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24D-009 (3) 38HAYESAVE BP-2019-0150 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24D-009 CITY OF NORTHAMPTON Lot--001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildlno DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cateeorv' KITCHEN&BATH RENO BUILDING PERMIT ermit# BP-2019-0150 Proiect# JS-2019-000239 Est Cost, $8995.00 Pee $65.0 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use croup: Homeowner as Contractor_ Lot Size(sa. f.): 13895.64 Owner: KRUSELL BRIAN Zoning,URB(100y Applicant. KRUSELL BRIAN AT. 38 HAYES AVE ApplicantAddress: Phone., Insurance: 38 HAYES AVE (312) 888-0302 0 NORTHAM PTONMA01 060 ISSUED ON.81712018 0:00:00 TO PERFORM THE FOLLOWING WORK.MOVING BACK DOOR AND WINDOW, REPLACE BATHTUB, REMOVE WALL BETWEEN LIVING ROOM AND KITCHEN 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 Occuoancv Signature: FeeTvpe: Date Paid: Amount: Building 8/7/2018 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2019-0150 APPLICANT/CONTACT PERSON KRUS=;I,L BRIAN ADDRESS/PHONE 38 HAYES AVE NORTHAMPTON (3:2)888-0302 O PROPERTY LOCATION 38 HAYES AVE MAP 24D PARCEL 009 001 ZONE URRj100 / THIS SEC CION FOR 0 FICIAL USE ONLY: PERNLTAPPLICX11ON CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid J- Buildirez Permit Filled out Fee Paid TvaeofConstruction: MOVING BACK R A INDOW REPLACE BATHTUB REMOVE WALL BETWEEN LIVING ROOM AND KIT New Construction 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 INFQRMATION 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 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 mo 'tion Delay Si ofB ldi ..a / Date" / Note: Issuance of V&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 we granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. EIVED Department use only 6 I tlI Vpf rtha pion Status of Permit ng epa ant Curb Cut/Driveway Permit it �I 212 M in St eat Sewer/Septic Availability of awLDlrIyyG1NSPE 10 We[er/Well Availability ORTHAMPT61[JO[N 01060 Two Sets of Structural Plans one 413-587-1240 Fax 413-587-1272 PloVSfte Plans Other Speciry 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 by office 2 4 II�eS �U� Map Lot Unit Zone Overlay District 111 1 V lL' Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record, 9'-'-3o K4QW3B Na se , e t IUo ,MA otoGt Na (Pnry) ( Cu,eni Malting Atl ss Telephone I Sigreture 2.2 Authorized Anenm Name(Pint) Current Msiling Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only ',. completed bpermit applicant '.. i. Building 1(L0000 (a)Building Permit Fee ',. 2. Electrical �//'' Ul (b)Estimated Total Cost of l0 7 Construction from 6 3. Plumbing O q'C,oo Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection �( 6. Totai=(1 +2+3+4+5) 995, Check Number (} This Section For Official Use Onl Building Permit Numbe Date Issued. Signal 7 ildirg isuimedlmpectoraf Buildings Date k(usell @ mall .Covyl EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Dented Due To Incomplete Infofmttion Existing Proposed Required by Zoning ILrs column to be❑IIN In bs Building Dparonm, I't Size Frontage j Setbacks Front - ' Side L R: L.-:, R Rear - Building Height Bldg.Square Footage % Open Space Footage Imolio minds Ndg S p—d - -. nrkin=1 g of Parking Spaces -- - Fill: Iwlumc d laxnuoul --A. Has a Special Permit/Variance/Fin din ver been - sued for/on the site? NO O DON'T KNOW Y IF YES, date issued: IF YES: Was the permit recorded t the Registry of Deeds? NO O DON'T NOW O YES IF YES: enter Book Page and/or Document# B. Does the site contain a rook, body of water or wetlands? NO O N'T KNOW © YES IF YES, has a per t been or need to be obtained from the Conservation C mission? ',.. Needs to be o allied O Obtained O , Date Issued: '.. C. Do any signs xist on the property? YES O NO IF YES, escribe size,type and location: D. Are th re any proposed changes to or additions of signs intended for the property? YES © NO I YES, describe size, type and location: E. II the construction activity disturb(dealing,grading,excavation,or filling)over 1 acre or is it part of a common of that will disturb over 1 acre? YES © NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION e-DESCRIPTION OF PROPOSED WORK(check all applicable) Now House ❑ Addition ❑ Replocomonl Wlpdows Albntlonte) ❑ RoofIng ❑ r�-y Sr Doom G�" Accessory Bldg. EDm Demolition Nr New Signs IC31 Docks IO SIdIri Otherja Brief Description o Pope ed d �hitldai Work New d ktu +o.c1" to"ni - I/ No Alteration of axle mg bedroom_ I/ Yes_No Adding new bedroom Yea Attached Narrative \ Renovating unllnamed basement Yes ✓No Plans Attached Roll -Shoat ("04 eA W c 11 Sari house and or addition to existing houaina. complete the followili a. Use of but Creel'ani Two Family Other b. Number of roomy m e family unit Number of Bathrooms c Is there a garage an ached? 