24D-017 (2) 219 PROSPECT ST BP-2019-1390
GIs N: COMMONWEALTH OF MASSACHUSETTS
M=Block:24D-017 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv: Porch Repair BUILDING PERMIT
Pemtit N BP-2019-1390
Proiect4 JS-2019-002232
Est.Cost:$4976.00
Fee,$65M PERMISSION IS HEREBY GRANTED TO:
const.Class: Contractor: License:
Use Group: RICHARD T WEST 086947
Lot Size(sa.ft.): 2090.88 Owner: SENECAL ERNEST&BETH A
Zoning: URB(100)/ Applicant. RICHARD T WEST
AT. 219 PROSPECT ST
Applicant Address: Phone: Insurance.
10 BARSTOW LN (413)584-8528 SOLE PROPRIETOR
HADLEYMA01035 ISSUED ON:6/612019 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE PORCH FLOORING WITH
COMPOSITE FLOORING, REPAIR FRAMING AS NEEDED
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 Occupancy Signature:
FeeType: Date Paid: Amount:
Building 6/620190:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck-Building Commissioner
File P BP-2019.1390
APPLICANT/CONTACT PERSON RICHARD T WEST
ADDRESS/PHONE 10 BARSTOW LN HADLEY (413)584-8528
PROPERTY LOCATION 219 PROSPECT ST
MAP 24D PARCEL 017 001 ZONE URB(100
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tvoeof Constructiow REPLACE PORCH FLOORING WITH COMPOSITE FLOORING-REPAIR FRAMING
AS NEEDED
New Construction
Non Structural interior renovations
Addition to Ezistine
Accessory Structure
Building Plans Included:
Owner/Statement or License 086947
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved_Additional permits required(sce 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 Sturm Water Management
Demolition Delay
�r
L- ZO)9
Sigafinx,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 to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning& Development for more information.
r
Department use only
City of Northampton Status of Permit
Building Department Curb CWDnveway Permit
j212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
"a Othe S
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEM ISH ON ELIIING
SECTION 1.SITE INFORMATION y0— 6/7 JUN - 2019
1.1 Property Address: Is s 'on to be completed by officj
9 pEPT OF aU1LOMGINSPECTONS
dl r 4 ecl ,f.} Map U it
N,'�11G rwff�d H� jWA Zone Overlay District
0101600
Elm St District CS District
SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
r
A, -1-A 1--7. Seneca �/ vc� ��iee�
Name(PnM) Current Melling Address:
vis- S-,f
- arse
`ez Q. Telephone
Signature
2.2 Authorized Aeertt:
Name( t) Current Mailing AddressSIli :
nature Telephone
SECTION 3.ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed bv permit applicant
1. Building SO (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Permit Fee 11
4. Mechanical(HVAC) L95-00
5. Fire Protection
S. Total=(1 +2-3+4.5) Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: G- L' Z�19
Building Commissionemrlspector of Buildings Dale
Yt-tcl\ard T 32� @ c'\w+ter. r
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 filed in by
Building Dcparrmem
lot Size
F!2nmgc
5 backs Front
Side R: L R
Rear
Building Height
Bldg.Square Footage %
Open Space Footage
(Lot ares minus Bldg d paved
mkni
p of Parking Spaces
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW '2" YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry 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 �, 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
IF YES, describe size, type and location:
E. Wit the construction activity disturb(clearing,grading,excevabon,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 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows At innitionis) !' Reefing Q
Or Doors O ki
Accessory Bldg. ❑ DemolRlOn ❑ New Signs [0) Decks [O Siding[OI Other[O]
Brief Descrjpion of Prop osetl
Work.
Alteration of existing bedroom_Yes No Adding new bedroom Yes 9t, No
Attached Narrative Renovating unfinished basement _Yes _,!S_No
Plans Attached Roll -Sheet
Be.If New house and or addition to existina housing, complete the following
a. Use of building: One Family A_ Two Family Other
b. Number of rooms in each family u it Number of Bathrooms
c. Is there a garage attachetl? !J(
d. Proposed Square footage of new construction.wi Dimensions
e. Number of stones?
I. Method of heating? 40 Fireplaces or Woodstoves Number of each
g. Energy Conservation appliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100(L of wetlands?_Yes2/No. Is construction within 100 yr. floodplain_Yes No
j. Depth of basement or cellar floor below finished grade /Y
k. Will building conform to the Building and Zoning regulations? A _Yes_No.
