17C-191 (7) I WILDER PL BP-2019-1082
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Mao:Block: 17C- 191 CITY OF NORTHAMPTON
Lot,-01) PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildino DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Bath reno BUILDING PERMIT
PFt>m # BP-2019-1082
Proiect 4 JS-2019-001765
Est.Cost:$11500.00
Fee: $71.50 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor. License:
Use Group: STEPHEN CAMP 082531
Lot Size(sa.ft.): 5096.52 Qanei: SIMMONS KATHLEEN E
Zoning,URB(100y Applicant: STEPHEN CAMP
AT. 11 WILDER PL
ApplicantAddress: Phone: Insurance:
46 EAST ST (413) 527-7124 0 WC
EASTHAMPTONMA01027 ISSUED ON.4/3/2019 0:00:00
TO PERFORM THE FOLLOWING WORK BATH RENO
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:
FeeType: Date Paid: Amount:
Building 4/3/2019 0:00:00 $71.50
212 Main Strect,Phone(413)597-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2019-1082
APPLICANT/CONTACT PERSON STEPHEN CAMP
ADDRESS/PHONE 4ti EAST ST EASTHAMPTON (413)527-7124 Q
PROPERTY LOCATION 11 WILDER PL
MAP 17C PARCEL 191 001 ZONE UMIOOU
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION
OSED QUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out s
Fee Paid
fConstruction: BATH RENO
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 082531
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFIDRMATION 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 Plot 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 Q
-41,3111
Signature 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/Dnveway Permit
` 212 Main Street SewEr/Septic Availability
'�. Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 411587-1240 Fax 413587-1272 Plot(Sile Plans
Other Sped
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISA 0 LING
SECTION I-SITE INFORMATION 20�J
1.1 Promertv Addmss: This s ctio W be completed by ofll
�/ �f / /c✓ /��.e Nap I IlDIN6 tN5GC-C..yrrn
LL NOF HR
Zona Overlay District
Elm St DlHrlui CB District
SECTION 2.PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name(Pnnp Current Mailing Address:
zvV- oiQ1r
Telephone
Signature
2.2 Authorized Agent:
Name(Pnm,..L.�0 Curem MaiAddress:
rZ)- , I zy
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permitapplicant
1. Building f7ov O.J (a)Building Permit Fee
2. Electrical Y ' (b)Estimated Total Cost of
Construction from e
3. Plumbing �(!S(j� ep Building Permit Fee
4. Mechanical(HVAC) 1
5. Fire Protection
8. Tofal=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
CaynlpSaA4ln @
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING Att Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Thu column to ee WW in by
Building Depememt
Lot Size
Frontage
Setbacks Front
Side G _. R: 1.: R: __...
Rear
Building Height
Bldg.Square Footage no
Open Space Footage
I1At.on.bldg&pevcd
ahn
#ofParking Spaces
Fill:
vd,me&Lacntiao
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T 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#
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(deadng,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,men a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORN(check all applicable)
New House ❑ Addition ❑ FReplacernent Windows Alteration(s) ❑ Rooting ❑
. OAccessory Bldg. ❑ Demolition ❑ igns (O] Decks [E] Siding lot Other[O]
Brief Descnptioryof Proppsed _/. fa1.Yy\
Work: 4u} P)AS/oJ OrJA('fD 4{v9S lyra? �'�ae✓ W .�G�N11��- ry) V1�
Alteration of e>asbng bedroom_Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished ba7wmeM Yes _J�_Nc,
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the followina:
a. Use cf building One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is mere a garage attached?
J. Proposed Square footage of new construction. Dimensions
e. Number of stories?
L Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compllance. 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_ Pmate well_ City water Supply_
SECTION 7a-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.
Signature of Owner Date
I, as Owner/Author
Agent hereby declare that the sta is and information on the foregoing application am true and accurate, to the best Ary knowledge
and belief.
Signed under the pains and penalties of perjury.
