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17A-234 (3) 87 LAKE ST BP-2019-1461 GIS#: COMMONWEALTH OF MASSACHUSETTS Mao:Block: 17A-234 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category,chimney rebuild BUILDING PERMIT Permit# BP-2019-1461 Project# JS-2019-002372 Est.Cost: $2500.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor. License: Use Group: PAUL KORPITA 25671 Lot Size(sa.ft.): 13721.40 Owner. THOMAS JEFFREY J&MEGAN CONNOR-THOMAS Zoning: URB(100 Applicant: PAUL KORPITA AT: 87 LAKE ST Applicant Address: Phone: Insurance: P O BOX 263 (413) 774-4640 Workers Compensation DEERFIELDMA01342 ISSUED ON.612112019 0.00.00 TO PERFORM THE FOLLOWING WORK:REBUILD CHIMNEY 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: FeeTyoe: Date Paid: Amount: Building 621/20190:00:00 $65.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner 4 via I �01ti¢v)1� o�MovL Department use only City of Northampton Status of Permit: .>y Building Department Curb CuVDnveway,Permit �..,� 212 Main Street Sewer/Sepoc Availability :1 Room 100 WatwNVell Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 PloVSite Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1310—— 1.1 Property Address: This section to be completed by office Map. a_ Lot -2`3 Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: C �0Vii ';,? JA*-*- ST- 1 �0 N e(Prirp Current Mailing Address: Telephone ure Authorized Agent, P A-L, 1 ✓�D (�3 Name(Pring Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only competed brmit applicard 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number 1 This Section For Official Use Only Building Pemn Num r: Date Issued'. Signature: Building Commesioner/Inspector of Buildings Date P r;olrP )iA @ EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Ile Completed. Permn Can Se Denied Due To Incomplete Information Existing Proposed Required by Zoning This column m be fill m by Building Do amnent Lot Six Frontage - --. Setbacks Front Side L R: L R: Rear Building Height Bldg.Square Footage Open Space Footage (lot ora minus bldg a prod kin p of Parking Spaces Fill: wlwve&Lowhiwl - ... A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DONT KNOW O YES O IF YES: enter Bods 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 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(Gearing grading, excavation,or filling)over 1 acre or Is It part of s 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/cheek all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [OI Decks [O SidingI Other[ Brief Description of Proposed Work I A Alteration of existing bedroom Yes No dding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet ea.If Newhouse and or addition ta"e'xisting 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? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? It, 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. I. Septic Tank_ City Sewer Pnvate well City water Supply_ SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, GI� I A,6A,&�d' , as Owner of the subject property �. n ..n �,1q hereby authorize �r4'til IL17 1 1 "[— Q•yam {4TrT V4 to act on my behalf,in all matters relative to work au onzed by this building permit ap 'cation. Signalureof Owner Date I, 4A-) as Owner/Authonzed Agent hereby declare that the statements and informatl n the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. p I�LtI l ll7i Ti11- Print Name Signature of Owme pe Date 671-1 SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable �❑/ Name of Licimm Hdder Ji c4 A it I A Y - Lbence NunLer (tri 4i._.t.. ,nlG®�• Add.. n Expirati , < < - ��� pli Deft 8ipnaNha FTelephone 9.Realstered Home Improvement Contractor: Not Applicable ❑ F+ H n`I� ✓LGF � Comoanv Name �TT Registration Number 1G� nr .ineph 1aKrte Address ^PE Expiration Date Telephone SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.1 25C(8() Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will resut in the denial of the issuance of the buildi permit. Signed Affidavit Attached Yes....... No.._- ❑ City of Northampton Massachusetts iz DSPARTNENT OF BUILDING INSPECTIONS ' 212 Main Street a Municipal Building p CY NorUsa pion, col 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"reconstruction, alteration,renovation,repair,modemization,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 has contracted with a corporedon or LLC,that entity must be registered. Type of Work: Est. Cost: Address of Work: 61 :!)"r Date of Permit Application: (e I ALO 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 herepby apply for abuilding pe the en�f thel� �b/ to V,5110 Dat 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 a Massachusetts 212 .IIETIT OF BNILDING INSPECTIONS YSY xain Street xun 010 Building xarNampton, rut 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 farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Section 110.85.1.3.1 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 r Massachusetts �- •<< 1 DEPABTIffiiT OF BUILDING INSPECTIONS 212 Nein street eNunicipal Building Nor=ton, 4 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: C , (Please print house number and street name) Is to be disposed ooffat:,�/�� co(Pleas name and location of facility) face ity) Or will be disposed of in a dumpster onsite rented or leased from: Pe and Address) � .� C 6 Signature of Permit Applicant or Olviner 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 Wxl.rken'Compennation Department of7ndustrialAccidents 1 Congress Street,Suite 100Boston,MA 02774-10177www.massg"AUa Insurance Affidavit:Bodden/Convaemn/Eleftrifians/Plumben. TO BE FILED WITH THE PERMITTEVG AUTHORITY. Applicant Information Please Print Legibly Name(Bminess/Orgmizaliomindividlul):K4„ n ra�& Address:_ I (e5 tp 1 A A- 4\, d 1't_ City/State/Zip: Phone#: Are you employer'Chert Ne appropriate box: Type of project(required): I are a employer with—3—employeee(fau anNor pert-time).