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15B-003 P, bR BP- 2011 -0047 GIs #: COMMONWEALTH OF MASSACHUSETTS Na g k: 29 - 337 , , " 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 -0047 Project # JS- 2011- 000092 Est. Cost: $2000.00 Fee: $160.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sg. ft.): 10018.80 Owner: PURDY MARILYN A C/O RAYMOND F JACOBS Zoning: URA(100) //WSP Applicant: PURDY MARILYN A C/O RAYMOND F JACOBS AT. 228 ACREBROOK DR Applicant Address: Phone: Insurance: 228 ACREBROOK DR (413) 341 -3490 O FLORENCEMA01062 ISSUED ON. 712212010 0 :00 :00 TO PERFORM THE FOLLOWING WORK.- REMOVE CLOSET, REPLACE DOORS & ADD HEADER 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 7/22/2010 0:00:00 $160.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo File # BP -2011 -0047 APPLICANT /CONTACT PERSON PURDY MARILYN A C/O RAYMOND F JACOBS ADDRESS/PHONE 228 ACREBROOK DR FLORENCE (413) 341 -3490 Q PROPERTY LOCATION 228 ACREBROOK DR MAP 29 PARCEL 337 001 ZONE URA(100)//WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 4444 J4 44 Fee Paid Tyneof Construction: REMOVE CLOSET, REPLACE DOORS & ADD HEADER New Construction Non Structural interior renovations Addition to Existing Accesso1y Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 .7 ,9-4 J/ c) Signature of Building OhIcial 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. �p City of Northampton Building'bepartment 212'Main Street " q J Room 100 Northampton, MA 01060 phone 413- 587 -1240 Fax 413- 587 -1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Prooertv Address This section to be completed by office creel -��/� ���'iC /�ler�e -`7 ��U� Map lot, klnit /� Zone Overlay Distncti ' IM District 'CB District" " SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record Name (Print) CU ffen t Ma' in Ad ess• Telephone Sig e Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Bullding'Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 4 + 5) Z O o Check Number This Section For Official Use Onl Building Permit Number: Date Issued: Signature: Building Commissionedlnspector 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 I Setbacks Front Side L: R: : R: _ - Rear ) Building Height°) \ Bldg. Square Footage Open Space Footage % - -- (Lot area minus bldg & paved parking)� # of Parking Spaces -- Fill: 3 volume & Locatio A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW M YES Q IF YES, date issued: � IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW Q YES 0 IF YES: enter Book Pagel( and /or Document #__ B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW )"' YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained , Date Issued N mm nm. 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 Q 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. 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 [❑ Siding [0] Other [O] i Brief De cription of Propose Work: t?rHore C'wrid Clete S;OLcc,411--le 6�P,_01a,,_ oo/^ AYW CX8 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet �R � -- .�����,_" .tb' %.ilM_�����g. ,. ��■ � v ... ��tk 3`. '' ��i,:���)l�-7t:�'� - a. Use of bu g :One Family Two Family Other b. Number of rooms 1 ch family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new corlst�uction. Dimensions e. Number of stories? !� f. Method of heating? Fireplaces or Wood es Number of each g. Energy Conservation Compliance. the nergy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? es No. Is construction 'thin 100 yr. floodplain Yes No j. Depth of basement or cellar floor w finished grade k. Will building conform t e Building and Zoning regulations? Yes No. I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION'; - TO BE COMPLETED WHEN F. 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 relativ ork authorized by this building permit application. Signature of Owner` Date I, a�s Own Authorized Age ereby declare th the state sand ' ormation on the foregoing application are true and accurate, to tmy knowledge elief. Signed under the pains and penalties of perjury. P *y/f? ot? O &S Print Name 19 Z o/o Si ure f Owner /Agent Date , SECTION 8 CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Ho License Number Address :7` Signature Telephone .. EII[ f�$ iirtktt1 >trlClt�11T111r11tr�COr` Not Applicable ❑ Company Name istration Number Address Expiration Telephone SECTION 10- WORKERS' MPENSA TON INSURANCE AI'FIDAVIT (M.G.L. c.152, §'.25C(fi))', Workers Compensati 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...... ❑ 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 Officia that he /she shall be resronsible 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. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State d Local Zoning Laws and State of Massachusetts General Laws Annotated. —'"-� Homeowner Signature • The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 v t www.mass gov /dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electrici.ans/Plumb.ers Applicant Information Please Print Lm*bIy Name ( Business /Organiiation/lndivid W): ,/ Z4Yl' a-4 --I 0;611 Address: 2Z City /State/Zip: Dtf /�! Phone. #: Are you an employer?. Check the appropriate'box: Type of project (required):, 1. [1 I am a employer with 4.. E] I am a general contractor and I 6. ❑ New construction employees (full and/or part- time).* have hired the soli- contractors 2. El I am a sole proprietor or partner- listed on the attached sheet 7. ❑ Remodeling ship ;nd have no, ewployees These sub - contractors leave. .8. r_1 DerioWon working for -me in any capacity. employecs_ and have workers' j aeon No workers' COIDp inSlnanCe tn ince 10. Electrical r epairs or ad required:] � 5. � We are a corporation and its additions 3 I am a homeowner doing 0 work officers have xercised they 11.�] Plumbing repairs or additions elf (No workers' comp. right of exemptio' § n per MGL 12. .Roof airs c: 152 1(4), and we have no insuran required:] t 13.[] Other _ employees: [No workers' comp. insurance regtiired.J 'Any applicant -that checks -box #k must also fill out the section belowshowing thcQwodccs'- compensation policy information: t Homeowners who subrmt this affidavit .indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. :Contractors that check this box must. attached an additional sheet showing the name of the sub= conwtctors grid state whether or not those-entities have employees. If the sub - contractors have employees; they must provide dicir workers' comp. policy mmniber_ I am an employer that is providing workers' compensation insurance for. my employees Below is the polity and job site information Insurance Company Name: Policy # or Self -ins. Lic. A Expiration Date: Job Site Addr C' /State/ ri3' ziP= Attach a copy of the workers" compensation policy declaraizon page'(showing the p9licy number. and expiration date). Failure. to secure coverage:as required under Section 25A ofMGLc. TSZ can lead - to the imposition of crin� penalties of a fine tip 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. Be advised that a copy of this statement may be forwarded to the Office of r nvestisations of the 17IA for insurance' coveraie "vcrihcation —.� 1 do hereby certi under the pains penalties ofpm*7 that - the in ormation providedlrbove_ s_tme_and cvrrerl____ Si tore. Phone #: /J YZ t� Of� j`icicl use only. Do not write in this area, to be completed by city or fown'offwWa1 City or Town: NxmltUcense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk .4. Electrical Inspector 5. Plumbing Inspector 6. Other a 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, 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 -- understand the above . ome owner /r sident% signature requesting exemption) will call to schedule all required building inspections necessary for the building permit issued to Date Address of work location