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31A-115 40 VERNON ST BP- 2011 -0287 GIs #: COMMONWEALTH OF MASSACHUSETTS Ma : lock' 3 I 115 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category BUILDING PERMIT Permit # BP- 2011 -0287 Project # JS- 2011- 000479 Est. Cost: $2000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 10628.64 Owner: COFFEY KELLY & RICHARD WEIS Zonin URB(100)/ Applicant. COFFEY KELLY & RICHARD WEIS AT. 40 VERNON ST Applicant Address: Phone: Insurance: 40 VERNON ST (413) 687 -2543 O NORTHAMPTON MAO 1060 ISSUED ON. TO PERFORM THE FOLLOWING WORK: REPLACE PLASTER W /SHEETROCK & INSULATION (2 ROOMS) !! Smokes and COs must be installed per code in renovated rooms 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: FeeType: Date Paid: Amount: Building 9/30/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner File # BP- 2011 -0287 APPLICANT /CONTACT PERSON COFFEY KELLY & RICHARD WEIS ADDRESS/PHONE 40 VERNON ST NORTHAMPTON (413) 687 -2543 Q PROPERTY LOCATION 40 VERNON ST MAP 31A PARCEL 115 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: REPLACE PLASTER W /SHEETROCK & INSULATION (2 ROOMS) New Construction E Non Structural interior renovations N 6 Addition to Existing �+J l+' L t ,03 i^A � a (�- Accessory Structure Fi A:4 ID Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IJP)1kMATION PRESENTED: Approved 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 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. City of Northampton ; Building Department r 1 0 212 Main Street q Room 100 Nort ampton, MA 01060 r pho - 587 -1240 Fax 413- 587 -1272, APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 7 -SITE INFORMATION 1.1 Property Address This section to be completed by office Map =� Lot 'Unit Overlay District " v \ Etrrt 5ti District ' C1 District SECTION 2 - PROPERTY 'OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record 4D ii v Name P{{��'n) Current Mailing Address: / !� �. Sz/ 3 ' ` Telephone `, Signature 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only com leted by ermit applicant 1. Building n © � (a) Building Permit Fee 2. Electrical 1- (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 This Section For Official Use Onl Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date 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 L: ...,..J R: = L: R: Rear I�.. Building Height Bldg. Square Footage % i Open Space Footage % _ (Lot area minus bldg & paved p arkin g) # of Parking Spaces -- Fill: volume & Location A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO DONT KNOW Q YES 0 IF YES, date issued:1 IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book I t Pagel and /or Document # B. Does the site contain a brook, body of water or wetlands? NON DONT KNOW 0 YES 0 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 0 NO IF YES, describe size, type and Location D. Are there any proposed changes to or additions of signs intended for the property ? YES i NO 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 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 1 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition New Signs [0] Decks [0 Siding [O] Other [C>) Brief Description of Proposed t Work: ��� .S (J �rt 5I-V _ f i N Adding new bedroom Yes No Alteration o existing bedroom Yes o g Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa. � nr i r ai c i .: .�5cistl g ` Ifin of ipt+�te h ��olt W Ana: 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? 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. I. 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 I, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date as Owner /Authorized Agent hereby de re 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. III (', r%P Print Name Signature of 0+0/. -nt Date 1 +. SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9 : Regsteri ;Irrlithltsrairemeircitcaii PP Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L, c. 162,:: 25C46)) 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 of the building permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ �ma The current exemption for "homeowners" was extended to include Owner- occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of 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 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 buildine 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. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, Sta7-73 cal Ztate of Massachusetts General Laws Annotated. Homeowner Signature r aL y The Commonwealth of Massachusetts DepartmentoflndustrialAceidents . Office of In vestigations 600 Washington Street Boston, MA 02111 v www.mass gov /dia -Workers' Compensation Insurance Affidavit: Builders / Conti - actors/Eiectricians/Plumbers Applicant Information Please Print L - 'blv Name ( Business /organization/Individual):. Address: 4_� City /Stat 4L91 J /A A 1 5) ' Phone. #: y� Are you an employer ?.Check the appropriate - box: Type of project (required):. 1. [] I am a employer with 4.. [] I am a general contractor and I 6. ❑ New coristtruction employees (full and/or part time). # have hired the sub- contractors 2.. ❑ I am a sole proprietor or partner- listed on -the attached sheet 7. O. Remodeling ship and have no loyees These sub - contractors have. .8.' Dernolit working f or me in any capacity. earployees_and have workers' mcrrrantr ._ IIBwldrtig atidrti [N6 workerS com insurance — -- r e& 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions egtnr j h ffi ocers ave Exercised their l 1. Plumb' r 3. 1 am a homeowner doing all work ❑ . repairs or additions myself [No workers' comp. right of exemption per M{'rL 12: ❑.Roof repairs insurance required) t -c: 152, § 1(4), and we have no " employees. [No workers' 13.0 Other comp, insuranc reg6ined.1 'Any applicant •that Checks box #1 Est also fin out the section belowshowing theirworlcers'..compensation policy information t Homeowners who submit this affidavit.indicating they art doing all work and than hire outside conhaators must submit a new affidavit indicating such. :Contractors that check this box must.attached an additional sheet showing the nano of the sub- contiaetors grid S= whetlierornotithose entities have employees. If the sub-cont:actors have employees, they mustprovide their workers' comp.policynumber. t am an employer that is providing workers' compensation insurance for my em th employees Below is e policy and job site information Iusarance Company Name: Policy # or Self-ins. Lic. #: Expiration Date: Job Site Address: City /Stawzir): Attach a copy of the workers' compensation policy declaration page "(.showing the ppIicy number and expiration date). Failure . to secure covers - _.. __ • ge_ as requu ed under Seahon 25 'of1GIGI c: 152 can lead'to the imposition of cnm in 1 penalties of a fine up to $1500.00 and/or one -year imprisonment; as well as cavil 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 Investtzraizons of the bIA foritisuraince` coveraze verification M - 7 - p - n , thepains. an dpenah*s ofperjury that - the informs onprovidedubove_ slruE:and corr Si tore: Date, 711-0 �2 — Phone #: y J J J _ .... y ; — Official use only. Do not write in this area, to be completed by city or town offci'd . .City or Town: P6rmitUcense # Issuing Authority (circle one): J. Board of Health 2. Building Department 3. City/Town Clerk .4. Electrical hispector 5. Plumbing :Euspector 6. Other r� Contact Person: Phone #: J r HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends 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 home owner." The building department for the City of Northampton wants person(s) who seek to use the home owner exemption, - to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation /footings (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper �ermits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, ( understand the above. .(Home oiviier ArAide&s signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to Date 9/2 Address of work location