24D-153 (2) 22 CARPENTER AVE BP-2019-0088
GIS#: COMMONWEALTH OF MASSACHUSETTS
MV*.Block:24D- 153 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-2019-0088
Proiect# JS-2019-000138
Est.Cost$14000.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: VISTA HOME IMPROVEMENT 111478
Lot Siu(sq ft.), 3702.60 Owner: STERNBACH NANCY
Zoning: URC(100)/ Applicant VISTA HOME IMPROVEMENT
AT: 22 CARPENTER AVE
App[icantAddress: Phone: Insurance:
2003 RIVERDALE ST (413) 382-0249 WC
WEST SPRINGFIELDMA01089 ISSUED ON.-712312018 0:00:00
TO PERFORM THE FOLLOWING WORK:STRI P SHINGLES, REMOVE CHIMNEY, INSTALL
NEW SHINGLES
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 Occugancv Signature:
FeeType: Date Paid: Amount:
Building 7/23/2018 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck-Building Commissioner
Department use only
City of Northampton Status of Parrott:
Building Department Curb Cut/Ddveway Permit
212 Main Street Semir/Septic Availability
IQ Room 100 Water/Weli Availability
Northampton, MA 01060 Two Sea of Structural Plans
phone 413-587-1240 Fax13 Wr
APPLICATION TO CONSTRUCT,ALTER,RE AIR, RE A OL H A NE OR/n1TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION q- Yf
1.1 PfODeftV Address: NORTHAMPTON.MA Ot se Ion to be completed by office
as �� 1A/ I T'[JI VtvV IUe Map .ZyD Lot ►03 Unit
V� T Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
1�J�n� U SI P a� SCha�1
ISame(Prmt) - —^ Currwgt t a il s � � ��./
Telep T
Signature
uthorized A nt:
Add oy.3 � vefdQ (_e_ s+.w,
B!a (Print) urrent Madmg Atltlress: Q �O
y (2) ?D(��u� uu O
ure Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permita licant
1. Building (J1) (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
fi. Total=(1 +2+ 3+4+5) Check Number
This Section For Official Use Only
Buildin Permit Number: Date
9 Issued:
Signature: G 7�7A I
Buildi g Commissionedinspector of Buildings Date
1
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Must Be Completed, Permit Can Be Denied Due To Incomplete Information
Firming Proposed Required by Zoning
This column to he tilled to by
Building Depertmem
Lot Size
Frontage
Setbacks Front r-O--�� �r
Side L� R:= L:u R:= 0
Rear
Building Height O O O
Bldg, Square Footage 11
Open Space Footage
Op(Lor area minus bldg at paced
arkin I
#of Parking Spaces O O
Fill:
(—h me&Looation)
A. Has a Special Permit/Variance/Find
in 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 DON'T KNOW O YES O
IF YES: enter Book F Pagel and/or Document p�
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOY 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�
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(Geaading,egcavation,or filling)over 1 acre or is it pad of a common plan
ring,gr
that will disturb over l acre? YES NO" )V
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK Icheck all applicable)
New House ❑ Addition ❑ Replacement Windows Alleration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [ol Other[t:A
Brief D i tion ofRroppsed_
Work:
Alteration of existing bedroom_YesNo Adding new bedroom Yes Y No
Attached Narrative Renovating unfinished basement Yes u No
Plans Attached Roll -Sheet
Ga.If New house and or addition to existing housino. complete the following:
a. Use of building .One Farmli 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
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 AUTHORVATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ,as Owner of the subject
property
herebyauthorize \ � �`x` • "�i \" 191 U�l 1 rLLJ.I 1
to act on my behalf, in all matters relative to work aut1onz81 by this building permit application.
Y1 'g
Signature o Owner .y//� Date
I, C :�na(-\ i� �C�.t� 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 a pains and penalhe erjury.
I a/) ( Ad
Print Nar
Signature of /A 1 Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supp—ervisor: ,�//�
Not Applicable ❑1 , Q
Name of License Hot e fY\h�� l . l— ► `1� O
icense Number
wadak� f9(
d s Expiration Date
ure Telephone
Home Im mwment Contmi Not Applicable ❑
NCf ►StGm � o ��t7►��yernant �1O �, u�Q
C�mpanv Name Registration Number
�1 66-5, '(gym r (-6 LR ,9F iiI a I ► a
ddresss�( ' Expirallion D to
Telephone I
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
I G
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building �i• CD
�\ Northxthampton, IM 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, modemization, 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 hom►e//r/yne/t,�h{/a-�•contracted with a corporation or LLC, that entity must be registered.
