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04-004 5�OAU0460N RLD BP- 2011 -0508 GIS #: C OMMONWEALTH OF MASSACHUSETTS MSleo k:4`flU4 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate gory: BUILDING PERMIT Permit # BP- 2011 -0508 Project # JS- 2011- 000830 Est. Cost: $12000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: TIMOTHY SENEY 061088 Lot Size(sg. ft.): 81021 .60 Owner: KELLIHER PAUL G & JOANNE F Zoning: RR(100 )//WSP Applicant. TIMOTHY SENEY AT. 520 AUDUBON RD Applicant Address: Phone: Insurance: 43 COUNTY RD (413) 667 -0230 HUNTINGTONMA01050 ISSUED ON:121112010 0:00:00 TO PERFORM THE FOLLOWING WORK .- STRIP & SHINGLE ROOF 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 12/1/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner City of Northampton Building Department' 212 Main Street a�u Room 100, Northampton, MA 01060 phone 413- 587 -1240 Fax 413 - 587 -1272 ff APPLICATION 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 j-.z Map - Lot - Unit 'Overlaii District , E St'District CB District SECTION -2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Name (Print) Current Mailing Address: 6 - 7 -Oa3o Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only ` completed by ermit applicant 1. Building �Q (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Constriction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total= 0 +2+3 + 4 + 5) t ' Check Number This Section For Official Use Onl Date Building; Permit Number: Issued Signature: j 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: ' R: _ i L: L---- j R. Rear Building Height - r Bldg. Square Footage % - --- I — Open Space Footage % (Lot area minus bldg & paved '. p arkin g) # of Parking Spaces - - - -•- Fill: .. I volume & Location A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO W D K NOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT K 0 YES 0 IF YES: enter Book Page and /or Document #,' B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q 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 Q NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO IF YES, describe size, type and location: i 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 Q 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 Alteration(s) Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [Oj Decks [p Siding [O] Other [p] Brief Description of Proposed Work: sT?Z.,i' RoCezac" Alteration of existing bedroom Yes oc= No Adding new bedroom Yes _K No Attached Narrative Renovating unfinished basement Yes >< No Plans Attached Roll - Sheet 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 APPLfES FOR BUILDING PERMIT I, �y as Owner of the subject property hereb on / / ham/ J.c' /►ice Cd.�%"� /9 f, �i"i '�0 to n ehalf, in all m tte reI tive"to work authorized by this building permit application. Signature of Ownel Date as Owner /Authorized whereby declare that the statements and information on the foregoing application are true and accurate, to the best of my kno ledge and belief. Signed under the pains and penalties of perjury. Print Name �L f Signature of Owner /Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder �f/L/O�!`� ��i'�nJ,CJ 6 r 0 aZ License Num er ,Iv TA501 Address Expiration Date -B 3d Signature Telepho e Not Applicable ❑ Ad ��t.t/.t✓ �ru7ii✓li ('di�/772�1C'TCJ�C' /cl Y�(� �� Company Name Registration Number A15 6041,J; y )CP Address Expiration Date Telephone SECTION '{0- WQ . KERS' CQMPENSATIQN INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))',. 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....... gj No...... ❑ , ©�r 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, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature v The Commonwealth of Massachusetts Department of f Industrial Accidents Office of Investig, ations _ 600 Washington Street Boston, MA 02111 www mass gov/dia •Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb.ers Applicant Information Please Print Les bly Name ( Business /Organization(individual): I P i✓I - Address: -1 City /Stateop: ��Uv'�.J iO �1 d lOS o Phone. #: K, 6 7 — J A 3 Are you an employer?. Check the appropriate'box: Type of project (required):. L ❑ I am a employer with 4._ E] I am a general contractor and I 6. Fl New construction employees (fall and/or part-time). * have hired the sub- contractors 2� I am a sole proprietor or partner- listed on the: attacht sheet 7. [] ship- and. have _+o: employees These sub - contractors have. .8. ❑ DeM- b ifion working for me in any capacity. enployees and have wooers'. y Q gadding aiidifion O p m p mcura _ #._ _ [No workers' eornlr msuraace 10 Electrical r additions required:] 5. (] We are a corporation and its 0 - repairs or ad 3. E3 I am a homeowner doing all work officers havexxercised their 11.[] Plumbing repairs or additions myself: [No workers' comp. right of exemption per MGL 12. [].Roof repairs insiaance required] t c. 152, § I (4), and we have no employees. [No worke 13.[] Other comp. inaiiranc ICgiltLt!d ]. *Any applicant ghat checks box #1 must also fill out the section below showing works s'. coition policy iaformmtion: t Homeowners who submit this affidavit.indicating they= doing all work and then hire outside contractors must submit a new affidavit indicating such. IContractors that check this box must.attached an additional sbeet showing the oases of the sub - contractors and state whether or not tkwstemitia have employees. if the sub - contractors have employees, they must provide their workers' comp. policy number. tam 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. #: �,70f1��✓ /off �/ Expiration Date: Job Si A d dr ess: -:5-jo gvyC "911A C' /State/ m' ZiP - -Attach a copy of the workers'" compensation policy declaration page - (showing the policy number and expiration date). Failure. to secure coverage: as required and&. Section "25A 'ofMGL'c 15z can lead - to the imposition of cnmm l penalties of a fine up to $1,500.00 and/or ode-year imprisonment, as well as civil penalties is the form of a STOP WOR$ADRDER and- a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Iavestieafions of the bIA for insurance coverage vosficafion _ I do hereby certify under thepazns enables ofperjury:that in,�ornmatiionyrovL le abQVe islrue_aadcarrect__-- Signature: ate : D Phone #: O icidl use l on . Do not write hi this are to he co feted b - ff y a, mp y cit b town offccraL .City or Town: PermitUcense # Issuing Authority (circle one): .1. Board of Health 2. Building Department 3. City/Town Clerk .4. Electrical Inspector 5. Plumbing Inspector Y 6.Other Contact Person: Phone #: 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 permits 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 owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to Date Address of work location