23D-045 (4) 119 RIVERSIDE DR BP-2019-1412
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23D-045 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2019-1412
Protect# JS-2019-002265
Est Cost: $5388.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License.
Use croup: Homeowner as Contractor_
Lot Size(sa.fl.): 12806.64 Owner: GATRALL JEFFREY
Zoning: URB(100/ Applicant. GATRALL JEFFREY
AT. 119 RIVERSIDE DR
ApplieantAddress: Phone: Insurance:
119 RIVERSIDE DR
NORTHAMPTONMA01062 ISSUED ON.611712019 0.00:00
TO PERFORM THE FOLLOWING WORK:CONVERT EXISTING MUDROOM/PANTRY INTO
LAUNDRY ROOM/PANTRY
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:
Cas: Fire Deyetrtmen[ 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 6/1720190:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File q BP-2019-1412
APPLICANT/CONTACT PERSON GATRALL JEFFREY
ADDRESS/PHONE 119 RIVERSIDE DR NORTHAMPTON
PROPERTY LOCATION 119 RIVERSIDE DR
MAP 23D PARCEL 045 001 ZONE URB(IOO)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid OC_OLD
Building Permit Filled out
Fee Paid
TvoeofConstmclion: CONVERT EXISTING MUDROOM/PANTRY INTO LAUNDRY ROOM/PANTRY
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plat Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION PRESENTED:
pproved_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
G-12 -2019
Signature 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.
Department use only
City of Northampton Status of Permit
..�•` Building Department Cum CutfDnveway Permit
) ,{ �Y 212 Main Street Sewer/Septic Availability
IQ1 Room 100 Water/Well Availability
` Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 41 ^C o s
APPLICATION TO CONSTRUCT,ALTER,REPA R,R NOVATEE ORR DEMOLISH ONI OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 ProoeM Address DEPT OF BmIDIN.INS on o be completed by office
NMAMPTON.MA GiM
111) `21V61q.SJDEDRIIAE Map Let Unit
�'ORENc Ef MA olo62 Zone Overlay District
Elm St.District CB Distdct
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Osmer of Record: DAY ID TErFpE'( GArptALV
CORY Ir LLEN GATRALL 119 RtVER5lpfo DRIVE
Name(PrirR) Current Mailing Add
=LdRENG 'MA
01062 1O62
TebPho ^3_ 2 3— 7
Signature <
2.2 Authorized Agent:
Name(Print) Current Wiling Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building A*$ 342 ,5a (a)Building Permit Fee
2. Electrical1 1®Q ®O (b)Estimated Total Cost of
/ Construction from 6
3. Plumbing 945. O® Building Permit Fee 1' ,^,
Jus-.4. Mechanical(HVAC) / � cU
5.Fire Protection
6, Total=(1 +2+3+4+5) Jr' Check Number
hla Section For Official Use Only
Building Permit Number Date
Issued:
Signature: 12 -W19
Building Commissionerlinspeclor of Buildings DW,
je�fV-e - !yktrallI @ 9MCI 1' I . com
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Stolon 4. ZONING Nt Infarmal Most Be Competed. Permit Can Be Denied one To Incampene Information
Existing Proposed Required by Zoning
This cowmn m Iz fillcd in by
Buddmg Dc sant
Lot Size
Frontage
Setbacks Front
Side U - R: 1,: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(int asu minus bldg&l
hn
#of'Parking Spaces
Fill:
(wIua &lucadanl
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW O 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#
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW O YES 0
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
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 Alterations) ❑ Roofing ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [0I Decks [0 Siding[DI Other(�
BnefDescriptonofProppsad CONVEP-5109 OF EXISTIIhtG MUD ROOM PAkTPY INTO
Work: j-AGNDRYROOM / PANTRY
Alteration of existing bedroom_Yes �)<No Adding new bedroom Yes '>e_No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Be.If New house and or addition to existina housing, complete the following:
a. Usecfbuilding: 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 stades?
f. Method of heading? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 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.
1, 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
PAN
I, ` AN D TCr FR5—'Y Cr- TALL , as Owner of the subject
property
hereby authodze SONA-Ttt N R�tMANt`I
to acta my behalf,in ma relative to work author ed by this building permit application.
TwNC 10 Zo/
Sign tum of Owner Date
1 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.
