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BLDG PERMIT APPLICATION - 230 EMERSON WAY signed HOAPPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address This section to be completed by office Map Lot Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 2.2 Authorized Agent: SECTION 3 - ESTIMATED CONSTRUCTION COSTS Building Permit Fee This Section For Official Use Only PO BOX 6664, LAWRENCEVILLE, NY 08648 23 EAST HADLEY RD, HADLEY, MA 01035 300,000 20,000 25,000 20,000 365,000 413-695-8795 MARIE 609-620-6937 TIM 230 EMERSON WAY TIMOTHY BROWN & BARBARA ELKINS ROSEMUND, LLC - GREG & MARIE QUILL 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 filled in by Building Department Lot Size Frontage Setbacks Front Side Rear L:______ R:______ L:______ R:______ Building Height Bldg. Square Footage % Open Space Footage (Lot area minus bldg & paved parking) % # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained ,Date Issued: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES NO IF YES, describe size, type and location: 10,598 26 16 30 16 30 2,493 85.08 2,602 25% 4 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House Addition Replacement Windows 0r Doors Alteration(s)Roofing Accessory Bldg Demolitio New Signs ] Decks Siding Other 6a If New house and or addition to existing housing, complete the following SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT CONSTRUCT SWO-STORY INGLE FAMILY RESIDENCE WITH TWO-CAR GARAGE & FRONT PORCH 8 2-1/2 YES 2,493 53' X 55' 2 ELECTRIC MINI-SPLIT GAS FP 1 WOOD-FRAMED 7' TIMOTHY BROWN & BARBARA ELKINS ROSEMUND, LLC - GREG & MARIE QUILL ROSEMUND, LLC - GREG QUILL GREG QUILL SEE ATTACHED SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Name of License Holder 9. Registered Home Improvement Contractor: Company Name SECTION 10- WORKERS’ COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) 23 EAST HADLEY RD, HADLEY, MA 01035 413-695-4195 GREG CSFA-105857 04-29-2021 GREG QUILL City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street Municipal Building Northampton, MA 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, 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 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 corporation or LLC, that entity must 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 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: Date Owner Name and Signature City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street Municipal Building Northampton, MA 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.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 Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street Municipal Building Northampton, MA 01060 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: (Please print house number and street name) Is to be disposed of at: (Please print name and location 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 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. SOLID WASTE SOLUTIONS, NORTHAMPTON, MA 09/03/19 230 EMERSON WAY The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers’ Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):______________________________________________________ Address:__________________________________________________________________________ City/State/Zip:_____________________________ Phone #:________________________________ *Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information.†Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.‡Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees, they must provide their workers’ comp. policy number. 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. Lic. #:__________________________________________ 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, §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 verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: 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 #:_________________________________ Type of project (required): 7. New construction 8. Remodeling 9. Demolition 10 Building addition 11. Electrical repairs or additions 12. Plumbing repairs or additions 13. Roof repairs 14. Other____________________ 1. I am a employer with _________employees (full and/or part-time).* 2. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers’ comp. insurance required.] 3. I am a homeowner doing all work myself. [No workers’ comp. insurance required.] † 4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers’ compensation insurance or are sole proprietors with no employees. 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers’ comp. insurance.‡ 6. We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers’ comp. insurance required.] Are you an employer? Check the appropriate box: ROSEMUND, LLC 23 EAST HADLEY RD HADLEY, MA 01035 413-695-8795 MARIE 09/03/19 413-695-8795 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 a joint 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) 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 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 burn 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 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/diaRevised 02-23-15