11� \ O F Proposed Square footage of new comsnur cllrn. Dirfransf.ns e. Number of stories. I. Method of,soling? fir p ces or Wootlstovos Number of each_ g. Energy Conservation Compliance. / Massoh.ck y Compliance form attached? In Type of construct,., I Is construction within 10 ,of weaand0_Yes No, Is consifuchme within I OC yr. odpleln Yes No I . Depth of base rpa a,cellar floor below finished grade k. Watling conform to the Building and Zoning regulaaonso Yea_No, t ' Septic Tank Cily Sewer Private well City water Supply SE ON To-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNE GENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, KI I CAp J . as Owner of the subject property .rF' may\ hereby authorize •Y to act on my behalf, in all matters relative to woliauthmnzed by this building permit application. ',. SlgnaNm MCvnar Date 1, ,as OwnerlAuthorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the beet of my knowledge and belief Signed under the pains and penalties of Perjury. Print Na naluro e( Dal i SECTION 8-CONSTRUCTION SERVICES 81 Li need Commctio,S Not Appli®ble ❑ None of License Holder Uues Number Address Expiration Date I 5iwwbae Tekptune 9:ReMMared Horne lrmxwement Contrast...- Not Applicable ❑ Co WM Name Registration Number Address 6yiratton Data Telephone SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(Sp Workers Compensation Insurance affidavit must be wmpleted and submitted with this application.Fa9ure to provide this affidavit mil result in ft denial of dte issuance of the buildifg permit. Sgrwd ARdawt AdaCCE Yes._._. C No_.... ❑ L� City of Northampton Massachusetts �• c in� 1212 lft OF BOZLOZNe INSPECTIONS 212 Main Street • Mwaicipal Building North�ton, 5A 03060 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, modemizabon, conversion, improvement removal,demolition, or construction of an addition to any pm-axisling owner-occ 1pied 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:Iffhe homeowner has contracted with a eorporalion or LLC,that entitr must be registered Type of Work Est. Cost: .Address of Work: Date of Permit Application: _ 1 herebycertify that Registration is not required for the following reason(s): _Work excluded by la. (explain):_ _ Job under$1.000.00 _Owner obtaining own permit(explain);__ Building not owner-occupied Other OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS W11 11 UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELICIBLE FOR AND DO NOT HAVE ACCESS TO ]'HE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.C.L.Chapter 112A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEFI'PAGE FOR MORE INFORMATION. Sighed under the penalties of perjury: 1 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 Notwithstanding the above notice,I hereby apply for a building permit the owner of the above property: � 011ie Owner N.aAmnd Signature City of Northampton Massachusetts c 1112 .a E S OF BOILDZNG INSPECTIONS �!. 11yy\®//1/ 212 Nein 8 by a Nun 010 euiltlinq O� �Y J Nortpepyten, !A 01060 90 Massachusetts Residential Building Code '... Section I 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 I IO.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 1 I O.R5, provided that if a homeowner engages a person(s) for hire to do such work,then such homeowner shall as 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. i 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"...cvery 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 moor 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 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 herow shall not because of such employment be deemed to be an employer." MGL chapter 152,F2506)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,§2 5C(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 ofcompliance with the insurance requirements ofthis 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 compam'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 he submitted to the Department of Industrial Accidents for confirmation of insurance coverage Also be sure to sign and date the affidavit l be 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 workerscompensation 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 Detainment has provided a space at the bottom of the affidavit for you to fill out in the event the Office Of Invesfig mons has to contact you regarding the applicant. Please he sure to fill in the permitilicense number which will be used as a reference number.In addition,an applicant that must submit multiple perent/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 prooffl at a valid affidavit is on file for future permits or licenses. A new affidavit most 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 Boston.MA 02114-2017 Tel. 9 617-727-4900 ext.7406 or 1-877-MASSAFE Fax #617-727-7749 www.mass.gov/dia F.Revved 02-23-15 r 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 ofanother under any contract ofhire. express or implied,oral or writer." .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 ora deceased employer,or the receiver or trustee of an individual,partnership,inguen lion or other legal entity,employing employees. Howeverthe owner ofa dwelling house having not more than three apartments and who resides therein,or the occupant ofthe dwelling house ofanother who employs persons to do maintenance,concoction or repair work on such dwelling house Or on the grounds or building appurtenant thereto shall not because of such employment be deemed to bean employer." MGL chapter 152,$25C(6)also states that-'even state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construe(buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally.MGL chaplet' I S?,§25C171 states"Neither the commonwealth nor any o(i[s political subdivisions shall enter into nay 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 011 out the workers'contpemation affidavit complcwly, by checking the boxes that apply to your situation and, if necessary,supply sub-connactor(s)namc(sl-addresslest and phone numberts)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited liability Partnerships(LLP)with no employees other than the members or runners,arc not required to carry workerscompensation insurance If.. LLC or LLP does have employees.a policy is required- Be advised that this effidacit may I,scounted to the Department of Industrial Accidents for nmflnnation of insurance coverage. Also be sure to sign and date the affidavit The amdavi[should be trimmed to the cin nr town that the application Gtr the peumn or Ilcensc is biting requeaed,not the Department of Industrial Accidents. Should you has am questions regaidins the laws or Ifyou are required to obtain a workers' compensation polio'.please call the Deportment at dtc number listed below. Sch-nsured companies should enter their self-insurance license number ea the appropdme 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 thin must submit multiple perann,license applications in any given year.need only submit one affidavit indicating current policy information(ifnecessaty')and under"Job Site Address"the applicant should write"all locations in (city or lowrok' A copy of the affidavit that has been officially stamped or marked by the city or town may he provided to the applicant as proof thin a valid affidavit is on 01c for future pemdts 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 ale.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax num her: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston. MA 02114-2017 Tel. # 617-727-4900 est. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia r City of Northampton [4assachvsetts 0212 Bin SOF B*MnicO INS tzld In NS 21Y Main 5[ieet •Municipal Butltling JqC� NOrthamp[onr [9 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: (Please print house number and street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased fromAft& : 5:tuz-klna (Company Name and Address �/Z S nature of Permit Applicant or Owner DUtupe 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. r The Commonwealth of Massachusetts Department of IndustrialAccidems I Congress Street.Suite 100 Basion,MA 01174-10777 www.macrgov/dia Ulkvivers'Compensation Insurance Affidavit:Builders!Contractors/Electrici.../Plumbers. TO BE FILED WITH IHE PERf11TTItiG At THORRT. Applicant Information Phase Print Legibly Name(BusincsyOrganira6nn/Individuap: Address:_- a _ City/Statef7ip:_ 04c'1 to Phone 4: &p 0 Ore you en emploperP('hark me apprugln(e bur: Type of project(required): 1❑I.un eemelmer wilN__ emplofee..... ]. ❑New construction ❑1so lr,,,,h.panJ Remodeling ol 'anacr Iv k .'one pnrWI a❑l oma homrouna romp Al—k 1111 lNe rremus ollap meu.aarugmn'e 1' 91 Demolition 4�asranvm w n'. r e nr aa,rrr,,,fr _ 1 al 10❑Building addition army annoy ha r orkrc .ivT- r aim III. Elcroeal repmrs oraddition propuetors rrlm nn cnmlm.er . I_. Plumbing repairs or additions ❑t- ura i - l h n . N l a . M-I 1heer. I I E]Roof repairs PIIIIIn- orsN.mcnpl re I'll Iv111.d, p IIIIJ111 a❑0'c ...d I, udth ( mvnnper IAO! , 14.❑Othcr - 1 2�h114, Td ve bare nn empl,l f4exrorken ro.on •oammr,creGlr 1,J All,applranr cher Ill—h 1111 1111 IT.tls ixa. r f,n :newI IT .fl,". ar,pen' nprlcv mirmeuon '!(mnmuncn rrb nbm. h.undev � hrr ,,J cell xahmart t r vhv1I w afidavr,,d,euaesun r a,sl, III,, klhalw>mrrraaI,h1rl al ml rrd r >,II 1 "111,1­1111—TIT,' rd score xholaT or as LLmie emtes Lase mato}les hare b ..a ., wr p d,Ii. i, ­,I l am an emplgrer thus is providing nevdera'rnmpensabnn imarmme(ia my employee. Below is the poll and job site hifimu utlmr. Insurance Company Same Policy IT or Self-ms Lrc !' __. Explmtion Date: Job Site Address: ('ity/Stntc'Lip: _ .Attach a ropy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure covemae as required under MGL c. 153.§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP N'ORK ORDER and a fine of ap to 5250.00 a day against the violator.A copy of this statement may be forwarded to be Office oflnvestigations of the DIA for insurance coverage verification. If do hereby,certify ander the pains and penalies ofperjuer Boothe information provided shovels true and correct. Signature Phone p- %lo O —ION I Oficial use(,my. Do not write in this mea,to he completed be city or town official. City or Town: Permit/License a Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone p: '. EWGLPIC PEY __. -_. assmvj mnev ----. Kwnwlfdro�m mnuiuunm � wN/mmeotn � uvnnnm aw�LI�Y. ' wu'em�w { avn�w I I i ' eaatrune¢ ecww PflYrv.�M'i9.m ix T umli cou'E� RM RESIDENCE � wr+iaw .ee w � veuc � rnwr v xne ra rn YH.YES nvFM£ x '� sa .1 .umn ware i.•�e �� \ _d,se r,u / '"�" . uvn • f�wo. wx �. r'm / l -nmr rem''1i> rgf+tN/u/vlOP.w. t � OIOM i Q-0 U QCP } 1 ,a I 3' .Enem-.I elaesse+s7u _. 'S vreerf � �$ soul I PPOPOSEO FLOOD PIAN 2REFLECTED CEILING'ELECiPICAI PIAN vw "Evcv IDwr S&odub iWi do Schodub PRC oRaW9 us _ v' aweovd � -�— p vex �e rWw ♦v'e -�e Prm auVOrM ue WWuss Ix�-10 y - A-1 i r �