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32C-163 (36) 2- 14 RANDOLPH PLACE BP-2019-1120 GIs#: COMMONWEALTH OF MASSACHUSETTS Mao'Block:32C- 163 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cateeory ROOF BUILDING PERMIT Permit BP-2019-1120 Project# JS-2019-001821 Est.Cost $18500.00 Fee:$t 30.00 PERMISSION IS HEREBY GRANTED TO: Const. class: Contractor: License: Use Grmm FAMILY TREE AND HOME - JILLIAN SOUTHWICK- HALL 112720 Lot Size(sq. ft.): Owner: SPENCE GEORGE A Zoning: URC(105)/)M53)/ Applicant: FAMILY TREE AND HOME - JILLIAN SOUTHWICK - HALL AT: 2 - 14 RANDOLPH PLACE Applicant Address: Phone: Insurance: PO BOX 3699 (413)478-8i59 WC AMHER5TMA01004 ISSUED ON.411012019 0.00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF 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 11 Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: OiI: 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 4/10/20190:00:00 $130.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner _ Versionl.7 Commercial BuildingPermit May 15,200d I- Department use only ! `'-� of N rthampton status of Permit: Buil Ing apartment Curb Cunodveway Permit APA 1 0 2019 2 2K in Street Sewer/Septic Availability Roc 100 WaterNyell Availability pt n, MA 01060 Two Sets of Structural Plans ruin o Pic 7-12 P Fax 413-587-1272 Plo7Site Plans Other Specify APPLICATION TO CONSTRUCT,REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING / f� SECTION 1 -SITE INFORMATION 1.1 Property Address This section to be completed by office Map -6� C Lot t(-.e 3 Unit ✓1 Cb I 'rI I,�/l�IC4CC- Zona Overlay District Elm St Dismcr CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: c' S viCC PO G"X /6 f(Rt o /7�i9 0«.�g Name( Current Mailing Address' X c, �3 - 626= 9a51 Signature Telephone 2.2 Author nt: (c le 4 wrC�C (I Pa gOX 3Lav9 Fit Wjt- MH o1Do-1 Name(Pant) Current Mailing Address (413 418 -8159 Signature Telephon SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by pe"it applicant 1. Building I O SOO `VD (a)Building Permit Fee 2. Electrical o V V (b)Estimated Total Cost of Construction from 6 /J 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 41 j 3a 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: y-io-2oiq Building Co missionerfinspeclorof Buildings Date Venionl.7 Commercial Building Permit May 15,2000 _i SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Well Signs ❑ Demolition Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing Change of Use❑ Other❑ Brief Description Enter a brief description here. 5'+-ip cAndDrip l2a1 ' " GS' Of Proposed Work: n-v S fb'-6n + F„/ Dri A•vtSI,S GripYi "FF'Coi(�”` SECTION 5-USE GROUP AND CONSTRUCTION TYPE rtor I I S Idanr USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly1:1A-1 13A-2 ❑ A-3 111A ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Proposed Use Group. Existing Hazard Index 780 CMR 34). Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1. 1. 2na 2m 3� 3ra 4 t 4m Total Area(aft Total Proposed New Construction(sfry Total Height(tt) Total Height it 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone❑ Municipal ❑ On site disposal system[] Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This whim to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: t.: R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg&paved arldn #of Puking Spaces Fill: volume&Incation A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO © DONT 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 © NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs Intended for the property? YES © NO O IF YES, describe size, type and location: E. Will the construction activity disturb(Gearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Versionl.7 Commercial Building Permit May 15,2000 'SECTION 9•PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 36,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): Registration Number Address Expiration Data Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Dale Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor I� / 1-- Vf �. Wit:-(,o (w 5j'A✓'f� 'l Not APPlicable ❑ Company Name: Ep,nI\y I-LcC c�-J Responsible In Charge of Construction two c3(3 99 old Address Si re Telephone Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR RAAPPLIES nnFOR BUILDING PERMff I �Ir rt( 7O�-sPw'V C' /' /�' / as Owner of the subject property h yauthonze /�/1yI1i (�� ��1.W "f gem �Gv� 4Jp✓Tkwi-(C'- f/f7{t to a y behalf, in all matters relative to work authorized by this building permit application. Sign u,I/f Owner c,, f,r•� f Data I, / (`tiO IpS � '_ J �� I 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. Signedand r the pains and penalties of perjury. p, C bio � CiS SV7-e((C —4^ Print Name Sgnaluvree of OwnnedAgent —Z" Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Sunervisor. Not Applicable ❑ Nemeoi License Holder �I��IA./1. Joumma-tW License Number Pi A.