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16A-026
24 CHESTERFIELD RD BP-2019-1017 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 16A-026 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categorv' Siding BUILDING PERMIT Permit# BP-2019-1017 Project# JS-2019-001669 Est.Cost-_$17840 00 Fee:S60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group AARON PUNSKA 105542 Lot Sim(su. ft.)� 19994.04 Owner: FERRIS MARGARET R Zoning: URA(100)/ Aoplicant: AARON PUNSKA AT.- 24 CHESTERFIELD RD Applicant Address: Phone: Insurance: 111 KINGS HIGHWAY (413) 626-6033 0 WESTHAMPTON MA01 027 ISSUED ON:3/19/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-install vinyl siding 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 Occupancy Signature: FeeTvpe: Date Paid: Amount: Building 3/19/20190:00:00 560.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Buitding Commissioner SInI 6_ Department use only City of Nort mp on of emg Building De rtm n1 MAA 1 9 2019 Cu Permit 212 Main tree dS1 Avabatu(by Room 1 0 W Avai�bilby Northampton, A P QI. roimnrnulNsaF Twbuts $ phone 413-587-1240 'JAM QMer,Speafy. APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWOFAMILYDWELLING SECTION 1 -SITE INFORMATION 8('- �'I �10� 1.1 PropertyAddress //� ((`` � QQ g ' Thissectionto be completed by oRice Z� (�NCSiLGYl ed & Mapes Lot yal,! Unit Ja 'Ofo 53 Zone Overlay District C Elm SL Disfdct CS District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT cas�'A 2.1 Owner of Record: Z'sGhcslr�&,lY t2a. Na�me/(P/ri�n� p Current Mailing�55tlfpss6 / r (o• n��.,� - Telephone NNII Signature 2.2 Authorized A ent: II �"m✓ vt Li3k,,9- I/ k1l .1 G Name(Print) Cuoent Mailing A tlress: AL3 6Z6 �6a33 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only comicleted by pe"it applicant 1. Building p N a w (a)Building Permit Fee 2, Electrical U (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Feel y 4. Mechanical(HVAC) 1 V� 5, Fire Protection VVV 6. Total=(1 +2+3+4+5) rJ Check Number 3 This Section For Official Use Only Date Building Permit Numb r: Issued. q Signature: 1�vl3 - )q �) I Building Commissionerllaspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L R: L: R' ._... ....... Rear _ Building Height Bldg. Square Footage % Open Space Footage % (Cot oma minus bldg&paved arkin #of Parking Spaces ----- Fill: ...... (volume&Lowfianl 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 © DONT KNOW;`O YES O IF YES: enter Book Page and/or Document# . ... B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained O , Date Issued: C. Do any signs exist on th/pro rty? YES NOIF YES, describe size, d location: D. Are there any proposed s to or additions of signs intended for the property? YES ONO O IF YES, describe size, d location: E. Wit the construction activity disturb(clearing, grading,excavation, or filling)over 1 acre or is it part 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. Y SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable( New House ❑ Addition ❑ Replacement Windows At ❑ Roofing ❑ Or Doors D \/ Accessory Bldg. El Demolition El New Signs [0D] Decks [q Siding [®] Other[C] Brief Work Description of Proposed LSA/IJ VIHNI D]u/h ''\\ Alteration of existing bedroom_Yes /No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Sa. If New house and or aildition to extatina housing, complete the followin a. Use of building : One Family Two Family Other E. Number of roams 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? I, 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 fl.of wetlands?_Yes _No. Is construction within 100 yr. floodplain_Yes_No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank_ City Sewer Private well City water Supply_ SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I. Ae fCel-17 as Owner of the subject property I hereby authorize �%f�✓�YJ to act on my behalf, in all matters relative to work authorized by this building permit application. is- 21l ignature or Own r Date I,�✓y✓rA u/� as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed der the pains and penalties of perjury Print IN Signatu Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction /S�upervisoyfrnl: I�. Not Applicable El Name of License Holder'. ^VYV✓[ (t/('!1 K'J ('- /SSS 12-- / License Number q /DlZZI Address j Expiration Date r Signalija Telephone IN Replstwed Homs Improvement Contractor: Not Applicable 11Avo , 0✓tieti�v- G,.�sr(-✓r- An ` !"u,� r 17z 9 -' ?— CompanyName Registration Number AtltleExpiration Db Ue3i � t0 Telephone SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.752,§25C(6(( Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes-.... $� No...... ❑ City of Northampton Massachusetts ' DEPARTMENT OF BUILDING INSPECTIONS 212 Hain Street a Municipal build nq aortha ten. Ma 01060 'y'jAJ AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCA-BR")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, modernization, conversion, improvement,removal, demolition, or construction of an addition to any preexisting owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the 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: q t� 61yr1 If 7212 /Nraz Pl-I k* / -]Z / I Z- Date ° Comractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton Massachusetts d x I DEPARTMENT OF BOIIDING INSPECTIONS i m 212 Hain Street • Municipal Building Northampton, MA 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 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 110.R5, provided that if a homeowner engages a persons) 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 !