25C-046 (10) 9 WOODIHNE AVE BP-2019-1107
GIS#: COMMONWEALTH OF MASSACHUSETTS
M=Block:25C-046 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: ROOF BUILDING PERMIT
Permit BP-2019-1107
Project JS-2019-001794
Est.Cosr. $6000.00
Fee:$80.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class Contractor: License:
Use Group JAMES ROBERTS 99404
Lot Size(sp. ft.): 4094.64 Owner: JAESCKE RICHARD E&SANDRA H GO SANDRA H JAESCKE
Zoning, URB(104)/ Applicant: JAMES ROBERTS
AT. 9 WOODBINE AVE
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTONMA01027 ISSUED 0N:41W2019 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# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oyl: 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 4.!9/2019 0:00:00 $80.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Qom'
�_—_ Department e only
City of North mptP C of t
Building Dep rtmept Curb Permit �Pr
212 Main S eat j ppR q 201 sa Assailablfdy
Room 10 Wate ell vailability.
Northampton, M 01g6C�— y7aBals of ral
Plans—phone 413-587-1240 Fa 413=587-f '72 s
Other Speciy
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION ��J- ( q '���
1.1 Property Address'. ' This motion to be m lleted by offic
bee
Mapes Lot�Unit
Zone Overlay District
Elm St District CB Distri
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record,
2
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized A ent:
Nemint) Current Mailing Address_ _
/—
Signature
" Telephone -
SE ION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimat Cost(Dollars)to be Official Use Only
mm le tl by permit applicant
1. Building �... (a) Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from fi
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
B. Total=(1 +2+3+4+5) Check Number 6
This Section For Official Use Only
Building Permit Num r Date
Issued: JJ
Signature:
Building Commissionedinspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled an by
Building Detrainment
Lot Size
---
Frontage ...__..
Setbacks Front
Side L. . R: L R:.._.
Rear
Building Height ---
Bldg.Square Footage "'' % -
OpenSpaceFootage %
(Lot area minus bldg&paved
padkjnio
9 o Parking$ aces -- ----
Fill: ._... _.. .....
'.'L. @ Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'TKNOW 0 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 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 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. WII 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 Stow Water Management Permit from the DPW is required.
SECTION 5.DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [ol Decks [q Siding I01 Other[I7]
Brief Description of Proposed
Work'. C-
Alteration of existing bedroom_Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
St. If New house and or addition to existilm 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
e. Number of stories?
f. Method of heating? Fireplaces or Woodsloves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
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 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 b If, in an tters re five to wo a orized by this ilding permit application.
7
Signatu of Owner Date
I. as Owner/Authorized
Agent hereb7clihe 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 Pe u
Print Name
Signature of GtTTgert Dale
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder'.
License Number
Address Expiration to
��
Signature elephome
9.R ur elm rowneem Contractor: _ Not Applicable ❑
Registration Number
z/\ /
Address
Expiration Date
Telephone
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 Affidavit Attached Yes....... ❑ No...... ❑
City of Northampton
Massachusetts .3 >•- 'rl
\ ( * mattos 'usu'r OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
„ Mcrtha ton, MA 01060 SbhT ,1
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 o/an addition to any pre-existing owneroccupied building containing
at least one but not more than lour 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 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 gen[of the owner: j, q
(/ L
Date Contra for'fame 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
Q,�,
Massachusetts U
TMENT OF BDILDING INSPECTIONS212 Nein Street a 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 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.
City of Northampton
Massachusetts
DEPARTMENT OF BDTLDTNG INSPECTIONS 2
212 Main Street *Municipal BuilQing 4 '^
NOLCI�ton, HA 01060
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:
(Please print house number and street name)
Is to be disposed of at:
(Pled a and location of facility)
Or will be
disposed of
in a dumpster onsite rented or leased from:
Company Name andel Address i
I�
Signature o ermit Applicant or Ovber 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
Boston, MA 01114-4-100177
IR
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contra"ors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legible
Name(Business/Organizatimilndividuap:
Address:
City/State/Zip: Phone
Are you an employer". Check the appropriate box:
Type of project(required):
L�Inme Inym with emplovees(fullond/orpan-time).* 7. ❑New construction
2 propdemrorpartnershwandbave noemplove—raking for—. R. ElRemodeling
y capacity [No workerscome,insurance required.]
3.F-1 l am a homeowner doing all work myself[No workers'comp.inuancerequitea]' 9. ❑Demolition
4.n 1 amahomeowner unit will he hiring contractors to conduct all work on my property. Iwill 10 Building addition
enure that an contreuors ease,havcworkcrs'ocarenasaar mamma oraresele II.E]Electrical repairs or additions
proprietors with no employees.
12. Plumb- g repairs or additions
s❑l am a general contractor and l have hired the subcontractors listed on 61 atmehed sheet 13 of repairs
These subcontractors have employees and have workers comp.msuran
6We arc a corporation and its officer,have exercised their right of exemption per MGL c. 14. Other
152,p 1(4),and we have no employees.[No workers comp insmnnce required.]
"Any applicant that checks box#1 must also fill out rhe section below showing their workers'compensation policy information.
'Ham who mbmlt this aRidwo mm,mmg they are doing all work and area hire outside contractors most submit a new affidavit indicating such.
tCommeuors that check tis box most attached an additional sheet showing the time of the sob-cpnhaMrs and smen whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp Policy number.
i am an employer that is providing workers'compensodan ' sconce r my a pl the policy artd job site
information.
Insurance Company Name:
Policy#or Self-ins.Lig.#: Expiration Do
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 ane-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 ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify V&rjhepatns and penalti o perjur that the informationprovided above is true and correct
Si nature: 477� L,i/ '' ✓ _Date: —�
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 m"...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,§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 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 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 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 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
4135451975 Institute for Social Science Rese 09.4709a.m. 04-08--222019 t !1
City of Northampton
' G Massachusetts ryaj(�®ft
V
LSPANTMBNT OF BUILDMO INSPSCSIONS
E12 Huin 6krao[ . NunmiWl Building
xorth ,
7,,0\kNFR
EIVED
LOU"
Hasbrouck �— Chuck Miller
cadlna Commissioner Assistant Commissioner
2019mus
I XIIM PI ION ACKNOWLFDUFM I;N'I'
The State of Massachusetts allows the homeowner the right under 780CMR 108,3.4 to act as his/her
construction supervisor. The state defines "Homeowner" as, ' Person(s) who owns a parcel on which
he/she resides or intends to be, a one or two family dwelling, attached or detached structures j
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 home owner."_
The building department for the City of Northampton wants any persons)who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages, which include
foundatlonNooting;_(before backfill) sonotube holes(before pour) a rough building Inspection
(before work is oencealed),insulation.inspection,(if rogatrei and a.final.building inspection.
The building department requires these inspections before the work is concealed, failure to secure
these inspections can result in failure to obtainer.oartit(cefe_of_pscUpancv until the_work can be
inspected.
If the homeowner hires other trades to perform work (electrical, plumbing &gas)the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspections are made ./ -
1, Mark Pachuckl c /�''t a. understand the abolie.
(Home owner/resident's sign ure requestifig exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Dale 4/6119
Address of work localioni0 Bright Avenue
Northampton, MA 01060
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