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13-014 (4) I I LAUREL LN BP-2019-0909 GIS#: COMMONWEALTH OF MASSACHUSETTS Moiji it: 13-014 CITY OF NORTHAMPTON Lam:40j_ PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation BUILDING PERMIT Permit# BP-2019-0909 Project# JS-2019-001527 Est.Cost:82500.00 Fee: $65.00 PERMISSIONIS HEREBY GRANTED TO: Const.Class: Contractor: License: Use croup: Homeowner as Contractor_ Lot sizasci.lt.): 19602.00 Owner: LAMOTHE PHILIP Zoning, Applicant. LAMOTHE PHILIP AT: 11 LAUREL LN ApplicantAddress: Phone: Insurance: 1 I LAUREL LN (413) 588-8620 () NORTHAMPTONMA01060 ISSUED ON.•3/4/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.BUILDING CLOSET FOR LAUNDRY, MECHANICAL CLOSET, WORK SPACE ROOM & REC ROOM 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: Drivexav 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: Feelyve: Date Paid: Amount: Building 3/420190:00:00 565.00 212 Main Street,Phone(413)597-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File 9 BP-2019-0909 APPLICANT/CONTACT PERSON LAMOTHE PHILIP -" ADDRESS/PHONE I 1 LAUREL LN NORTHAMPTON (413)588-8620 Q PROPERTY LOCATION I l LAUREL LN MAP 13 PARCEL 014 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid IL I Building Permit Filled out Fee Paid Tvaeof Constriction: BUILDING CLOSET FOR LAUNDRY,MECHANICAL CLOSET,WORK SPACE ROOM&REC ROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans lncluded� Owner/Statement or License 3 sets of Plans/Plot Plan THE FOL WING 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: § Finding Special Permit Variance• Received&Recorded at Registry of Deeds Proof Enclosed _Otter 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 Demolition Delay � Si&ature 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. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street SewedSeptic Availability -I. r Room 100 WaterNVell Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify 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/ Map 13 LW o7 Y Unit Zone Overlay District Elm St.Distinct CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: Ne Pring Current Mail' ss: �/i3Fr P(J1S telephone Signature 2.2 Authorized Agent Name(Prim) Current Mailing Andress: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed loy permitapplicant 1. Building 011 (a)Building Permit Fee 2. Electrical .f3 (b) Estimated Total Cost of Construction from 6 3. Plumbing Q'/ y Building Penult Fee 4. Mechanical(HVAC) t `7 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section F Building Penni[Number Date Issued: p Signature: Building Commissionerllmpector of Buildings pate X 7Pa(^-, g, EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING Ml Infwmatim Must Se Completed.P ft Can h Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Depamnrni Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg.Square Footage % Open Space Footage �F__... (Lot.minus burp&paved _..._.... B of Puking Spaces — Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O 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 N B. Does the site contain a brook, body of water or wetlands? NO O 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 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(clearing,grading,excavation,or filling)over 1 acre or is it pan of a common plan that will disturb over 1 acre? YES O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. l SECTION 5.DESCRIPTION OF PROPOSED WORK(check all aoolicabiel New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [q Siding[0I Other[m Brief Descnption f Pm WON, i c 4a.� , vn 4-4o....n l(/os<f .✓ar�cs.� t f2<RB.�TMb✓ Pope, Alteration of roasting bedroom__Yes_No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement _X Yes No Plans Attached Roll -Sheet es.N Now house and or addition to exlstlna housino. complete:the followlna: a. Use of building One Family Two Family Other It. Number of rooms in each family unit. Number of Bathrooms c. Is there a garage attached? J. 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? 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_ CitySewer_ Private well City water Supply SECTION To-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. Signacce of�Owner Date I as Owner/Authorized Agent hereby dedareat the s ments and i form n on the foregoing applicebon are true and accurate,to the best of my knowledge and belief. Signed er Me pains and penalties of perjury. II '' A L o_fh Ptlm Name D1 / SIgnatius of 0 r/Agem Dat SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder Uceme Number AGCress Expiration Date Signature Telephone 9. Reolstered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Address Expiration Date ,Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152,§25C(8)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in 81e denial of the issuance of the building permit Signed Affidavit Attached Yes....... ❑ No...... ❑ City of Northampton f , Massachusetts �JlA:PARTNENT OF BUILDING INSPECTIONS lie 212 Mein Street • Municipal Buildin0 xacthee¢ ., Ma 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, modemizalion, conversion, improvement,removal, demolition, or construction of an addition to any pre-existing owneryoccupied 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 hes contracted with a corporation or LLC,that entity must be registered Type of Work: Est.Cost: Address of Work: Date of Permit Application: 1 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: Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the wrier of the above property: /a-I /19 �� Dale 1 wrier Name and Signature City of Northampton //. Massachusetts D212B inn OF Bal icG INSDLCSIOBS 212 ILin rfs • NW 01l Builtlinq �T NorNa�ton, MA 01060 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 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 fort 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 f � Massachusetts ; { DEPMT NT OF BO - LDING INSPECTIONS \ 212 N in street •Munampal Builtlang NorNamptan, M 01060 , Y 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 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 ofMassachusens Department of IndustrialAccidents I 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 Please Print Legibly Nagle(Business/OrganizalioNlndividual): Address: City/State/Zip: Phone#: Are rot as emplorar Cheek roe appropriate box: Type of project(required). I.[3 l ams empkwm with employees than maker mer-coact' 7. ❑New construction 2.❑lamasokpapsinororprmnshipmdhavenoemployeesworking fmmom 8. ❑Remodeling any capacity.[No workers'comp.immmnce required.] 3,[]]am n hommwnerdo.g all work myself[No workers'comp..s.e requiscd.l t 9. ❑Demolition 4.R 1 am a Mmerwner said will be hiringactors m conduct an work on 10 E]Building addition can Yty (will ensure chat all conaac.n enter have workers,nnmpevaaon msmaneemar,re volesole 11.[]Electrical repairs or additions propnemrs with m employee'' 12.❑Plumbing repairs or additions 5.[3 1 am a general connmctm mad 1 have hired do rut-emanium,Ivied on the couched ahem. 13.�ROOf repairs Thew,snb emaramm,have emplower and have workers comp.huurmee. 6,F1 We are a rings iov anditsoRars have exercised their right of exempeoo per MGL c. 14.❑Other 152.$1(4),and we have tut employeer.[No workers comp.wernowe reenact] "My applicant that checks box at must aho fill out the mention below show.,than workers'compemainu a It,infommion. I Homeowners who submit this affidavit rationing they me doing all work and then hire outside smartiors most submit a new atiidavit indmming such. k'onumemrs that check this box most abashed an additional sheet showing the more of the sub-contmcun and sate whether err not Muse entities have employees. If the subcoommons have employees.they must provide their workers'comp.p,licY number. I am an employer that is providing workers'compeneadon hismance for my employees. Below ie the policy and job site information, Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job 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,p25A is a criminal violation punishable by 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.A copy of this garment may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under rhe pains d penalties ofperjury that the information provided above is nue and correct Signature: - w-� Date 1-F all�� Phone#: t'�j R .S � 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 smite of another under any contract of hire, express or implied,oral or written.' An employer is defined m"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 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 theme 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,§25C(7)slates"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-contracou(s)name(s),address(es)and phone number(s)along with their cenificate(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 ice 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 m 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 Departments 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.tnass.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 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 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,§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 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 Departnrnt of Industrial Accidents for confirmation of insurance coverage. Alan 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 permitAicense number which will be used as a reference number.In addition,an applicant that must submit multiple pennitilicense 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 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. 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