17A-210 (9) 116 NORTH MAPLE ST BP-2019-1336
GIS#: COMMONWEALTH OF MASSACHUSETTS
Moillock: 17A-210 CITY OF NORTHAMPTON
Lot,.00 1 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:Smir BUILDING PERMIT
Permit# BP-2019-1336
proieet# JS-2019-002156
Est.Cost $800.0
F o PERMISSIONIS HEREBY GRANTED TO:
const.Class: Contractor: License:
Use Grouo: Homeowner as Contractor
LotSize(so. ft): 24916.32 Owner: LUSARDISARAFJ
Zoning, URB000]/ Applicant: LUSARDI SARAH
AT: 116 NORTH MAPLE ST
ApplicantAddress: Phone: Insurance:
116 NORTH MAPLE ST (�40) X17-3887 0
FLORENCEMA01062 ISSUED 0N.•5/13Q079 0:00:00
TO PERFORM THE FOLLOWING WORK:RELOCATING BASEMENT STAIRS
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: 2,jly Insulation:
Final: Smoko: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occuoancv Signature:
FeeTvoe: Date Paid; Amounts
Building 5(23!20190:00:00 $65.00
212 Main Street,Phone(413)587.1240,Fax:(413)587.1272
Louis Hasbrouck—Building Commissioner
I
File#BP-2019-1336
APPLICANT/CONTACT PERSON LUSARDI SARAH
ADDRESSIPHONE 116 NORTH MAPLE ST FLORENCE (540)517-38870
PROPERTY LOCATION 116 NORTH MAPLE ST
MAP I7A PARCEL 210001 ZONE URB(1001/
THIS SECTION FOR OFFICIAL USE ONLY•
PERMIT APPLICATION CHECKLIST
CLOSED REQUIRED DATE
NTNG F T
Fee Paid
Building Filled
Fee Paid
Tvneof Construction, RELOCTINGABASEMISNT 5AIRS
New Construction
Non Structural interior renovations
Addition to Existing
Accessery Structum
Building Plans Included:
Owner/Statement or License
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 Project: Site Plan AND/OR Special Permit With Sita Plan
Major Project: Site Plan AND/OR Special Permit With Sim Plan
ZONING BOARD PERMIT REQUIRED UNDER:§
Finding Speeial 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 Sturm Water Management
Demolition Delay
zz5-z-3-2a9
Sigitliturre of Building Official Date
Nom: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.
r Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
41
Department use only
City of North mptc n S a of p mit.
i� Building Dep rime t Cu CuVE wanvay Permit
212 Main 4 treat MAY 2 2 201 6mir/Sep is Availability
ROOM 1 10 Wati rNVel Availability
} Northampton, I A Od cBuiloiNG Structural Plans
phone 413-587-1240 Nu" ^ ns
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Prooem Addren: This section to be completed by office
r'Apyt s� Map Lot ";"7/D Unit
T I orr—"—t if RA 01
D b Z Zone Overlay District
Een SL DYbkt CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZE AGENT
2.1 Owner of Record:
S PrP-A" 1 t kP-01 ) I b N . KU U
Name(Po/nt/�-r1I Current Mailing Ada
I/ / Telephone D SI } 3 y
Sig
2.2 Authorized Adam,
Name(Pant) Cuvent Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cast(Dollars)to be Official Use Only
completed by permitapplicant
1. Building (a) Building Perk Fee
2. Electrical (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Permlt Fee .(J
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) C3 0� Check Number as
This Section For Oficial Use Only
Building Permit Numb e . Date
Issued
Signature: 5-Z3 2014
Building Commissioner/Inspector of Buildings Date
Gil tjASlcl-d,( 10 ko+maLj • porn'
EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Sarah
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This wauon m be filld in by
Building Do mtmer r
Lot Size
Frontage
Setbacks Front
Side L R:._.. L:__. R:
Rear
Building Height
i
quare Footagepace Footageminus bull&'a
d I
q ofParking Spaces
Fill:
volume&Loatim
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES Q
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(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 DESCRIPTION OF PROPOSED WORK Icheck all applicable)
New House ❑ Addition ❑ FReplacerrrentWinclows Alterations) ❑ Roofingm 0
Accessory Bldg. ❑ Demolition ❑ igns 1171 Decks [p Siding[0] Other[p]
Brief Description of ro osed
Work: �e�pt�finm baSevnsy,4- S ir-s
Alteration of existing bedroom____Yes No Adding new bedroom_Yes _No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ga.H New house and or addition to existing housina. 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?
J. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of hearing? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 R.of weflands? Yes No. Is construction within 100 yr. floodplain_Yes_No
1. 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 behalf, in all matters relative to work authorized by this building permit application.
Sigrahre of Owner Date
YGt-41L 4t5a,ry as OwnerlAuthonzed
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 perjAupA
Q`Yvl,
Print Name
S Yo
Sig tur erlAgenl Date
SECTION S-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Eviration Date
Signature Telephone
8.Registered Home Improvement Contractor. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L a 152,s 25C(e))
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 Ves....... ❑ No...... ❑
City of Northampton
Massachusetts
\ 212R xn3 oe B*I nicO INSPECTIONS f,
212 lLin rtho • . io, 010 auiltli,g /S C�
Nostheq,Coo, as 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"reconstnrction, alteration,renovation,repair, modernization, conversion,
improvement,removal, demolition,or construction of an addition to any preextsting ownerbccupied 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 revistered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that enri&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 I42A.SUCH OWNERS ALSO ASSUME THE RESPONSIBDATES 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,II hereby property:
for a building permit as d wner of the above propy:
JXlt 1 5 l
*aa WLriEtibi
Date Owner Name and Signature
City of Northampton
S�
Massachusetts cl
Ii
DEPARTl2NT OF BUILDING INSPECTIONS
212 l in St—t • l nicipal Building \
Noithuq n, ! 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 fans 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
1 DEPA TRENT OF BUILDING INSPECTIONS
212 Hain Stcoat •Municipal Building
Ho.tnampt_' . 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:
114 N. .Mgple S+- loruue MA IN 6Z
(Please print house num rand street name)
Is to be disposed of at:
VOMN 12e ��rl tc� Q
(Please pirldt name and locobn of fac")
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Si na Permit Applicant or "��te
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 ofMassaehusetts
Department ofIndustrial Accidents
I Congress Street,Suite 100
Boston,MA 01114-1017
boww.mass gow'dia
Rorkers'Compensation Insurance Affidavit:Builders/Contrastors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Ann&mat InformaHoo Please Print LeObiv
Name(Business/OrganizahoMndividual):
Address:
City/State/Zip: Phone#:
Are you an employes!Oneida an,appnspAue host:
Type of project(required):
L❑I min a employer with employees(full anal parr-time)' 7. ❑New construction
2.❑I amasole ma,mot.r.,pm ooship and base no employees warking for me in g. ❑Remodeling
any ca,asny,[Nowoken eon,, Immense requi d.l 9. ❑Demolition
3.E]Ism a bomen.domg all work mywers
lf[No work 'comp.item ece required.]'
n.I l=a homwwner aM wdl h hiring cwtncmn w condom as wok on my wooeaty. I wdl 10❑Building addition
"Penotivilantidl cornecmoseimnbavewokent,compeosaiai meuuncemmeaok 11.❑Electrical repairs or additions
,munitions with no employes. 12.[]Plumbing repairs or additions
S{:l 1 o a senml contractor mW l have hired the submnnacmn listed on Ne attached sheet. 13.❑Roof repairs
These sulo
b-emitramars ve empbyees and have workers'conte.insurance.
6.❑we meacorpmalumand its officanhawexerasedtherright ofenempdonpe MGte 14.00ther
152,§l(q),and we have m mnplo ,INo workers'emnp.imumntt requaM.l
'Any aMixant that cheeks box#1 most also fill out the section below showing their woken'cmu,sm tion policy infonwtion.
'Homeownen who submit this offdavit indicating they are doing all work and than hire outside coatruMns must submit a new amduvit iMicaung such.
t('ontmeton out check thie box must aluche d an additional sheet showing the name of the s.b--aacmn and sole whether or nm Nose entities have
employees. If Ne sub conuecton have employees,they most provide Neu workers comp-Pdicy number
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
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,§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 verification.
' hereby hereby cert derthepains andpenaities ofperjury thatthe informationprovidedabove is due andcorrect
S:AlkreL/ Date, S�7-OII
Phone#: ITI0 7r Q{Ia --
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.Cityrrowo 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 slates 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 prbsemted 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)camels),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 retuned 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 tali 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 Once 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/icense 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 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 Departments 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
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116 NORTH MAPLE
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Florence, Massachusetts