
Zoning, URB(100)/WP(50)/ Applicant: TIMOTHY SENEY
AT: 191 MAIN ST - LEEDS
Applicant Address: Phone: Insurance:
371 PROSPECT ST (413) 667-0230
NORTHAMPTONMA01060 ISSUED ON.612012018 0:00:00
TO PERFORM THE FOLLOWING WORK:BUILD 10X9 DECK
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meters
Footings:
Rough: Rough: House# Foundation:
DrN4wby 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 6/20/20180:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2018-1283
APPLICANT/CONTACT PERSON TIMO' iY SENEY
ADDRESSIPHONE 371 PROSPECT ST gORTHAMPTOr.. (413)667-0230
PROPERTY LOCATION 19p{/ IN ST- ;EDS
MAP IOB PARCEL 092 001 ZONE URI 1001/WPS91/
THIS SE( CIONFOROFF _ALUSEONLY:
PERK r APPLIC.4TIC1. CHECKLIST
Et'J'LOSED REQUIRED DATE
ZONING FORM FILLED OUT _
Fee Paid _
Building Permit Filled out
Fee Paid VZ
Typ of ConstructionBUILD IOX9 DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included
Owner/Statement or License 061088
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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:§ r
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
y Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
Signature of Building Official 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.
�t d
Department use only
/- City of Northampton Status of Permit.
Building Department Curb Cut Driveway Patrick
f� 212 Main Street Sevier/Septic Availabtl'dly
. 9( Room 100 Water/Well Avallablilly
Northampton, MA 01060 Two Sets of4tocFural Plans
phone 413-587-1240 Fax 413-567-1272 Plot/Site Pallia
Other Spe ffl ':
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed p by office
Map LOIS Lot Cqz- Unit
��/ ///�✓ J>-
Zone Overlay District
Elm St.District CB Distdd
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record: /
/y/ kA N 5;-
Jin,Address
Y/'- T7 r Hr/tiG
4 / _ _ elephone
Signature
2.2 Authorized Agent:
\7
r�;;cY �..J--icncrr,.%c_ 27/ /�ti5y�c— J' /T�✓.[TJ/nMv:w
Name(Pring Current Mailing Address:
yi3 cab
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed bpermit a licant
1. Building -2 5-60 (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) .>7SUV" Check Number
This Section For Official Use Only
Date
Building Permit Number: Issuetl:
Signature:
Building Commissionedinspector of Buildings Dale
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Most Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column b be Blled in by
Building Department
Lot Size
Frontage _
Setbacks Front
Side LR ._. L''_R /:5— ..... . /S
Rear .. y°
,SO(a
Building Height
Bldg.Square Footage -- % -- ---
Open Space Footage
(Lot arca minus bldg&paved _. ...
parking)
#of Parking Spaces --
Fill: _.... _......
(,-olnmc&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT 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 0 DONT 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 0
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 0
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 O NO 9
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S.DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
0,
Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [RT Siding[0) Other[O)
Brief Description of Proposed
Work: 6to 9 '71 — 2zr.2 A -rR+J>NCrt
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 existlna housina, 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 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 AUTHORRATION-TO BE COMPLETED WHEN
OWNERS AGENT OR(ICONTRACTOR APPLIES FOR BUILDING PERMIT
I, �L1/[ I`IHCI.-lLL as Owner of the subject
property
hereby authorize Z//L( Sfr✓�y (� -¢ 1C .✓'
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Data
--
I, �( y07-79Y 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 penafti�of perjury.
Printer /
�� ey
Signature of OwnertAgent —Date
SECTION 8-CONSTRUCTION SERVICES
8.7 Licensed Construction Supervisor: Not Applicable ❑
Name of License NoldernF- / OX7
License Number
n Cf
22/ //IG.iOszf: J/ . 1G //li
Address Expiration Dale
Signature Telephone
M
9.Registered Nome Improvement Contractor: Not Applicable ❑
,SAMA f- 4-4 3d y
Company Name Regisiran Number
/u /!6 // CF
Address Expiration Date
Telephone
SECTION 18-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.752,§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....... Ph No...... ❑
City of Northampton
� Massachusetts
G DEPARTMENT OF BUILDING INSPECTIONS of
212 Main Street • Municipal Building
�V Mectbaa ton, 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 pre-existing owner-occupied building containing
at least one but not more than four dwelling units.-or to stmctures 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 DTCK // Est. Cost: 7,5017
Address of Work: /17/ 4ok, i Sr 216c4S
Date of Permit Application: 3-/2y.0-!"