Prim Name
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holds
License Number
Add.. Expiration Date
signature Telephone
9,Registered Home Improvement Contractor: Not Applicable ❑
Company No, Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L C.152,$2SC(6))
Workers Compensation Inwrance affidavit must be completed and submitted with this application. Failure to provide this alfidavd vdll rew8
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
City of Northampton
/// MassachusettsDIW
212 Min
OF B. M i cG al BuilTIONS
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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 owner-occupied 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 with a corporation or LLC that entity must be registered
c:omvEp.Slp41 oro VA5TlN6 MUD9_a0M/PAMA1Py
Type of Work:r,h= LAuml>(a`fP ANT2`) Est.Cost: t'iltr) 357.6
Address of Work: I 1 9 R(V6P5(UE D4a.{VTE �LOQF,)`1G� l ry y7 of Q 62—
Date
2Date of Permit Application: SV�,)= (� t 7-019
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:
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:
DAV \D JEFFRZ ( GATRALL ioviiw g {.
Date Owner Name and Signature
r
City of Northampton
/ - Massachusetts
! �c
D212 R in S O.BDIL i.. INSPECTIONS
212 Main Sin o Municipal xvilCing
xaztnampton, [A 01060 �a
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 1 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 110.85, 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
r� s,
Massachusetts
j t
i` DEPARTMENT OF BMLDLNG INSPECTIONS
212 Main Street *Municipal Building 50': OCT
1 Nornanpton, !D. 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:
I l poigep,51DS 'p�IV �I G(z NC MR at a62
(Please nt house number and street name)
Is to be disposed of at:
V4 RE C`�6 L-1C4 �t„� 5 pANSFER t=/3t 1-I T Y
23 + E:&5TffXMPWa / RQ&,b I�oPHAMPTO�J 0I060
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
- , JUNE- /0
i
Signature of P pp r Owne 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
J, Department of Industrial Accidents
I Congress Street,Suite 100
7
Boston,MA 02114-1017
www.massgov/dfa
Workers'Compensation Insurance Affidavit:Budden/Con&acton/Electricians/Plumben.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant but.rmano. a�J l ���—y��y �r���Pl�ease Print Leeibly
Nalne(B temeavOrgaactatioNlndividual): P"T p �1 EFfp-e ( G14rTPA . L—
Address:te9 (�ilV�Sf0e DP4VE-r P�-opz r—EI, MA 010.��/
City/State/Zip: Phone#: 323 - 4Z3 - 46 / t
Are You an employer?Check the mprnpdate boa:
Type at project(required):
I.❑l an a employer with employao(full it/.,part-time)' 7. ❑New construction
2.❑1 amasok P.M.or pummanip and lave no employees working fm nn in 8. Remodeling
any esneiN.[No workers'camp.mourn ee required.1
d.❑1 w is homeowner doln all work myself No wo lams'cam d. 9. ❑Demolition
6 Y I P.irnsumvcc requirt ]'
001 w is lnmeowner anal will be borons canuamars to conduct all work w my Pnpntr� I will 10❑Building addition
�atnaum that an mnaamomeitber have woronss mmprnsuion thmmnr<mare sok II.❑Electrical repairs or additions
pmpdeaam with an empk,yees. 12.[]Plumbing repairs or additions
5❑1 mars lateral-.and I have hhN the sub—e..looms on the mooched ahem. 13.�Roof repairs
These subtioaa
nours have emna
ploymes and have wos'comp.insm osee
b.❑We area coma.and in oRcers have exeeised their right of exemption per MGL c. 14.�Glhtt
152,I I(4),std we have no employees.IN.warke s comp.anu ur ce required.)
'Any applicmt that checkox s b #1 must also fill out the section below showing their workers'compemation policy information.
t Homeowners who submit this a%davit indicating tiny me doing all work and thea hire oumide emomm s must submit a new affidavit indicating such.
k'envacmrs Nat check this box must amched an additional sheet showing the reme of rembemrrow sand smm whether or not thou entities have
employes'-s. If Ne sub-cmuacmrs have employees,Ney muse provide Neu workers'comp.polity number.
1 am an employer that is providing worken'compensation insurance far my employees Below is Me policy andjob site
information
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Dare:
Job Site Address: City/slate'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$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.
/do hereby car the ainndties o ,jury th the information provided above is true and correct.
5ianature: Date: JUNe- /D/ 22-019
Phone#:
ficial 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?awn 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,anemployee 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
ofthe 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-contmetor(s)mantels),addresses)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/licems,number which will be used as a reference number. In addition,an applicant
that must submit multiple penniulicense 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
t Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-NIASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia