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42-007 (2) - mbas RD C I BP- 2011 -0514 GIs #: COMMONWEALTH OF MASSACHUSETTS h 42 - t 7 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2011 -0514 Project # JS- 2011- 000842 Est. Cost: $10000.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(ssq. 1): 51836.40 Owner. ALTHOFF JONATHAN J Zoning: SR(100) //WSP II Applicant ALTHOFF JONATHAN J AT. 291 WEST FARMS RD Applicant Address: Phone: Insurance: 291 WEST FARMS RD (413) 584 -3567 (� FLORENCEMA01062 ISSUED ON. 121812010 0 :00 :00 TO PERFORM THE FOLLOWING WORK: I NSTALL SIDING,WINDOWS,ROOF,SHEETROCK &INSULATION TO BARN —A�� 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 Si FeeType: Date Paid: Amount: Building 12/8/2010 0:00:00 $60.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner File # BP- 2011 -0514 APPLICANT /CONTACT PERSON ALTHOFF JONATHAN J 1 �� ADDRESS/PHONE 291 WEST FARMS RD FLORENCE (413) 584 -3567 PROPERTY LOCATION 291 WEST FARMS RD MAP 42 PARCEL 007 001 ZONE SR(100 )//WSP II 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: INSTALL SIDING,WINDOWS,ROOF,SHEETROCK &INSULATION TO BARN New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOL OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON 1NF9AMATION 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 Demoliti ela / 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 212 Main Street Room 100 'Northampton, MA 01060 g , 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 Property Address This section to be completed by office , � s �� �"' '� - Map Lot Unit Overlay Dstnct Elm.$t Distrfct CB SECTION =2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record N e Print Current Mailing Address: Telephone Sig ature 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 completed by ermit a licant 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) <555 1.8hock 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 - - - -, 1 Side L: R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage % (Lot area minus bldg & paved w m.. pai- # of Parking Spaces Fill: i volume & Location A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued: ; IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book i Page, and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Q , Date Issued C. Do any signs exist on the property? YES 0 NO Q 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 0 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 0 NO 0 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 [p] Decks [C] Siding Other [Cn Brief Description of Proposed p (+ �`- 1 Work: 11-�OC � � L•�i we <i e,%'��1 `t�Tloc-- 61 Ins Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa: IflVeltl >hct%se aar,. afi+ia�C�tlaa.+usi�ic: aco`it;`tlre`�otc �irtla: 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 APPLIES17OK BUILDING PERMIT 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 declare hat the state ents 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 . Print Na e Signature o gen - Date SECTION 8 - CONSTRUCTION ;SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone € 9.ea[sterrl lntrr :inirissrernbrtioitrtctar: „.N b _. e' .,�,.. .. Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10 -WORK . ERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c!. 162,_§,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 buildipg permit. Signed Affidavit Attached Yes....... No...... ❑ �+r CWere�lpon 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 consider 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 "homeo " certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances tae and 19r44oning Laws and State of Massachusetts General Laws Annotated. Homeowner Signatur T The Commonwealth of Massachusetts Department of Industrial Accidents - Office of Investigations _ 600 Washington Street Boston, MA 02111 5� y www.massgov /dr'a _. -Workers' Compensation Insurance Affidavit:. Builders/ Contractors /Electricians/PIumb.ers Applicant Information Please Print L j 'blv Name ( Business /Orgmiiation/Individual): - ©''1C, (� • "t• Q Address: QC( C�5 fe -17wl%_&.5 �cX City /State(Zip: ylo r4e -t C � / d �� iC one. #: 413 -J �i -3 5 Are you an employer?. Check the appropriate box: -Type of project (required):. 1. ❑ I am a employer with 4.. 1 am a general contractor and I 6. ❑New construction employees (full and/or part time). # have hired the sub - contractors 2. Q I ani a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no =Tloyees These sub - contractors have. .8. ❑ Demolition working for -me in any capacity. catpIoyexs and have wor ='.. -Burl = addition tN `workers' com r p. ins ane _. comp- nsurince ., 5. E3 We are a corporation and its 10.0 Electrical repairs or additions ure 3. I am a homeowner doin all work officers havexercisecl their 11.0 Plumbing repairs or additions g myself: [No workers right of exemption* comp. per MGL 12:[].Roofrepairs insura required.] t c. 152, § 1(4•)', and we have no to ees: o workers' 13.[] Other Y Ll`l. comp. insurance requited.]. *Any applicant that checks box #1 must also fill out the section belowshowing dwirworkers' compensation policy information: t Homeowners who submit this affidavit.indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must .attached as additionafsheet showing the name of the sub- conu=to s and state whether or not those entities have employees. 'If the sub - contractors have employees, they must.ptovide their workers' comp. policy number. lam an employer that ispkoviding workers' compensation insurance for my employees Below is the policy andjob site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City /Stafe/Ztp: -Attach a copy of the workers' compensation policy declaration page'(showing the policy number and expiration date). Failure. to secure coveragc:as required under Sectton`25A ofl�IGI; C. 152 can* lead_to tiie osrtton of her of a - � p fine up to $1, 500.00 and/or one.- year as well as civil penalties is the form of a STOP WORK- O.RD.ER and. a fte 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 . Investieatzons ofthe - DIA for nsurance`coveratre verification _ I do her._ e rtify erlFie pains penalties ofperjury that - the informadon vvrnvcdedlibav •'� , � _asdrorrect —:__ Si ture ate Phone #: L 11 `� _Lj `6 4. J Cr1 0 : ena Offrcial use only. Do not write ih this area, to be completed by city or town oelrcw City or Town: Permlt/License # Issuing Authority (circle one): J. Board of Health 2. Building Department 3. City/Town Clerk .4. Electrical Inspector 5. Plumbing Inspector 4 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, 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 your), 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. ome 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 2 y IFO 01�1,� 003&Z