42-044 (8) 661 WESTHAMPTON RD BP-2019-1264
GIs u: COMMONWEALTH OF MASSACHUSETTS
Map:elock:42-044 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catecorv:Building BUILDING PERMIT
Permit p BP-2019-1264
Proiect a JS-2019-001519
Est.Cost: $7500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO.
Const.Class: Contraetor: License:
Use Group; NIKOLAYGERASIMCHUK 063630
Lot Simian.ft.): 25047.00 Owner: O'BRIEN MICHAEL J&GAIL L
Zoning, Applicant NIKOLAY GERASIMCHUK
AT. 661 WESTHAMPTON RD
Applicant Address: Phone. Insurance.
322 FRANK SMITH RD WC
LONGMEADOWMA01106 ISSUED ON.511012019 0:00:00
TO PERFORM THE FOLLOWING WOR%ADD PARTITION WALLS
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 Occuoancv signature:
FeeTvpe: Date Paid: Amount:
Building 5/1020190:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File 6 BP-2019.1264
APPLICANT/CONTACT PERSON NIKOLAY GERASIMCHUK
ADDRESS/PHONE 322 FRANK SMITH RD LONGMEADOW
PROPERTY LOCATION 661 WESTHAMPTON RD
MAP 42 PARCEL 044 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FILLED
Fee Paid
Buildina Permit Filled out
Fee Paid
Tvoeof Construction: ADD PARTITION WALLS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 063630
3 sets of Pians/Plot Plan
THE FOL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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 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
IT- 11Z 5-10-Z0)4
Signature of Building Official Date
Now: 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 we 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 in Northam on RECEI to of Permit
..� - Building Depart ent 'tat Permit
212 Main Stre t Str"'Saptic Avai[abiliry
Room 100 NAY WaterNJe,,A 'iI billy
Northampton, MA 106 Q Set's of Sctural Plans
phone 4l&587-1240 Fax 13- 87-1272 Plovsit Plan
DBPT OF bUILDINC,IN PRAScify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE NE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 P/ro'osM Adtl'ress/'.
This section to be completed by office
66/ (� vy,//QM ,f.�A/ / Map�2 Lot Dy Unit
7( � �J 70 / f/ El.
Zane Overlay District
/�/Oc'}/Oo "// /"7 • lr/ '
Elm SL Oisbiot Ce District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name/Prinq p Current Mailing Address:
7/// ra S (�� r•r�'��j �r Telephone
Signature
2.2 Authorized Agent: r� /
Name(Prino Current Mri Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cast(Dollars)to be Official Use Only
completed� b nnit applicant
1. Building (a) Building Permit Fee
2. Electrical / (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) Vj
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Num r DateIssued
Signature: 5-16-W19
JJBuilding Commissioner/Inspector of Buildings Data
--
EMAIL ADDRESS (REQUIRED; EITHER OMEOWNER 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 io be filled m by
YAM Building Depamnmr
Lot Size
Frontage
Setbacks Front
Side L _ R:-_— Lo_ R:
Rear _.._
Building Height
Bldg.Square Footage
Open Space Footage
ILor mea minus Wit&paved
N of Parkin Spaces
Fill:
volume&Umber)
A. Has a Special Permit/Variance/Finding eyef been issued for/on the site?
NO O DONT KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Reg' ry of Deeds?
NO O DONT KNOW YES O
IF YES: enter Book Page and/or Document p
B. Does the site contain a brook, body of water or wetlands? NO er' 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
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 Q/
IF YES, describe size, type and location:
E. Will the construction acaNly disturb(Wearing,grading,ex tlon.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.
SECTION S DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) Q Rooftop IDOr Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding l01 Other[
Brief Description of Proposed® 6G o �,' //r J
Work: 9 Lfr*c
Alteration of existing bedroom—yes_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _Yes No
Plans Attached Roll -Sheet
ga. tf New house and or addition txistin housin colo fete the WIcnefin
a. Usembuilding '. One Family Two Family Other
b. Number of rooms in each family unit: 3 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 Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
In. Type of construction
i. Is construction within 100 R. 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. Sepbc Tank_ CitySewer_ 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 behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, as Owner/Authorized
Ag ereby declare the he statements and inform a foregoing application are true and accurate,to the best of my knowledge
and belief.
Sig'Sunder the/p/ai'�_ns and penalties of pe7/ury.
Q ti t:7«.� S� � H �(.c.ci�I�
Print Name
Signature of Owner/Agent Date
SECTION e-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Nam.of Lic.n a Holder
License Number
Address Ergirelion Date
Signature Telephone
S.Re isterod Homs Im rovamem C nrector: �J Not Applicable 13 S -H 5-Al, d Lcrf<:D,,:7C W ce
Comport,Na � Registration Number
�J /5!i9 x,873 4'3
Address /� Expiration Date
Telephone7n
SECTION 70-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L o-152.§25C(8))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit vdll resu8
in the denial of the issuanceof the bulldin it.
