32C-292 (2) 14-16 VALLEY ST BP-2019-0918
Gls#: COMMONWEALTH OF MASSACHUSETTS
Map3lock:32C-292 CITY OF NORTHAMPTON
Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2019-0918
Project# JS-2019-001536
Est Cost: $25500.00
Fee-$166.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DAVID FORTIER 008026
Lot sug(sp. ft.): 13198.68 Owner. FORTIER ALYSON
Lorunp URC 100 Applicant: DAVID FORTIER
AT. 14 -16 VALLEY ST
Applicant Address: Phone: Insurance:
32 Laurel St (413) 586-8965 WC
NORTHAMPTONMA01060 ISSUED ON.212612019 0:00:00
TO PERFORM THE FOLLOWING WORKADD SHOWER, UPDATE WIRING, NEW
FIXTURES, REPLACEMENT WINDOWS, RESHEET ROCK OVER EXISTING WALLS IN SOME
ROOMS WHERE NEEDED
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: 91 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:
FeeTyue: Date Paid: Amount:
Building 2/26/20190:00:00 $166.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File 4 BP-2019-0918 )(— PEEOS
F(.COI? I�L19✓
APPLICANT/CONTACT PERSON DAVID FORTIER
ADDRESS/PHONE 32 Laurel St NORTHAMPTON (413)586-8965
PROPERTY LOCATION 14-16 VALLEY ST
MAP 32C PARCEL 292 OOl ZONE URC(1001/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
CLOSED REQUIRED DATE
ZONINGFORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
TypeofConstruction: ADD SHOWER,UP DA RING NEW FIXTURES REPLACEMENT WINDOWS
RESHEET ROCK OVER EXISTING WALLS M SOME ROOMS WHERE NEEDED
New Construction
Non Structural interior renovations
Addition to Existing _
Accessory Structure
Building Plans Included
Owner/Statement or License 008026
3 sets of Plans/Plot Plan
THE FOL NG ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION 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
Demolition Delay
_ 2- ZG- Z66
Si me of Building Oficial 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.
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Department use only
City of Northampton Statue olPemr
Building Department Curb CulfDrNeway Pegtiit
l,t 212 Main Street Sewer/SepticAval
Room 100 Waitangi A
� Northampton, MA 01060 Two Seta of Structural Plans
phone 413-587-1240 Fax 413-567-1272 plot/Site Plarm r l
Other Spedfy
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Prooertv Address: This section to be wmmppleted by office
IN -
16 UAL LfY 57 Map _ Lot ill Unit
Zone Overlay District
Elm St District CB District
SECTION 2.PROPERTY OWNERSHIPIAUTHORIZED AGENT
.1 Owner of Record: I ,,/I w�AIn
LY SON Foiz (GR i I 1A LES Sl /VO.Qigilhp-1/ji W QIMII
Name(Print Current Mailing Address. r 1 f 3 2 ,�.ln 1 Le
/c l'� l
Telephone
Signature
2.2 Authorized Agent:
GAUIn +-v R,ICQ sa L4
Name(P I) Current Mailing Address:
�t✓Lt� till— alD- 33diq
Slgnatu Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit alcolicant
1. Building �oua. UO (a)Building Permit Fee
iar.PLACC T
2. ElecMcal (b) Estimated Total Cost of
j -1 d o d + ac) Construction from 6
3. Plumbing SUD. r20 Building Permit Fee
V
4. Mechanical(HVAC) r
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature'. z'zG-Zo)9
Building Commissionedinspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Most Be Completed. Permit Can Be Denied nue To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled at by
Building Department
Lot Size _._. ..___...
Frontage ...__..
Setbacks Front "---
Side L R:- L: R
Rear
Building Height
Bldg.Square Footage as ---
Open Space Footage % -
(Lot area minus bldg&paved
ginseng)
k of Parkin Spaces ---
Ivolume&I eap a)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES Q
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
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 WaltII the construction
i
cttiivty disturb OO
(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S DESCRIPTION OF PROPOSED WORK(check all applicablel
New House ❑ Addition ❑ Replacement Wipdows Alteration(.) Q Roofing Q
Or Doors V
Accessory Bldg. ❑ Demolition ❑ New Signs (01 Decks [E] Sidiri Other[I71
Brief Description of Proposed r Eo NM1 Ey w
W
ork: Ado ftkrAfle iaJ41,12 "INE YIXTuQI.L RrPLACch A.1 IVIya/buA
Alteration of existing bedroom_Yes ...y_No Adding new bedroom Yes >6 No
Attached Narrative Renovating unfinished basement Yes IL No
Plans Attached Roll -Sheet
Ba.If New house and or addition to existing housing. complete the following:
a. Use of building: One Farmll Two Family X 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
9. 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 regulaliens? Yes_No.
I. Septic Tank_ City Sewer_ Private well_ City water Supply_
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENTOR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 9�a AO\ Q�� as Owner of the subject
property o ✓
hereby authorize 6AU 10 Y QYC� �aVl.
to act on my behalf, in all aft s re,
ative to work authorized by this building permit application.