5
Print Name A
A_ _
Signatu of Ow nAgeM jV Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: SW-4-1) ai4e 0'y Z 5--7/
License Numiter
'1/6 Ln4S� Sf L�43fily�l✓ M� //-23-iq
F�irntlon Date
Signature Telephone
9.Replstered Home Improvement Contractor: Not Applicable ❑
St � Uf Ca.1� Co15tr� a( /3s20Y
Company Registration Number
Addre//s``s �{ Expiration Date
76 �f}S�" S��""'/ SA it✓. pllfelephone
SECTION 16 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L C.1ZS28C(8))
Workers Compensation Insurance affidavit must be completed and submitted with Misapplication. 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
x
n212 a n S Qe nozz ici znsrrcxzons g
zsz win aeswc • tdn 010 B�1laing Ste`: pC�
eorm+ ,con, as ossa
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
perforating work on such homes,a contractor most be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction,alienation,renovation,repair, modamization,conversion,
improvement, removal, demolition, on construction of an addition to any pre-exisling owner-0ccupied 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.!f 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 re ucin(s):
_Work excluded by law(explain):
_Job under$1,000.00
_Owner obtaining own permit(explain):
_Building not owneruccupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE ROME 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,l hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
Massachusetts
212A in S ee BUILDING INSPECTIONS
313 lYan ro%u • municipal Building
No[tTavpton, !q, 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 I10.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
•'/f F ssachusetts
nepwaxacxx or aczsaras zaspccxioas
212 win street *N Impel Bu" nq C�
\ Northe ton, ! 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:
�t w! liar Plan
(Please print house number and street name)
Is to be disposed of at:
VQ�lL7 �tl�/G�� n /�/6/YFta✓
(Ple se print n e and don of facility
Or will be disposed of in a dumpster onsite rented or leased from:
(Company ams and Address)
42 y/Z/ f
Signature of Permit Applidaht 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
I Congress Street,Suite 100
Boston,MA 02114-1017
www.mass.gov/dia
V11rurkers'Compentration Insurance Affidavit:BuilderstContraclors/Electriciaos/Plumbem
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicaut Information Please Print ibl
Name(BusinesvOrganumitioMndividual):
Address: yLS'f✓,��-
City/State/Zip: Ml-& i 02 Phone#: !2
Are you m employer check We appropriate hoc Type of project(required):
I. 1 w a employer with employees full mother pert-time).• 7. ❑New construction
2. Imva sole pmprietmmpa,IrcMip asdlmvc no empbymswmking fmmein 8. Remodeling
my rapacity(No workers'comp.iromaoee ex,rired.] I•T'�Je''l,
l.❑I am a homeowner dem,rdl work myself.[No wmketi insurance
comp. required]' 9. Demolition
6.M I are a hommwmr and will be timing10❑Building addition
contractors to existent work on my popenY_ Iwai
methal en motracmrs eitherlmee wotkcn'woWensatim buvrmcemare sok 1IF]Electrical repairs or additions
pmpriem a with no employees. 12.❑Plumbing repairs or additions
5r]1 son.general mnbm,lor and I have hired the sub-.. on the miumbed sheet. 13.�Roof repairs
These std Kontrnwos been employees and have worker%wrap-m.wanee: p bb
6.E]We am.e 'ion and its oRmers have exercised theirs fight exemption 14.[]Other I9kA M1LrMp �
ryde gh ption per MGL o.
152,SIIII.end we love oo empby<es.[No workers'comp,immmce required.)
•Any applicant that cheeks boa NI must also fill out the section bebw showing then workers'compensation policy information,
'Hommwners who submit this affidavit indicating they are doing all work and then hire mrode coatrndors must submit a new amdavil mdieating such.
:Conhocmrs that cheek this has most attached an additional sheet drawing the came of the subsontracmts and sum whether more those entities have
employees. Ifthe mi-nonaacmrs have employees,they moa proodet then workers'comp.policy mush.
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. ^
Insurance Company Name: /Aa r to//K e.,,,c,,-_ �uj, zo /l
Policy#or Self-ins.Lie.N: /i S�2-P —1 ygOiF 7 Z Expiration Date:
�l jLCY F1 ti -es
Job Site Address: ��GG City/State/Zip: .; ryas dl0/,L
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$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 certif//shad-err the paaiinnsssaand penalties of perjury d arthe information providisesdd abovee istrueand correct
Signature: //yYr. t �1Date-
Phone#:
527-7 L
Official use only. Do not write in this arra,to be completed by city or town official.
City or Town: Permn/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 N:
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 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 152,425C(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 m your situation and,if
necessary,supply sub-contmclor(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. Alyn 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 Towu 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 permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitflicense 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. #617-7274900 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 smite 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 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 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(ILC)or Limited Liability Partnerships(LLP)with no employees other than the members
or partners,are not required to tarty workers'compensation insurance. If an LLC ar 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
insurancecoverage. 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 pennitAicense 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). 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 Departments 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.nmss.gov/dia
F.a i xlM-23-15
Stephen Camp Construction
46 East St.
Easthampton, Ma 01027
(413)527-7124
Submitted To : Kate Simmons Phone-5g"i%
Address : 11 Wilder Place Date—3-29-2019
Florence,Ma 01062
We hereby submit this estimate for—Bathroom Remodel
To start the job we will demo down to the framing and save the ceiling.
I will level the floors and install 3/4"plywood and any wall framing will be done.
The plumbers will relocate the fixtures as needed.
(Any electric will be done—customer will supply electrician.)
All insulating and sheetrock will be installed taped ready for paint.
The flooring will be installed by other flooring contractor.
The plumber will install the finish.
1 will install all new trim were needed to finish the job
Estimated Price=$ 11,500.00
Contractor Supervisors License number 082531
Home Improvement Contractor Registration number 135204
I propose to supply materials and labor-in accordance with above specifications.
This proposal may be withdrawn
By us if not accepted within 30 days
Authorized Signa.ur . '
Acceptance of proposal Sigrutt ( '" _
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