` DER" BUILDING INSPECTIONS 212Ma 212 innstMu • nicipal BuilEing �. i, Marthee amptan, !¢A 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40, 554, 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: ZY IN (ev A J(, cx (Please print house number and street name) Is to be disposed of at: V4// acid (Please pr/ t name and locabol of facility) Or will be disposed of in a dumpster onsite rented or leased from: heh s Voll �ff (Company Name and Address) ��- r/k_.Z, I C� Z)r ? Signature of mit 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 of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-20177 www.mass.gov/dia W orkers'Compensation Insurance Affidavit: Builders/ContractorsMectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individvap: VV17 101,l d W ✓f Address: In I City/State/Zip: O h `a .r DoWhonc#: 679 760?3 Are you an employer'!Check the approp ate boa: Type of project(required): 1.❑lam aemployer with employ.(full motor part-unesy. 7, ❑New construction 21<1 can a sole proprietor or partnership and have no employees wonting Ibrmein g. ❑ Remodeling any capauty_[No workers compmovance mquhed.] ].❑l am a homeowner doing all work myself [No workerirompinsurance required.]' 9. Demolition 10❑Building addition 4.❑1 am a homeowner and will be hiring workers' to conduct all work ee my property. 1 will ,.,.a mat all enno-mtors either haw workers'compenaarion insmen«or are ante 11.❑Electrical repairs or additions Proprietors with no employees. 12.❑Plumbing repairs or additions s❑1 am a general contractor and 1 hevc hired the sub-eciumemn[cared on the attached sheet. Thn ese sub-conuamprs have employees and have worke 'comp.insuran ];, t ce. ❑Roof re P airs 6.❑Weareaw time ditsofficemhaveexemisNthehri htofexem iwn 14.❑Other ryom g p RT MGL c. 152,41(4),end we have oo employe<s.[No wodcers comp.insurmec rcyuvea] "21ny applicant mat checks box#1 must also fill out me section below showing mev workerscompensation polky minrmatioa. t homeowners who submit this at shisit ind;esse,they are doing all work and men here nutvde convectors must submit a new andavd;ndkohng such, tfnnvectors mat cheek this box must couched m admnenal she.showmg are nameofine sub-cmar dors and state whether or out those clones have employees. if the sub contractors have employees,they most provide their workers omp .policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy andjob site information. Insurance Company Name: Policy#or Self-ins.Lic. #: Expiration Dafe: 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 a 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 andpenalties ofperjury that the information provided above is true and correct S mat 0ti� Datfik—t!(- 1s— S I I Phone#' 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 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 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 ofthe 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 scute 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 ofpublic 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 subcontractor(s)morels),address(es)and phone number(s)along with their certificate(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 Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permivitcense number which will be used as a reference number. In addition,an applicant that most submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Sob 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 proofthat 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, MA02114-2017 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 ofthe 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 thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every 9 w 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)stales"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 time,address and phone number along with a certificate of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees ether than the members or partners,are not required to carry workers'compensation insurance. Ifan 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 permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple perm t/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary). A copy ofthe affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proofthat 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 Departrnern of Industrial Accidents 1 Congress Street Boston, MA O2114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Pa.R--d02 23-15