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17C-113 (2) 44 STILSON AVE BP-2019-1060 GIs#: COMMONWEALTH OF MASSACHUSETTS MV.Bloc : 17C- 113 CITY OF NORTHAMPTON Lot; -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category: Siding BUILDING PERMIT Permit# BP-2019-1060 Proiect# JS-2019-001727 Est Cost $8300.00 Fee:$60.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group, EUGENETHOMAS 81882 Lot Size(sg ft Y 11979.00 Owner: BENEDISUK MICHAEL S&JEAN L BENEDISUK Zoning: URB(100)/ Applicant. EUGENE THOMAS AP 44 STILSON AVE ApplicantAddress: Phone: Insurance: 49 GRANT ST (413) 529-0902 EASTHAMPTONMA01027 ISSUED ON.•3/27/2019 0:00:00 TO PERFORM THE FOLLOWING WORK INSTALL VINYL SIDING OVER EXISTING WOOD 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 sig t re• FeeType: Date Paid: Amount: Building 3/27/20190:00:00 $60.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner J" City of Northampto it 'Mr Building De a' me�IECEIV g p t 212 Main Si e An I R 10 !AAO 28 20 sit vallabill Northampton, MI 011 Two 0 0 hall phone 413-587-1240 FIx 41 -587-1272 0Tr1J1lD1N1,MIS 6 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION -10a6l 1.1 Property Address This section to be completed by of .1i Map /7c.- Lot /13 Unit e, ej.4, o1061 Zone_OwrIayD1si El.at District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2 1 Owner of Record- 9e',7e-d,'5611( Y1 57-1ZLSo, Name(Punt) Current Mailing Address at�a'-�eQ �R�,ao� Vine 2.2 Authorized Agent- iP�-me 77a,-7,e9-5 Name(Print) .. ...... Signature Telephone SECTION 3.ESTIMATED CONSTRUCTION COST Item Estimated Cost(Dollars)to be Official Use Only completed bennit applicant 1. Building (a) Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) tyo 5. Fire Protection 6 Towl= (1 +2+ 3+4+ 5) Check Number C/ This Section For Official Use Only Date Building Permit umber Issued: Signature: 3 -Z7-ZO17 Building Commissionedinspectis of Buildings Date @ C-0,--7 EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Mus(Be Completed PermitCan Be Denied Due To Incomplete Information Existing Proposed Required by Zoning Ti column,be tilled m by Building Depamnent Lat Size ..__ ..... Frontage Setbacks From Side L R ..... L:_. R. ......... ....___... Rear Building Height - Bldg. Square Footage % — " --- Open Space Footage % _. (Lot oma minus Man&paved adcin H ofParking Spaces ---- --- volumeffiLace[ion —__.. ___ A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW © YES O IF YES: enter Book Page and/or Document q, B. Does the site contain a brook, body of water or wetlands? NO e('�'DON'T 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 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing oa grading,exv n, or filling)over 1 acre or Is It part of a common plan Othat will disturb over 1 acre? YES NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION S DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(.) ❑ Roofing ❑ gr Doo Rep= O Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks jp Siding[or-­Other[CX Brief Description of Proposed,.,1/�J /K/iCO✓� !S%�0.'m15,14,if Work: Alteration of existing bedroom__-Yes_±' No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes '-'No Plans Attached Roll -Sheet Sol If New house and or addition to eAsti housing, complete the following: a. Use of building: One Family Two Family 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 is, Number of stories? 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_ City Sewer Private well_ City water Supply SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, k YJ Llle-d l'J V & , as Owner of the subject property //�� 7 hereby authorize 6el6 e/1- / /ICY/gA-5 to act on my behalf, in all matters relative to work authorized by this building permit application. / V Y �Vrs" Q a.n t �/x& //$! Signature of Omer Date as-OwnertAuthorized 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 under the pains and penalties of perjury. ✓" 6j. -QS Pnnt Name Signature of L'0lW/Agent L Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicabbllelyl•❑/ Name of License Holder: D License Number _'res CIQARTST. 1s/�ia�rr�iit rc 9, 0/0-:17 Atltlress Expiration Date add y/3 -S;`7-o 9a� Signature Telephone 9.Rsaistered Nome Improvement Contr r: Not Applicable ❑ _ ce4o;5 / -7 7 /F Company Name Registration Number y9 G.P��j si F.g a�r¢/o �, r�ft a/o�7 9f A/d�dress �/ Expiration Date Date PeXY54r !