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:
""Cana /,,2736 y
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a building pentut as the owner of the above property:
Date Owner Name and Signature
City of Northampton
y
.'•�: Massachusetts
t' a DEPARTN6NS OF BUILDING INSPECTIONS p w
312 Hain Street • Municipal Building
Horthampton, tA. 01060
Massachusetts Residential Building Code
Section I10.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 11 O.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 v�
DEPARTMENT OF BUILDING INSPECTIONS 14 L
212 Hain Street a Hunicipal Building 5 srC°
Northampton, MA 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:
%9� /N L,J S, LR103
(Please print house number and street name)
Is to be disposed of at: //'�/J)
I /,ILL ley 21CY(cla%�—
(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.
The Commonwealth of Massachusetts
V;
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.massgov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information /J PI Print L oibly
Name(Business/OrganizatioMndividuep: ;r( /- /Cy LCiNYLIn i - /
Address: 7/ alf"21ce9- 157T.
City/State/Zip: 1-0.�1 p/o6i, Phone #: 4//3 - C-)C - /'7)
Are you an employer?Check the appropriate box: Type of project(required):
Lm 1 am a employer with employees(did and/or part-timet, 7. ❑New construction
2.❑l am a sole propriemrorparmership and have no employees working formein g. ❑ Remodeling
any uwpaci y,[No workers'comp_insurance required.]
JI am a homeowner doing all work myself [No workencomp.isuramc required.]` 9. ❑Demolition
4 I am a homeowner and will be hiring oamos to conduct all work on 10❑ Building addition
ensu-❑ Bwn my sole
twill
re that an wmrnnon Amer have workers'compensation insurance or arc sole I1.❑ElecMcal repairs or additions
proprietors with no employees. 12.E]Plumbing repairs or additions
5 71 am a general contractor and l have hired fie sub comramors listed on the attached sheet .
These subcn
ometors 13
have employees and have workers insurance[ ❑Roofre Pairs
6.❑We arc a corporation and its officers have exercised their right of exemption 14-[a Other Dr¢✓
[pore g p per MGL c.
152,x 1(4),and we have no employees Mo workerswrapinsurance inquired]
'Any liclieanl that checks box#1 must also fill out the section below showing their workers'compensation policy information
I Homeowners who submit his affidavit indicating they are doing all work and men hire outside computers most submit d new affidavit ivdiea m, .on
:Cwbactom that cheek this box must attached au additional sheet showing the name of the subcontractors and slate whether or tet those entities have
employce,. lfthe sub-contractors have employees,they most provide their worker omp.policy number.
I am an employer that is providing workers'compensation insurance far my employees. Below is normality and job site
information.
Insurance Company Name: — lr/ 6✓4r C
Policy#or Self-ins.Lie.# '
: Z0Ci 6„///11,7`;g Expiration Date
Job Site Address: /0 W,),N f7 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. 152,625A 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 forth 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 t ¢pains de lies of perjury that the information provided ab/n/}y'e is Mus and correct.
Sign t �iL"'"� �— Date
t / '��(�
Phone#: YZI- ,l L- /797
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 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 ajoint 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 employe"
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 authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contraclons)name(s),address(es)and phone numbers)along with their certificate(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. 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
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 pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple penau/licensc 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
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 oflure,
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 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 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."
MCL chapter 152,g25C(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 ofpublic work until acceptable evidence of compliance with the insurance
requirements ofthis chapter have been presented to the contracting authonty."
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 time,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
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 pennielicerese 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 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
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Foam Revived 02-23-15
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