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28-004 (4) 396 SYLVESTER RD BP-2019-1457 GIS a: COMMONWEALTH OF MASSACHUSETTS Mau,131 ck:28-004 CITY OF NORTHAMPTON Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Catcgorv�window replaced BUILDING PERMIT Permit# BP-2019-1457 Project# JS-2019-002365 Est.Cost: 8500.00 Fee S40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License. Use Group: WILLIAM FULLER 111440 Lot size(sa. fol 22064.92 Owner: HURLBURT JOSEPH Zoning: Applicant: WILLIAM FULLER AT. 396 SYLVESTER RD Applicant Address: Phone: Insurance: 26 MAPLE ST (413)345-0864 SOLE PROPRIETOR SOUTHAMPTONMA01073 ISSUED ON.6121/1019 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL 1 REPLACEMENT WINDOW 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 N 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 OccuoancY signature: FeeTVpe: Date Paid: Amount: Building 6/21/20190:00:00 540.00 212 Main Strcet,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner �v�NrJ0� Department use only City of Nort :am El CEI VE Permit / Building De art ro C Driveway Permit 212 Main Stre t r/ ptic Availability Room 100 2 0 2019 ter ell AvailabilNorthampton MA 1 7 o Se of Structural Plans phone 413-587-1240 Fa�C 72 P veil Plans EFT OF WIIDINC INSPECTI er etiy NORTHAMF APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOL SH A ON/E�OR TWO FAMILY DWELLING pp SECTION I-SITE INFORMATION Q� 9- /--4 1.1 Property Address:�,� �,,/ This section to be completed ��to office 06 S�/!K/��r 161 Map Lot -Unit Zone Owrlay District Elm at District CS District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: Name(Pard) , / ' Current Mailing Address' Telephone Signature 2.2 Authorized Anent: 7oS �//� b��icn� 34� s✓/r er�Tt ,Qd ^u /vo , NameName(� Cu Mallin ess: Ya�T .5115 f/—6766 Sign re Telephone TION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only wm leted by permitapplicant 1. Building j p6, (a) Building Permit Fee lv�+ 2. Electrical (b) Estimated Total Cost of Construction from 8 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number b This Section For Official Use Only Building Permit Nlmben Date Issued: Signature: Building Commissloner/Inspector of Buildings r� Date V 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 c.IBuan m be flld in by Budding DeFamnrni Lot Size Frontage Setbacks Front --" Side L:- R:—_. Lo.__"_ R:_....."_ Rear _. '_........_. Building Height - Bldg.Square Footage Open Space Footage dm vra mina,Wig&pavd #of Puking Spaces Fill: volume&Lacalionl A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O .,...DONT Kf OW O YES O 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. NAZI 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 Sion Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK Icheck all applicable) New House ❑ Addition ❑ FReplacement.Windows Alterations) O RoofingrsAccessory Bldg. ❑ Demolition ❑ igns [01 Decks lM Siding(0] Other lfDl Brief Desadption of Proposed Work: ZYr cF�Lr »sr� Alteration of existing bedroom_Yes_No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement _Yes No Plans Attached Roll -Sheet Ga.If New horse and or addition to existing housi complete the followina: 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? d. Proposed Square footage of new cimstwetion. Dimensions e. Number of stores? f. Method of heating? 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 I. 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 Cry water Supply SECTION 7a-OWNER AUTHORVATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, lT0 IL�,IxAI�� as Owner of the subject prop hereby authorize .\> a FILA, SOnS ferc�f- to a on my behal in matters relative to work authorized by this building permit application. AVatdFe La/2^%9 of oWher q Date /1 I, h) to 1�r 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. d ! r Hint Name - 1J / a Signature of OenerlAgent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable Name of License Holder: W11 .ow. A 1 ) fyyD Ucense Number Z L. M Cpl„ Sa rje 1rb.y,o/d. MA . -Je'13 11 . P7 -zczo Address \� Etpkaaon Date Signature Telephone 9 Reolstered Home Improvement Contractor: Not Applicable ❑ W;I1:o — P r—/L.