* 7. ❑New construction 1 em a sole pmpriemr mp�hip and have no cmployms working forenoon 8. []Remodeling any cepmiry.[No workms'comp.imumncc rcgwred.] 3 o am ahomco ner doing on work myself[No workers'con,anne ee required] 9. El Demolition 4.❑I am a homeowner and wid be hiring conaacum to conduct all work on or,pmlmry. I will 10❑Building addition me wt an mnnewoes eitherhavc workers'ewspenciawn Nsumom oraw note 11.❑Electrical repairs or additions proprietors with oo wgbyee. 12.❑Perm rep repairs or additions s lam ageneral cono-ac haecIhave hiredthevesub-conmoon week.,new lisadon Nratmchdshea. These sub-covwcmrs have employees and have workar'wmp.msmnnrc.: 13. frepairs b.❑We area coryoanare. dits officers have exercised tltehr la ofexempticn per MGL e. 14' Other 152,11(4),and we have no employees.[No workers'comp.insurance mquiml.] 'Any applicant that checks box#1.-,.].a front the sec4on Wow showing tech warkcrs'compemation policy infommtion. i"'aacowners who submit Nis affidavit indicning they are doing all work and then for outside contractors must submit a new affidavit indicating such. 1co.oaqun Nat check an,box must attached an additioml sheet showing Ne name of the sub-contractors and state whether or act thorn entities have employees. If Ne subauo racmrs have employees,they must provide Neir workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is rhe policyand job site information Insurance Company Name: Policy#or Self-ins.Lia#: J_P te,1-7 `S: Expiration Date. Z I Job Site Address: S1 ! �/ _ S7- City/Slam/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 verificatio l do hereby cerl unde the pains and p ales of perju that the information provided tore is true andeorrect Si nature: Phone q: Oficial 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,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 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 bean 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)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,are not required to carry workers'compensation insurance. If anLLC 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 ifyou 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 permitlicense 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 Department's address,telephone and fax number: The Couunonwealth 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 C X/ (29 w, fpomm onweaae 0/h/�aaet�`a Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Individual PAUL KORPITA Registration: 104540 D/B/A KORPRA MASONRY Expiration: 07/13/2020 P.O.BOX 283 DEERFIELD,MA 01342 Update Address and Return Card. SCPI O 30MdY9 OMHO of E IMPRO EME a e OWR Mpuletlnn NOME IMPROYEM ENTclual CTOR before Me valid for individual te. "found! only TYPE:IndiNdEx Wee Me Consumer date. "found!Bu inessmtum to: 9€9L d 07/13)tl41L One sh Consumer -SuiteI Business Regulation 100.,00 0]/1312020 One Ashburton Race-Salle 1301 PAUL KORPITA Bo7A 02108 Dr8/A KORPITA MASONRY PAUL KORPITA JR. 165 PINENOOK RD DEERFIELD,MA 01342 Ute, Not valid tritho-"Itignature LConmonweafth of Massachusens Division of Professional Lkensure Commonwealth of Massachusetts Division of Professional Lkensure Hoi@pNttinya�ef _ �� Board of Building Regulations and Standards / - Constrvctbn tuptrvlsor HE-0834341010112019 Firm; 10/01/2019 CS-025871 E)[c�ims: 10/01/2019 Tn PAULKOF FELDMA,JR V PO BOX 26WIRINENOOKROAD - PAUL KORPITA,JR OEERFELO MA 91342 PO BOX FI LO MA VIU2 ROAD - DEERFELO MA 913!2 Gommissioner n Q �� Commissioner ��{s•� ®Sf] - 36.003280182 This raN a,*rn , ages mat me reopen Iws s Ul,cmpined a 10-Mur Orcin tit el SaleN oral 11evMT ening Course in Construction Saf*sand Health PAUL KORPITA Michai3 MIWSap- 7/6/2010 WORKERS COMPENSATION AND EMPLOYERS'LIABILITY INSURANCE POLICY—INFORMATION PAGE INSURER: POLICY NO: WCP1753F NGM INSURANCE COMPANY 4601 TOUCHTON ROAD EAST RENEWAL OF: WCP1753F SDITE 3400 JACKSONVILLE, FL 32245-6000 NCCI Company No: 16322 Account No: CACP1753F ITEM 1.NAMED INSURED AND MAILING ADDRESS: AGENCY NAME AND ADDRESS: PAUL KORPITADRA KORPITA ENCHARTER INSURANCE LLC (SEE NAMED INSURED ENDT) PO BOX 263 25 UNIVERSITY DRIVE DEERFIELD MA 01342-0263 AMHERST, MA 01002 AGENCY PHONE NO.: (413)549-4971 AGENCY NO.: 201506 LEGAL ENTRY: INDIVIDUAL OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Location Schedule) ITEM 2 POLICY PERIOD: From: 12-31-2018 TO: 12-31-2019 Effective 12:01 A.M. Standard Time at the Insured's mailing address. ITEM 3. COVERAGE: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Iters 3.A The limits of liability under Part Two are: Bodily Injury by Accident: $ 100,000 each accident Bodily Injury by Disease: $ 500, 000 policy limit Bodily Injury by Disease: $ 100, 000 each employee C. Other States Insurance: Part Three of the policy applies to the stales, if any, listed here: all states except: ND, ON, NA, WY and states designated in ITEM 3A of the information page. D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. ITEM 4, PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. AN information required on the Workers Compensation Classification Schedule is subject to verification and change by audit Please see Classification Schedule. Tota Estimated Minimum Premium: $ 500 Annual Premium: $ 8, 609 Audit Period:ANNUAL Date: 10-26-2018 Countersigned by WC 00 00 01 A Copyrigldl9 IbCoral Courcil on Corripermlon Imu.nn man® or aRM 11 L Jeb EF at, -r rpv' Q