1
Signature of er Date
I, 17 �02: i�/„ ae6wner/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
Si/g�ned under the pains and penalties of perjury.
Pint e
� Ialli9
Signature of OwneAAgent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
� License Number
Oav l� r�zt(�rt a ilv ao
Address Expiration a[e
,�a LA-awLSr I�lozi+trt ��ny� C3�c ��
Signpore / Telephone
13 d a )3 cs
8.Registered Home Improvement Contractor: Not Applicable ❑
) c3SA9
o�an Nam-e Registration umber
A'J ��7 �p2�66/1 �ij/�LI�P�L(25 't � �'l � r�} O
Address ) ,Y Expirat n D e
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,525C(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. QQ
Signed AHidavt Attached Yes....... ❑ No...... �1'
t
City of Northampton
Massachusetts '6
c
r
DEPNtTlENT OF BUILDING INSPECTIONS
212 Main street • mnicipal Building w C�
Narthe ton, IM 01060 .gip\a
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 most be registered as a Home Improvement Contractor("HIC").
M.C.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement,removal, demolition, or construction o/an addition to any preexisting owneroccupied 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 has contracted with a corporation or LLC,that entity must be registered.
Type of Work: Est. Cost:
Address of Work:
Date of Permit Application:
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.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:
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
1
City of Northampton
—� aS
Massachusetts
� c
I DBPARTHF.NT OF BUILDING INSPECTIONS , ;
212 Main Street a N nlcipal Boiltl ng 4p
�( North m tan, 1M 01060 .^
Massachusetts Residential Building Code
Section 110.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 110.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
DEPANT T OF aOILDINO INSPECTIONS 91
212 Main Street Mipel Building C
Northamptoftan, HA 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:
1 ul- t� V�}ut. d Vii.
(Please pant house num er and street name)
Is to be disposed of at:
VAU,l;;-i 2U. Uij., as i, F i1{AnP;oN P. 2c 14RhF i
(Please pent name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
t_R.ni� �Kar� dFF �4 �o� 1 iAw R�. �9RiwE✓vFl��o� /HA'
(Company Nam and Address)
CI
Signature o e it p licant 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
WANDepartment of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.govildia
orkers'Compensation Insurance Affidavit:Builders/Contractors/Eleetricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Auolicant Information /{��/y I^ Please Print Leatbly
Nagle(Business/Organization/individual): 0a U V
Address: tAVACL '�T-
City/State/Zip: 'dn dd Phone#: N(3
Are you an employer?Check the appropriate box:
Type of project(required):
LL)l am a employer with_employees(lull and/or part-time). 7. ❑New construction
2 I�Ilaemasole prnprie[ot or partnership and have no employees working hrepe in g. ❑Remodeling
�a�— y caps ity.[No wurko x'comp.inswance improved]
y.❑I am a homeowner doing all work myself[No workera'emnpinsurance required]' 9. El Demolition
a.❑I am a homeowmr and will be burn 10 ❑Building addition
prog contmc[ors m penduct all work ve myce,sdo . 1 will
me that an commcmrs rimer have workers compensation inawance or arc ante 11.[9 Electrical repairs or additions
proprinora with no employees. 12. Plumbing repairs or additions
5 1 am a general conoocter and I have hued the sub-conuactors listed on the attached sheet. 13 ROOf repairs
These sub-eontrectnrs have employees and have workers comp.inmmnce. p
6.❑We area eomuecom.and its m1fi-ss base excessed their rightofexemprion per MGLc 14.❑Other M1p PCACCAF d,i
Isz,p qa),aw we nave no emvmrees.pvo wooers come.Nance regnire�L] tN 1 ry 7a mi
'Any applicant that checks box NI rims[also fill out the seetiun below showing their worker'compensation policy/nib muion.
Hummeravers who submit this affidavit indicating they are,doing all work and men hope mande contractors must submit a new atlidavit indicating such.
employees,
that check this box must attached as additional sheet showing me name urme sub-mtnradnrs and state whether or nut those en[itiey hove
ess., If the anbmntmemr have nnployccs,they mus[provide Meir workers'comp.polity nwnber.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.N: Expiration Date:
Job Site Address: City/Sta[e/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 o 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 form of a STOP WORK ORDER and a fine of up to$250.00 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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature' 1 `1 " Date' 0
Phone )Co- ug"k
Official use only. Do not write in this area,to be completed by city or town afoetal.
City or Town: Permit/License It
Issuing Authority(circle one):
L Board of Hcalth 2.Building Department 3.City/T.wn 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 bean 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 sub-contractor(s)name(s),address(es)and phone number(s)along with their certificates)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
ofthe 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 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 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 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 deceased employer,or the
receiver or tmstee 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 ofa 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 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 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. Han 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 pemnit or license is being requested,not the Department of Industrial Accidents. Should you
have any questions regarding the law or ifyou 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.
Cit,or Town Officials
Please he 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 that
must submit multiple permiv icense 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
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
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
Fmm fo,,—d02-2J-15