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.
The Department's address.telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street
Boston,MA 02114-2017
Tel.#617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
www.mass.gov/dia
Fain Reused 02-23-15
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