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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 ( '" _ ^l, a 0 q C C exy SMow��s �t