Type of Work: f�O�l l�,,.1E�Istt.. Cost:_/q.(U) /`
Address of Work4% Ca r g n�J 6 K NI11 I Y'�rn O61 �I(C O
Date of Permit Application:
I hereby certify that: ' 1
Registration is not required for the following reasorts):
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:
---I �n l ) s ' ,-n N"- �mo�uye�vtpnt I uaoa�z
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 A4es - c�c
I
DEPARTMENT OF BUILDING INSPECTIONS y
212 Hain Stowe •Municipal Building OL C
Northampton, qA 01060 s Yji:"yjC�g
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:
as Ca � �e r�Y��.n�.�-e.
(Please print house nu ber and street name)
Is to be disposed of at:
�JWA feLLI( IM - nnr�,� rn�tt
(Pleaselprint name arid location o acihty �
Or will be disposed of in a dumpster onsite rented or leased from:
V0 1WA A Cf C Ajd ► n�� — nc�rtl��rn l
(Comparly Name an Ad ress)
Al
PaWtilre otlWerrk/IpNiegnt 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
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gove'dia
*8A.rkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING Art HORITY.
Applicant Information Please Print Legibly
Name (Business%OrganieatioNlndividuaal)Lo /11 ,,L 0
fY>3Address:; 9\y caj U l
City:'State/Zip. L�
Are you an employer'Check the appropriate box: Type of project(required):
t�m wnpinycr with C1 employes(fall ondbrpan-dmc).* 7. ❑New construction
?❑Ian,role pmprlcmr or or panncohip and have no cmployces working tornclo 8. E] Remodeling
any capacity.[No workers comp_insurance required_]
.❑l am a boracownet doingall a,orkmysc If I No worker'cont,_insurance« - e 9. El Demolition
3
a 4wrc I
4 l amu homcowna,and will be hann comaemrtmeonductall work on m 10❑ Building addition
S ow will
crone wvtah commscmrsdmar naacworkers'compensanon insurance or are sole IL❑Electrical repairs or additions
pmpdomrs with no cmployces. 12.❑Plumbing repairs or additions
'r7I d I hhired the listed on the attached sheer.
am a general contractor and e sob-contractors
ITFAChe repairs.v
Thele hu
-cnuacmrs hat m
e zpinycel and hnv.workcom ¢
ers' p_insnran .�
b.❑we arc a coronation and is officer have exercised their right ofcxcanpdon per MGL e 14. Other �
152,C I tat.and we have as o nployecs.[No workers comp.insaanc.squircd.l
'Any applicant that checks box#1 most also fill oat the section hdow showing their workers'eompensaaon policy information.
`flommwnm who submit this affidavit indicating they are doing all work and two hire oaeide contractors must-band o new affidadt Indicating such.
Konnaetors that check this box must aaachcd an additional shwa showing the name ofthe sub conwemrs and state whether cr no, h,,, nota have
mnployws_ Ifthe sub-cnnbaerors have cmployces,they must pmcide their workers'comppolicy 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:SD1 QLd_1,1 yVV1�d tyJOS Q �
Policy#or S,,IEmso/s.��Lid.#: /��/t ' �J ,�,�� ��J,.y / I (1 � r) .xpira(ion Date:_
Job Site AddressnC� I "N � City/StatefLip: IVIy
Attach a copy ofthe workers'eompe ration policy declaration page(showing the policy number and expir tion 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 farm of a STOP WORK ORDER and a fine crop to$250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations ofthe DIA for insurance
coverage verification.
Ido hereby cergWpuderthrepains a it enaIt es perjury that the information provided above is true and correct
Signature: Date �1 1119
Phone#: LID
Official use only. Do not write in this area,to be completed by city or town official.
Citv or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.CityTFown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
08/09/2017 2 37PM FAX 4135729191 WILLIAM MIS INSURANCE fh,)002/0002
CERTIFICATE OF LIABILITY INSURANCE
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BELOW. THIS CERTPICATE OF INSURANCE DDE$ NOT CONSTITUTE A CONTRACT BETWEEN THE BSUWG INSUREINE, -UTFOR¢ED
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TIN&iZINKTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
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