¢ $f. 6elUU./+Vwtl, Mk 0,ao- 112-720 Address Expiration Date al EP,u.A .�nu �u� r��- n Cl_, 913 yo4yllo 0/21j22 Sin ure Telephone SECTION 13-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 affitlavit will result in the denial of the issuance 0' the b ilding permtt. Signed Affidavit Attached Yes No City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste 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. Address of the work: KG � The debris will be transported by: Q �✓'ee � The debris will be received by: Building permit number: Name of Permit Applicant r-rA^ 1Y Tom- C �i C( �- Date Signature of Permit Applicant �\ The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-1017 outran anates.gr v/dia Vx\'rkcrs'Compcnsation Insurance Affidavit:Builders/Contmetors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information p Please Print Le ibl Name(Business/Orgmirztion/Individual): �A Il ek ✓�`c-- Address: ib bo�//— 36 /Q ' City/State/Zip:A`1LVt/- AAA- Lk Ph...#: " , �3 6�0 /16 Are you an employer?Check the appropriate box: Type of project(required): 8am a employer with employees(full and/or part-time).' 7. E]New Construction son asnle propsworurpanne,ship and have no employees working for me in 8. �1'�Remodeling any capacity.[No workers'comp.insora - required.1 }LTJ 3.F1lamalmnow-nermt. shworkm If ken'com ueace d 9. Demolition g yse INo wor p im require .�' 4.❑I am a homeowner and will he hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers°eompereco lon imosyme or are sole I1.❑Electrical repairs or additions proprietors with no employma. 12.❑Plumbing repays or additions 5.❑1 sin a general wnvactm and I have hired the subcontractors listed on the anached sheet. 13.❑Roof repairs These sahcontractors have employees and nava workers'comp.insurance. 6.❑we are a em,,ralma and oe onicma have exercised their tight of exemption per MGI.c. 14.❑Other 152,§1(4),end we have no employees_INo workers'cmmp_insurance required.) *Any applicant that checks her 41 most also ill out the section below showing their workers'compereation policy inf rmation. t Itome ersom who submit this afidevit indicating they are doing sll work and then here outside contractors must submit a new affidavit indicating such. =Co assetors Nat check this box most attached an additional sheet strewing the name of the subcontractors and state whether or not those cooties have employees. Ifthe sub-contactors have employees,they must provide Neu 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 II Insurance Company Name: ca d i o\ h d-- Co . v1n Policy#or Self-ins.Lic.#: I ' 1 ai � V r AlD Gxpimtion Date: 19 n � Job Site Address: z /LGI.190I J2� 0_ #(74 ff"M- o''1 City/Slate/Zip:M4 01(--) 'O Attach a copy of the workers'compensation polity declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGI,c. 152,§25A is a criminal violation punishable by a line 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 certifyunderthe�pJain/s,andppeenalties of ' ry that the informadon provided above is true and correct Signature Date, 4I 9I1 q Phone#: )3` L4— N 0 Offnial 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 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 stares 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)motels),address(es)and phone numbers)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 maybe 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 sue 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 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 From: �q✓!11 �Y free GJ✓/oJ /7r//Jt� r Po 8O ,3699 11MbPK5;- M4. OJO01/ (c/13/y70-01SIq To: Louis Hasbrouck Building Commissioner City of Northampton 212 Main Street Northampton, MA 01060 The Massachusetts Building Code,section 107.1 allows for an exclusion from requirements for construction control in certain situations. In accordance with code section 104.10, 1 request that you grant a modification to waive the requirement for construction control of the project at L 1 y Ae7M,oti i71 lyertmn9e}rrj rl because the work is of a minor nature,will not affect structural elements,health,accessibility, life or fire safety,and will be done in accordance with the prescriptive requirements of the code. Thank you for your consideration. Respectfully,