-O Telephone /�3 -.S�d9-0 O' eg— SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§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 AffidavH Attached Yes....... No...... ❑ City of Northampton i Massachusetts L ➢ B OF =LDING INSPECTIONS 212 xin Seret 0 Mnicipal St Building C< xorNwpton, Mp 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, 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 contractedwitha corporation or LLC,that entity must be registered Type of Work: V'2 .S yl. /G1//1Est.Cost 00 bI / Address of Work: 1 y 5111,1,50,, eVe , F&,?e4ee_ Q(plo-.� Dace of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): —Job under S 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: � 1� G'ei0'S ff ,-; ee_ ��d,P7cn%S 17071 P l / q V Date Contractor Name /C HIC Registration No. culpe//p� t/xv/^7�.5 OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: M to AV\i _ 4Vla..r Date Owner Name and Signature City of Northampton � - Massachusetts N c x DEPABT.bE.NT OF BOILDZNG INSPECTIONS � 212 Hein Street a Municipal Building M.thampton, [A 01060 Je dCs 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. r City of Northampton / Massachusetts c x DEPANOHENT OF HOZLDING INSPECTIONS 212 Nein St —t alNninipal Building Northampton, . 01060 'a 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: Y1 ST1L5o.i Me. 0+0,Pe4ee (Please print house number and street name) Is to be disposed of at: ✓Wley QeCyC.0-�� (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 cr-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. S.'\ The Commonwealth of Massachusetts Department of Industrial Accidents 7 Congress Street'Suite Boston,MA 02114-2017 www.mass.gov/dia TR.rkoo,s'Compenmtion Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PI ase Print Legibly Name (BusineswOrganixation/Individua0: 67P-40S /o rye ,T� ✓�ratier e ITS Address'. 't'9 6YIA,17- ST : �/�� City/State/Zip !rt-t Phone#: Are you an employer?Check the appropriate box: Type of project(required): I l am a employer with empayees(full.&.I pan-time). 7. ❑New construction 2 q. I am a sole proprietor or pa enh p and�ehave m employees working forme in y-r4nseasonal,[No workerscomp ire, required] 8 ❑Remodeling 3.❑I an a homeowner doing as work myself [No workers'tempinsurance required]' 9. ❑Demolition 4.❑lam a bomenwner and will be andg canbactors to rovdmtall snakonmypropefxy. twill 10 []Building addition rewk, me dot all orientations armee have workers compensation insurance or am sole I1.❑Electrical repairs or additions proprietors wim ao employee,. 12.E]Plumbing repairs or additions s lam agrneml contracmraod 1 have hired the sub<ovbecters lined on We attached sheer. 13.❑Roof repairs flew subcontractors subontractors have eme,ployeand have workers'comp.insurance.t d.❑We arc a enrpom0ov and its officers have exercised rhe.right of exemption per Met.c. 14.�Other�/Llys 152,31(4),and we have m employees-[No workers'comp.insurance requbed.] ' Huomerapplicantwrs rho checks Iwx a mast also fillnutthe section bel ow showing then worknscompevsmiun policy inform a tion. t onewoo submit this affidavit indicating they are doingwo all rk and then h.e outside ntravemrs must submit a new not those indicatinglicha e $bnoyees. dot check this box must torched asadditional sheetstowing mename come sub-counacmrs and sure whether arm[those rntities have employees. Ifine sun-mvvdemrs have employees,they most provide tach workers'comp.policy number. 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.#: 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,§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 crop to$250.00 a day against the violator.A copy ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cortify �un�ddeerr the pains andisengigita of perjury thatthe information provided above is nue and correct Stimulate: �!/�>°�,y � 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 ofthe 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 ofa 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 ofpub]ic 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 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 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. 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 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 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, 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