I. Septic Tank City Sewer A Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
X1, ��Q as Owner of the subject
property
hereby authorize 'eJi.�
M act on my behalf, in all ma m relative to work authorized by this building permit application.
A.,& 0( 2L 4 2,/:2
Sig gur/e of Owner yy/OI Dal
I, ✓7.d� O �la �4� as Owner/Authorized
Agen hereby declare that t e state ents and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the
the pains�land penalties of perjury.
Print Name D
Signature pf OvmerlAgeM �Date �
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su r: Not
Applicable
/13 (/
Name of License Holder l/
/ License N mD r
/O
Addrea F pir Ian ate
R
Signature T-le0hone I/
9.Realowered Howne Im roveme ; rector. Not Applicable ❑
n Name }/ Registration Number
Address u EipofitionVale
Telephone /.3.549
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.I S 28C(e))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this afidavit will resuk
in the denial of the issuance of the building permit
Signed Affidavk Attached Yes....... ❑ No...... ❑
r City of Northampton
.rJ Massachusetts
a
IaR.1 Min S OF BUZLDZIPG ZnaB.ilZniS
212 Min etrwt • luras 01l Building \'
anzctwpton, 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. Prim to
perforating 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 ownerbccupied building containing
at least one but not more than low dwelling units....or to structures which are adjacent to such residence or building'be
done by registered contractors.
Note.If the homeowner has contracted wilh a corporation or LLC,that entity mast 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 ownff o cupied
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.
at 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
Massach.setts
DWMTI@IT OF BUILDING INSPECTIONS
212 Bain 9trwt • Mnicipal a ild W
xorthre n, 6 01060 Ver
Massachusetts Residential Building Code
Section I IO.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 IO.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
s � f
Massachusetts !'i
I MTIffiiY or RMWZW ZNSFz=CNS =,
212 r in BtrB t 0I ci"l Building
aorNB ton, r 01060
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:
ary' hs�
(Please pont house n ber and street name)
Is to be disposed of at: J/
(Please not name lad oca ' of facility)-
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
�t"� /�-
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.
The Commonwealth of Massachusetts
Department of industrial Accidents
I Congress Street Suite
Basion,MA 02114-2017
www.massgov/dia
W orken'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PER.NITTINC AUTHORITY.
Applicant Information Please Print Legibly
Name IBusiness'OrgmizMioNlndividua0: r
Address: ,k
City/State/Zip: 44CZ Phone#,
Are you an emplayerr cheek the Ontario.him: Type otprojeet(required):
113Iamaemployttwhh employees(fn11 and/or part-time)• 7. ❑New construction
z.�I am a rule pmprietoror permnshipatMlave no mvPloyem working forme th S, ❑Remodeling
any capacity.[No workers'comp.insurance n,.d.]
)❑Iamahommwner doing all work myxlf[No workers'eass,iawrowea resistant] 9. Demolition
4.❑I am a homnwncr and will he handsy preperty. I will 10[]Building addition
ouacmn m tmad�ct all work m
aware,out all eonaxmn eitheluve wwkcrs'«mpea tion immmev«mare mk 11.❑Electrical repairs or additions
mo'caos withno employees. 12.E]Plumbing repairs or additions
5,[:]1ams general convector and 1 have heart the soh-«nuacmrs listed on the attached sheet. 13.�Roof repairs
These subnvectors
-cohave employees nM have workess'comp.iman
arce
6❑We ve a corporation and in aaicm have eumsed Wevright ofexemption par MGL c. 14.❑Other
152,11III.aad we leve nn emplayas.(No workers'comp.uaannce re,wad.j
'Any applicant that checks hod,el must also fill out the section below stowing their workers compensation policy infomution.
Bommwnem who submit this alTalovit indicating they are doing all work mW then hireeanide convectors must sands".new aeideVo iadicrox such.
:Contractors shot check this hox most attached an additional sheet showing the name of the rah-coatracmrs and rule whether or not those entities have
employees_ Ifthe sub<eafir m have employs.they mon provide their workern'com,policy number.
/am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name:
Policy N or Self-ins.Lic.N: 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,p25A is a criminal violation punishable by a fine up to 51,500.00
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 certify under the pains and penalties of perjury that the information provided above is true and correct
Siimatom 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 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 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)camels),address(es)and phone number(s)along with their certificatels)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. Alan 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.
Planar 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 perm ulicense 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 furore 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
I 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