23A-188 (2) 136 SOUTH MAIN ST BP-2019-1160
GIs#: COMMONWEALTH OF MASSACHUSETTS
MV.,Block:23A- 188 CITY OF NORTHAMPTON
L,r_-001_ PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:ADDITION BUILDING PERMIT
permit# BP-2019-1160
Pro ject# JS-2019-001881
Est.Cost:$20290.00
Fee:$131.00 PERMISSION IS HEREBY GRANTED TO.
Const.Cies: Contractor: License:
Use Group: AARON PUNSKA 105542
Lot Size(sc.It.): 40946.40 Owner., COOPER RICHARD E&CATHERINE M
Zoning:URB0001/ Applicant: AARON PUNSKA
AT. 136 SOUTH MAIN ST
Appikant Address: Phone: Insurance:
11 I KINGS HIGHWAY (413)626-6033 0
WESTHAMPTONMA01027 ISSUED ON.417612019 0:00:00
TO PERFORM THE FOLLOWING WORK:REAR PORCH REMODEL
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 Dena r[ment Flreplaca/Chimney:
Rough: Oil: Insulation:
Finals 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:
FeeTyoe: Date Paid: Amount:
Building 426/20190:00:00 $131.00
212 Main Street,Phone(413)589.1240,Fax: (413)589.1272
Louis Hasbrouck-Building Commissioner
0
File 0 BP-2019.1160
p
APPLICANT/CONTACT PERSON AARON PUNSKA PI'-'
ADDRESS/PHONE III KINGS HIGHWAY WESTHAMPTON (413)626-60330
PROPERTY LOCATION 136 SOUTH MAIN ST
MAP23APARCEL1gg 001 ZONE URBIIM
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
EN REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid I
TypeofConstruction; REAR PORCH REMO
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 105542
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
_✓✓Approved_Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Projm: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan 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
ILq-Z6-ZDI'
Sigilatilie 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 In those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
—El VED
Department use only
City of Northam IT Status of emii:
Building Departm nt APA 19 Mcu nv y Permit
212 Main Stree Sewer/S tic A ilabdity
Room 100 vai bniry
� Northampton, MA 0 06&EN0'ATHAM°:o 7Nd` cal Placa
phone 413-587-1240 Fax 4 - Plot/Sue,Plans
Other Spedry
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Pronarty Addraw This section to be completed by office
13fo S.wtulnSpfi Map .7514 Lot t F/ unit
f(of evki Mtl Zone Overlay District
Elm SL District CO District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Ric 14u. Of (a ore-( 13b SS >L f=/or_e
Name rinp (+
CTWMIr_TI L 3 _ 0q!5—q
Signedxe
2.2 Authorized Agent: /
AA,, III k nyS Wr z Wes f ryAvtD
Name(Print)
Current MailingAdd ski s:�^�
(� N/3 gab - 64033
Signalure Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted by permit applicant
1. Building 41 2,D .a-D O (a)Building Permit Fee
1
2. Electrical (b)Estimated Total Cost of
Construction from fi
3. Plumbing Building PermN I"
4. Mechanical(HVAC)
5. Fire Protechon `
6. Total=(1 +2+3+4+5) a- Check Number
This Section For Official Ursa Only
Building an Num r. Dare
Issued:
Signature:
Building CommissionerAnspeclor of Buildings Dale
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING all Inionna[bn Must Be Completed,Permit Can&Ranted Due To Incomplete Infortnatbn
Existing Proposed Required by Zoning
Ibis column w be find in by
Building Dcpanmem
Lot Size
Frontage
Setbacks Front N�.
Side L: R: L �- R:
Rear -----
Building Height
Bldg.Square Footage %
Open Spam Footage
dm arm minus bldg&paved
q
ofParking Spaces
Fill:
volw,c&Lacnrion
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DON'T KNOW Q YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW O YES O
IF YES: enter Book Page and/or Document M
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. Wil 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 Storm Water Management Permit from the DPW is required.
SECTION S DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs 101 (` Decks [O Siding[0] Other(O]
Brief Description of Proposed
WorkR2Ar {Oicti r(FYIOCLe I See
fl �
Alteration of existing bedroom_Yes No Adding new bedroom Vas No
Attached Nartative Renovating unfinished basement Yes '_No
Plans Attached Roll -Sheet
sa. N New house and or addition to existina housina. complete the following.
a. Use of building. One Family x Two Family Other
b. Number of rooms in each(amity unit Number of Bathrooms
c. Is there a garage attached?
J. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
In. Type of construction
i. Is construction within 1 D 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 Pnvate well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, RlL�r10.((/� Coo) e as Owner of the subject
property
hereby authorize 7T A /A1 �`^^S Kof
to act on my bah ( in all matters relative to work authorized by this building pent application.
- J �° AX4--
Signature of Omer Date
{�
I, frCJ4 O✓t `�A S�°t .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.
Signed under the pains and penalties of perjury.
h6yon PivoSkg
Print Name
Signature of Owner/Agem Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction/^Superyisor: Not AApplicablle 0
Name of License Holder. &,,C t� M (✓I TIiNC 10554t2
Ucenm Number
` / f
�11 Ff H.91rr.iA✓ l✓Pliffe ne)l ,nA- 0102� 10/22 11
Address F�ira— an�Dal`
Yi 26 & 3
Signature Telephone
9.Registered Homs Improvement Contractor: Not Applicable ❑
40, V..nsK-a 19--2 7Y 2
Company Name R i tration Number
I!! IG,tc liit�lww . wc5} �wwls �eh MA Dza
Address F Expiration Date
Telephone N/3 626
SECTION 10•WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L a 13].S 28C(8�)
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
DEPMMNT OF BUILDING INSPECTIONS
212 !fain stat • mnicipal Building
Nezthu ton, I 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 most 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 pre-existing owner-occupied building containing
at least one but not more than four dwelling unifs....or to structures which are adjacent to such residence or building'be
done by registered contractors.
Note.ljthe 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$1,000.00
_Owner obtaining own permit(explain):
_Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
W'l$ug flr4Q1 -PV05S 11 2I YZ
Date Contractor Name 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
Massachusetts
r G
Z
�` DEPARTMENT OF BUILDING INSPECTIONS
212 main Street • Municipal Building aC>'
Northanryton, M 01060 y l
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 l 10.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
�.
DE7
212A An Street OF 8&MnD cS SNSuildT ONS 2
212 Mein h •Municipal BuilAing
xor[havpton, MA 01060 e'✓y� ��
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:
1365. ";k
(Please print house number and street name)
Is to be disposed of at: p L
C(Jeq RQC4CI;Al ril 1�1tLWrn�ta"t
(Pleasl print name and to ation of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Permit Applicant 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.
,yam
The Commonwealth of Massachusetts
Department of IndustriallAccidents
I Congress Street,Suite 100
Boston,MA 02114-20177
wwmmassgov/dia
Rorken'Compensation Insurance Affidavit:Builders/Contranors/Electricians/Plumben.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information /� p Please Print Levibly
Name(Business/OrgmizatioNlndividual): AgloN Rm5rn
Address: (I (C; 4I way q
City/State/zip: l.IfS' AA- 1 6+ d114 Ob'Z phoneM H13 (oZ L 6037
Are you as pop[ayer?clack me approprieve two Type of project(required):
L❑Iwacmvlorer wiN employees(full avd/or ptt-time/' 7. ❑New construction
2.�lamasole pmpdemr or pamsership mdhavero employees working forma. 8. ❑Remodeling
anY capacity.IN.wodkms'comnurarcc
p.o tcquimd.]
1.❑Iran ahomcowmrdoivg allwmk myself lNr eschars wmp_wmmKe requued.]' 9. ❑Demolition
4.❑1 vo a hommwner and will be hen,co urierrs mMuwork cme all k on my pmRno. 1 will 10❑Building addition
eawve one all conaacmrs Collier have wotken'compensation iiuumnce or are sole 11.❑Electrical repairs or additions
proprinors wiN no employee:. 12.❑Plumbing repairs or additions
5{:]1 am a gull conanctor and I have hind Ne sul commnon listed on the auached shunt. 13❑Roof repairs
Vne,csubconuvemrs have employees and Fay.esu,kers comp.w—c: [/1 /p is h
d❑We area corpomnon and in officers have exemised Nein nils of exemption per MGLe 14.EoOther yVftk/�WtaO'a-I
152,$It4),aM we have no®ployws INo workers comp.hputmce raiuwnlJ
'Anyappliwn[thatchecks box#ImuaandiMtvut Ne no!do Ml ow working Neu Ionrkenindec anon postsubf tiov.
Hnmmwners who submit Nis amdavlt indiwting Nen are doing all work and Neo hire ounidc.... ors most submit a pew oon in,,, indiwting such.
k'wmacturs Nat<Feck Nis hoc muvt attached w addikional Shen working Ne tome ofdn sub-conuactors and wmm wheNer m not Ihott wtities ha,
empNyees. lfNe subaronwcmrs have emplryays.Ney must provide Neu workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy andlob sire
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,Q25A 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.
tt�� f do hereby certify under tthhhezpaJins�/fd�pen�d,Nes of perjury that the information provid/eJd above is hue and correct
y�W¢nature: ` // / Date' -I/ 18
119
Phone#: LlI 210 bc.3�
Oficial use only. Do not write in this area,to be completed by city or town ofrwial.
City or Town: PermitfLicense#
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#:
e
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,y25C(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 of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes thin apply to your situation and,if
necessary,supply sub-contractors)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,arc 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 m the bottom
of the affidavit for you to fill out in the event the Office of Investigations has in 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/licenw 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
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employer 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 m"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 he 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 of this chapter have been presented to the contracting authonty."
Applicants
Please fill out the workers'cumpensmion affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply your insurance company's time,address and phone number along with a certificate 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 in 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 miff 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). 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
mus[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
I Congress Street
Boston, MA 02114-2017
Tel.#617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
www.mass.gov/dia
F.Revised 02-2345
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