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16A-020-115 115 FAIRWAY VK,LAGE BP- 2005 -0696 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 16A - 920 CITY OF NORTHAMPTON Lot: -016 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Non structural interior renovations BUILDING PERMIT Permit # BP- 2005 -0696 Project # JS- 2005 -0951 Est. Cost: Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): Owner: BURICK MARCIA E Zoning: URA Applicant: BURICK MARCIA E AT: 115 FAIRWAY VILLAGE Applicant Address: Phone: Insurance: 115 FAIRWAY VILLAGE (413) 584 - 1927 () LEEDSMA01053 ISSUED ON:1 /4/05 0:00:00 TO PERFORM THE FOLLOWING WORK:ADD BATHROOM IN FINISHED BASEMENT 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: Receipt No: Date Paid: Check No: Amount: Building 1/4/05 0:00:00 8980 $50.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo „ File # BP- 2005 -0696 APPLICANT /CONTACT PERSON BURICK MARCIA E ADDRESS/PHONE 115 FAIRWAY VILLAGE LEEDS (413) 584 -1927 0 PROPERTY LOCATION 115 FAIRWAY VILLAGE MAP 16A PARCEL 020 016 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out �' �j9� Fee Paid Typeof Construction: ADD BATHROOM IN FINISHED BASEMENT 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 FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN ATION PRESENTED: Ap proved 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 Co r1'.sion /e . 4 ,./ P------ /1.1-22( 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. a , ? 4 Dep ar t t'e n t use only �___- -- °� �� • Status-9- y of Nortf�ampton fP __- u Idin De ,; - ,� �� , y 9 Partm Curb C- r., -....w-- P , ���1 �--- �" � � �'F2 Ma Street � � Sewe r� ept� � c at Ca� , � C+t y � „ t �' IRoom 100 �Water/We1l Av �� 2 g L. � - N o,,rthanpton; MA 01060 Two S et s of Str �ctural Ptans phone 41 3587 -240 Fax 413- 587 -1272 Plotlstt Plans t �; "!` dS Other . APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A O SECTION 1 - SITE INFORMATION NE OR TWO FAMILY DWELLING 1.1 Property Address: Map District This section to be completed by office /21;7e CLot Unit: G� Zone ; Overla y , Elm District CB.District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: _ • ` E � p a c' ► f1 - , 6 � , e e___-__ / /S 1/1, L 1_,.#64-7,-- , � Name (Print) �a- � �` Current Mailingre 4/ -- / "� /`7 /III' -(c Z Telephone / Signatur 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION Item Estimated COSTS Co st (Dollars) to Official Use Only completed by permit applicant 1. Building 1 1>--" . (a) Building Permit Fee 2. Electrical � 17 (b);EstimatedTotal Cost of Construct from (6) 3. Plumbing 5 Building Perm Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) () Check Number This Section For Official` Use Only Date Building Permit Number. Issued: Signature: r Building Commissioner /Inspector of Buildings Date I 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: _ L: R: �� ,__ ___ Rear Building Height Bldg. Square Footage I Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces . Fill: �_� __ ___ _ ___ ___. (volume & Location) —• -- • -- A. Has a Sp ial Permit /Variance /Finding ever been issued for /on the site? NO DONT KNOW 0 YES 0 ` IF YES, date issued:: IF YES: Was the permit recorded at the Registry of Deeds? NO (j 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 CY DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: I . D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO (2 / IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, ex vation, 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. h SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House [l Addition in Replacement Windows Alteration(s) Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition n New Signs [D] Decks [D Siding [D] Other [D] Brief Description of roposed J j f Work: Odd/ Ill � /' 1( l,.y r�� "- Ids 2:1 Edd � -t�� is Lo G,ri'5f'G At�/n1- Alteration of existing bedroom Ye s No Adding n w bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house °and -or addition: to extstingi-houslnq;° complete the--fo low[nq: 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 , 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 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. Print Name Signature of Owner /Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 9 Registered Y�arrie .'lmproveri�entCoritractor° mm ,' K „ :F.„ Not Applicable ❑ Company Name Registration Number — Address Expiration Date Telephone SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.GtL. 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 ❑ No ❑ ll. :�vm ©w:l�er Ex.�mF�ll ®ii Dwellings o ne t The current exemption for "homeowners" was extended to include Owner Dwe,,, „� of .,..., ,. (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 - vear 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 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 and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature r 4 ZHAMp i . y -;)" $ ) � + ,t>rtassacipisetts - 1= l DEPARTMENT OF BUILDING INSPECTIONS =i /_ INSPECTOR 212 Main Street • Municipal Building '� a Northampton, MA 01060 ‘' HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as Lis /her construction sup' :: ,. sor. 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 any 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 1, l{�t `�� understand the above. (Hom owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date / d . 0 t / Address of work / - i location / ( 1� �� �,1 &-.c/- • 4 ' :tw f nTO ( \L \ � • )iti of ;>:�ri1ia11tptoil l ° 1 a3awrEl rrsrl( • •� • .% g" . • DEPARTMEITT OP BUILDING INSPECTIONS 212 Main Street Municipal Building Northampton, Mass. 01060 to WOm1 R'S COMPENSATION . ENSTIRAI`tCE AFF'II)A.ViT • I (IICCAS'Jpc.t tiiittcc) with a pr ncipai place of businessfresidence at: (phone) (sit /ci t} /natc/a p ) do hereby certify, under the.pains and penalties of perjury, t112,1 ( ) I am an employer providing the following worker's cornocnsarion coverage for my employees working on this job: • (tasuric Coi a ) (Policy Number) ( : Dom) ( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired the cone actors listed below who have the following worker's camoensaaon policies: (Num.': ofCoctracro: (In franc; Company/Policy N =(r) (1=_::nr uon Date) (Name of Coo ac or) (Insurancz Comoa.nv PoLic; Nuni r) (E t r tion Date) (Name of Coturactor) (Insurance Company/Policy Numlu) CExpirdon Date) • (Name of Contractor) (Lnsuranca Company/Policy Numbs) (Expirdio❑ Date) . (aax'v . t�:�oc31 c`cc ifacc=un- co mc!u& iafcc -x oa pc-taiaias to all • ( ) I am a sole proprietor and have no one world.ng for me. ( ) I ain.a home owner performing all the work myself. NOTE: plctc w a•rxrc the wir:ic bancw.acrs •tso ccaplay pcac2 Lo r^‘ ora aar ma t 1 E 4 - 3 ' h. era is «3ich the bomoowws raider cc co the grouoda z.ppu t4-=-= tbeao L-r we C Y cccs:d..vi to bo to =Lc the was - �TtP Y� m Aa (GLl 52.n 1(5)). - ^plin.Uoa try a homcUaaa fc a tip __ a Ixzmit ray c.-id=o« trc Ics l r zlra of as cnp ioyoc un&r ciao Wocic.w'r CoCocca.t on Act 1 uoeczrand tbs a copy or this mramcm ca.) b ron ,err d.a a t o Dopartmn t of 1. - 0t o or trr� r ro< th. covczbc vciBciioa a_'1d the !_iliac to saauc `coverage undo s.oction 25A of MOL 152 cut icc4 m the i ,�IIioa of cimias' pcaitrio oomaiag of a Ilia ofup to 51,300.00 and/or orup b ooc ycr tocl cv11 pcnallio a Sc focal of a Stop Worb Onic and a fu of S100.00 1 thy agiinA Lo c. For dcp.rtm"'I u+c only Permit l`turnbcr - _ -) Signature of Linscrlpciuc L}3te rm