Signed Affidavit Attached VCs....... N.......
❑
City of Northampton
f Massachusetts
ra; 8 HNT 08 BUILDINGZn8P80TZONe �t
21212Hein txeet e ILaninipel building
NnrGhemp[en, Nx 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 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 of an addition to any pre-existing ownenoccupied building containing
at least one but not more than four dwelling units....a to structures which are adjacent to such residence or building"be
done by registered contractors.
Nate.If the homeowner has contracted with a corporation or LLC,that entity mustberegistered
Type of Work: r V C le
// Est./Cost:
Address of Work: Ig 6
01
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):
_ owner
occupied
not ownerccupied
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 RESPONSIBD.ITES 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 buildin t as �`''e owner:
S -i9 / e 1S;73�_ 3
Date�� Contra m ame 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 Signamm
_ City of Northampton
Massachusetts
�\ DEPMT OF E LDZNO INSPECTIONS 111\\\
.. 212 Main rthw on, Mci01l Building
NorChay,[on. !P 01060
Massachusetts Residential Building Code
Section I I O 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 i 10.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 1 I0.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[his permit.
City of Northampton
' Massachusetts
DEPAFPl'D11:NT 08 BUILDING IN$P&CTIONS
212 ILSn St eet •l4�ovcip&l eullai'y L�
Nerth�ten, b 01060 da
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 property 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 sAfeet name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Sin ure o d A cant 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 0211 4-2 01 7
www.massgov/dia
R'orkers'Compensation Insurance Affidavit:Builders/ContraMon/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leatibly
Name(Business/OrganizatioNlndividual/al): 14
Address: .B 6 .S' a f/ '/ 3 j;5 /
City/State/Zip: Lu e-4/ a eJ Phone#: ( S/32 7a 6- 42,2_k
Are you an employer'Cauca Ne appropriate boa:
Type of project(required):
I.CRH<�Impbycr with--g�a_employen(full reNorpur-mr.l' 7. ❑Newt etion
2.❑lam asale preprinoror pmmmhip mdhavem employees working fmmeui g, emodeling
my capacity.[No workers'wmp.arammae required]
01 m
aa homeowner riin6 all work myself.(No workeencomp Immerse mquine.l 9. ❑Demolition
4.❑1 as a homeowner rail will be harm,canummrs m cnMucl all work on my property. I will 10❑Building addition
sett dial ml conuacross either home workers'moµ,mussao msumn«m are sole ll.❑Electrical repairs or additions
prupnmon wbu no employees. 12.❑Plumbing repairs or additions
5.C]1 am a general conbvcmrmd 1 have hired Ne subcovnxmrs(tern on die ranched sheet. 11.�Roof repallS
These sub-conuve m
acmrs how rest have workers'comp.mormai rz.
6.❑We are a coryomtwa wast in oaten have examined their right ofexempuon per MGL a 14.❑Othef
152,§441,and we have on empbym.(No workmY comp.unumwe required.]
'
:Any apphram thm checks box g1 must also fill out the section below showing their workers'compensation policy information.
NumiLm who submit this of rlsyn instwi ing they are doing all work mW den hire ounide conbacmn must submit a new affidavit indicating such.
:forearm ors that check this box mus[attached an additional sheet showing the name of de Sub-cuntmetom wall sate wheeler or not dow entities have
emplovms. Ifde sub-cony corn have employes,they most provide their workerscomp.W Ilcy number.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information. ,,0 n/ Z�'— //
Insurance Company Name: 'FJ 5S- t!a r/{z 1Mq W-1/! r S LO.
Policy#or Self-ins.Lic.#:�/CC OSoI /'nal a//9AEzpimtion Dale: d'rL—
Job Site Address: < c/ 6CAYZZ a 'as./10W L�-'�C City/State/Zip:/�teles �..��eh
Attach a copy of the workers'compensation pot declaration page(showing the policy number and eta al on date).
Failure to secure coverage as required under MGL c. 152,§25A 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 verificatio
I do hereby cera6 on a ties of perjury that the information provided above is true and correct
Signature Date:
Phone# If 171 /^� C' 4.31
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 7.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
r
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 w"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or tmstee 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 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)name(s),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 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 To"Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space in the bottom
of the affidavit for you to fil I 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 pennit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"lob Site Address"the applicant should write"all locations in_(city or
town)."A copy of the affidavit thin 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 fume 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 fav 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
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