� !9!134 Company Name Registration Number '2 L. ✓'Torts S+ :!;- mA -173 4/2✓Zioe o Add.. Expiration Date Telephonegl 31 ;y'-'au,y SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c,152,f 25C(8)) 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 ofthe building permit. Signed Affidavit Attached Yes.......bo No...... ❑ City of Northampton Massachusetts 4� � a a 212 Hain S 08 B. LDINGnunici al Building 212 Hain Btraat Munielpal Building .C1 NertLaapten, Mx 01060 �e 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 most be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction, alteration,renovation,repair, modemimfion, conversion, improvement,removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note.If the homeowner hss contracted with a corporation or LLC,that entity must t be registered Type of Work:�?lw, / W.,^ioo,.J ry Est.Cost: � 40� Address of Work: 391, 514� Kgr- S-J Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): Sob under S 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 RESPONSIBH.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 building permit as the agent of the owner: %-.1-7c j/4 %,Y.)1:4„, A F-1 LAr 191231 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: Date Owner Name and Signature City of Northampton PT ' // Massachusetts A. m D212 MTIn S ee BUILDING al SQ ,uW 212 [Nin Strut • �, ee 020 Buildup xancn.eq,ton, ew 01060 Massachusetts Residential Building Code Section 110.85.1.2 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 I O R5.L3.1 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 TS Massachusetts L 'p � c F DEPaA1ffi'NT OF BDILDING INSPPCTIONS 212 Nain Strut aeanicipal BuilA nq y C� NoSt anpton, M 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: 34c. ' 1I!"'M "' cs�.� 2 (Please print house number and street name) Is to be disposed of at: Jo-)it 'i�acia e��'L,.� (P ease print n me an tion of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature of Permit Applicant or Owner Dafte 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 ofMassaehuselts Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www,massgov/dia VNNorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Native(Business/Organ¢atioNhid...dust): F—x.'' Address: Pt. of ei.. sb City/State/Zip: Se..j-1....,„P+.— n,X Phone#: 1/0- 3K- GUO Me you m employer?Cheok me appropriate box: Type of proJeM(required): Il am a employer with Ioc<s not motor lmn-truel' 7. ❑New construction 2�Iamamk pmprietmmpamenhip mdhave no employees wodwg forme. S. 0Remodeling my cutesy,[No weirkm'eump.inswanc< r<anh 1.] J�1 rat a hommwmrdoiug all work myselr INo workers'cmnp..surmu requimd.j' q. Delllplltlpn 4 1 am a homeowner and will be hiring wooamors an conduct all work em my pmpmy. twill 10 Building addition more met an Contraction either have workers mmcemation insurance or are sole I IQ Electrical repairs or additions popiiterswith m employees. 12.❑Plumbing repairs or additions 501 ran u general contractor and 1 have hired me sWrwnaacmrs acted on now munched sheet 13.❑Roof repairs These sub conmemrs have employees and have workers comp.imumnee. 6.[]Kb me a corporation and in.afrmm have exemisNth<w right of<n<mpdov per MGL e. 14. Other 152,00,and we have no employees.[No womens comp..sutmce required.] "Any applicant mut checks box#I most also Ill out the section below showing their workers enmpensmion policy.f ernamn. I Homeowners who submit this aaidpvit indicating they arc doing all work and than hire outside contactors must submit o new affidavit indicating mill, TC.00rs mm check mil box must mltached mWar..]sheet showing me name of the sub-cennacters and stale whether err,net those entities have employees. If the sub-comctors be,,employees,they must provide mew workers'comp. rch,numher. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site Information. Insurance Company Name: Policy#or Self-ins.Lia #: 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$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 DLA for insurance coverage verification. I do hereby certify under thepoins and penalties`ofrj �pe 'uy that the information provided above is nue and cot rrec Signature: C-o���-a..�. (S._ �} v Date- Phone#: ate-Phone#: H735 74<i - -q4y Official use only. Do not write in this area,to be completed by city or town official. City or Town: Perecit/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 M 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-contractors)name(s),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,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. Also be sure to sign and date the affidavit. The affidavit should be resumed 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 permitilicense 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 I Congress Street, Suite 100 Boston, MA 02114-2017 Tel. #617-7274900 ext. 7406 or I-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.rtrass.gov/dia