36-109 (7) 239 BROOKSIDE CIR - BP-2019-1404
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:36- 109 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv: Door Replacement BUILDING PERMIT
Permit# BP-2019-1404
Proiect# JS-2019-002267
Est.Cost:$3800.00
Fee:$40.00 PERMISSIONIS HEREBY GRANTED TO.
Const,Class: Contractor. License.
Use Group: LOWES HOME CENTERS INC 103003
Lot Size(sa.R.): 24306.48 Owner: JILL M SNIADACH
zonine: Applicant: LOWES HOME CENTERS INC
AT.- 239 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
282 RUSSELL ST (413) 588-0270 WC
HADLEYMA01035 ISSUED ON.6/1312019 0:00:00
TO PERFORM THE FOLLOWING WORK:NEW ENTRY DOOR
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:
Drive%.v 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 Sienature:
FccTvoe: Date Paid: Amount:
Building 611320190:00:00 $40.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck-Building Commissioner
RECEIVED
City of N rtha ptoptN - 7 2019
Building epa m
212 M n S Bet
Roo 106Pt.oFeunniv,inxPEC`n
NOrthampt 'rrtw.tnemneo
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWE WNG
SECTION 1 -SITE INFORMATION 60_(� -(yore
taM COIrr,PINedOY alRee
1.1 Properly .Atltlress:
jAGENT SECTION 2-PROPERTY OWNERSHIP/AUTHORI7ED
I (l i' d6ch 773cl 8rojilc5idii, C; r
Name nt) `/I CunentMehl g tleren: '(n-z' !j �' 4
Agent
LtuwFS (r„ CAA we a��o rlPorav;u. qc 2gr( )
Name(PhaL� / mnra
1-)� -
S'gnalli e— Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cast(Dollars)to be Official Use Only
oom leted by Pennitapplicent
1. Bullding U0 (a)Buildinj 1 Peonh Fee
2. Electrical (b)Eallme ad Total Cost of
Consboction frem.6
3. Plumbing Building Permit 1" (v�1
4. Mechanical(HVAC)
I
5.Fire Protection
6. Total=(1 +2+3+4+5) (✓ Check Number
This Secaon For OMdal Use Only
Da e
Building Penna Num Issuetl:
Signature: IS- 7-2019
Buk"Commwwiwnnspeator of Buildings DaN
GK 9,15 T e P.F( R . M (ti( E @ w W QC7 - Ce ^\
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
����< -�
L �� :._._- . _. .. _._.._.. '-1 �
'U1�1 - '. �J;J i
r i,
I
Section 4. ZONING Alt IMannatbn M.t Be Completed.Perini[an Be Netledoue To Incomplete Iniormanpn
Existing ProposedRequired by Zoning
This column a be fillcd N by
Build."Dcpamnmx
Lot Size —� �
Frontage
Setbacks Front O Q
Side L:0 RD L:= R.-
Re.Rear O O
Building Height O O O
Bldg.Square Footage O O % O O
Open Space Footage %
(Lot era min.bldg&paved O Q
#of Parking Spaces
0 C O
Fill:
solime&Laetioo
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES
IF YES,date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES
IF YES: enter Book F J Page[__ and/or Document# J
B. Does the site contain a brook, body of Water or wetlands? N O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the onservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES Oto O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intro 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 i acre or is it part of a common plan
Mat 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 I Aftration(s) E3Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding[0] Other[[:q
Brief Description of Proposed f t�. We
, Ne "f n
Work:
Alteration of existing bedroom_Yes No Adding newbedroom Yes No
Attached Narrative Renovating unfinished bas ment Yes No
Plans Attached Roll -Sheet
and or addition to exlerlina housinct, eom wnNiWoIlow n
a. Use of building:One Family Two Family Other
It. Number of rooms in each family unit: Number of Bathrooms
c. Is mere a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
I. Method of heating? Fireplaces or Wo stoves Number of each
g. Energy Conservation Compliance. Masscheck Energ Compliance form attached?
h. Type of construction
I. Is construction within 100 ft.of wetlands? Yes No. Is construct' n 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_ CitySewer Private well City water E upply
SECTION 78-OWNER AUTHORIZATION•TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOO�RA`PKIES FOR BUILDING PERMIT
I, Jill f ADI I /�` 1 ,as Owner of the subject
property
he authorize -e,, .M6 LEtiiE2S
to on`(rhy be all(patters lab'"to work auMorized by this building permit app ication.
15
Sig hxeot Dab J-
I, 040,1( 4 (AJ I & ,as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing applicado i are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
(> ( os,
RIM Name
Signature of Data
r
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holden 0\61,0 6 — (o�7ou7
License Number
2L (' WI(WIR AD -S - zo
Address E)0lratlen Date
Sijfia um Telephone
Not Applicable ❑
L �S C2(/US tCIT6,rst
Company Name Registration Number
Joao co-Vel At, kti fXtwr v.11e Nc 4-sff to - I -r_ f
Add re /r((( Expiration Data
Telephone"il�— 131
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.1 2.§25C(S))
Workers Compensation Insurance affidavit must be completed and submitted with th application.Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes...... No...... ❑
The Commonwealth ofMassaehuseas
Department of Industrial Accidents
Office of Investigations
600 Washington Street
t/ Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name(Business/Organization/Individual): Burgers Home Improvement
Address: 22 Granville Rd
City/State/Zip: Southwick, MA 01077 Phone #: 413-222-6324
Are ou an employer?Check the appropriate box: Type of project(required):
I. 1 am a employer with , 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y P Y• 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] r c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#I must also rill ora the section below showing their workers compensation policy information.
'Homeowners whu submit this affidavit indicating they are doing all work and then him outside contractors must submit a neo affidavit indicating such.
1('ontmetors that check this box must atmched an additional sheet showing the name of the sub-contractors and state whether or not those entities have
emplo,ees. Ifthe sub-amtractors have employees.they must provide their workerscamv policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the puller and job.site
information.
Insurance Company Name: Acadia Insurance Co
Policy #or Self-ins. Li,.#: MAARP300120 Expiration Date:
10/6/2019 f
Job Site Address: 2311 6r,- (65 ea 1 C.t City/State/Zip:PoArc e, ' t4 0[ 66 -L
-'
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ger nder t/r pains and penalties ofperjurr that the information provided above is true and correct.
Signature: / , &2�-- Date: —�
Phone#: 413-222-6324
Official use only. Do not write in this area,to be completed by city or town ojrciaL
City or Town: Permit/License#
Issuing Authority(circle one):
L Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
J
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 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)morels),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 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
Please do not hesitate to give us a call.
The Department's address,telephone and laa number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax# 617-727-7749
www.mass.gov/dia
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste 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.
Address of the work: 7 q V �K51 DB C t
The debris will be transported by: M 146V Ri"tx+idei
The debris will be received by: Q1 lle4 (-PcLg-I rte.
Building permit number:
Name of Permit Applicant ( SFS A(-K
Date Signature of Permit Applicant