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23A-103 City of Northampton k =w 6 M assac h uset t s ' k' .rtr s DEPARTMENT OF BUILDING INSPECTIONS b: rz, 212 Main Street • Municipal Building 0', ,: g ar+' Northampton, MA 01060 r y INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner 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 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 thper••'ts and inspections as req 'red can DELAY the project until such time as the proper permits and 'nspe tions re mad I, ) t -✓ understand the above. ' (Ho e owner /resident's si nature requesting exemption) I will c. I to schedule all required building inspections necessary for the building permit issued to me. Date JD'l y ( 242- Address of work location • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable [V Name of License Holder : License Number Address Expiration Date Signature Telephone e, 9. Retaistered Home Improvement Contractor: - Not Applicable ❑ /4c� L' h i mne� Su> -G�s I 1 l P 3 4 85 - Registration Name gistration Number 15" riA C.l r\ 33 IV a D 3- o a- • Address ( c6 3) Expiration Date L (i( -"*' / u /' r fr d i d (D Telephone `C cf 'Coo SECTION 10- WORKERS' COMPENSATION 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 11" No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied Dwellines 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 -vear period shalt 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 res e s sibili for compliance with the State Building Code, City of Northampton Ordin. , 't. e and Local Zonin ! . aws . Stat• of Massachusetts General Laws Annotated. omeowner Sign : ture itits, 4 ?J2e €oniw'itweaI o/ ��e ____;______„ ,______,.., +t__ a Office of Consumer Affairs and usiness Regulation = 1 -I � 10 Park Plaza - Suite 5170 Y om = = Boston, Massachusetts 02116 Home Improvement Contractor Registration — _ Registration: 118355 Type: DBA Expiration: 312/2013 TM 209147 ACE CHIMNEY SWEEPS JOHN KAPINOS 115 MAIN BLVD LUDLOW, MA 01056 Update Address and return card. Mark reason for change. El Address (] Renewal ED Employment El Lost Card • SCA1 0 50M- 04104 - 6110011 - 216 ✓i /7� Office t1.0ss6der eft ��eSS��J � License or registration valid for individul use only T 2 Office of Consumer Affairs and Business Regulation , HOME IMPROVEMENT•CONTRAC1OR before the =Oration date. If found return to U tl -= 118355 Expiration: -31212013 DBA 10 Parr Plaza -Suite 5170 Boston, MA 02116 A '. IMNEY SWEEPS_ -- - ,^1, / / JOHN KAPINOS _ __ 115 MAIN BLVD �,, LUDLOW, MA 01056 Undersecretary f / Not ' ' ` '. utsignature • - s= • WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Industries of Massachusetts Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803 (800) 876 -2765 NCCI NO 26158 POLICY NO. AWC 7027806012012 PRIOR NO. NEW BUSINESS ITEM 1. The insured Kelly M Kapinos dba Ace Chimney Sweeps Mail Address: 115 Main Blvd Ludlow MA 01056 Street No. Town or City County State Zip Code FEIN xxxxx8598 ®Individual ❑Partnership ❑Corporation ❑Joint Venture ❑Association DOther Other workplaces not shown above: 2. The policy period is from 10(08/2012 to 10/08/2013 12:01 a.m. standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here; MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500.000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance; Coverage Replaced By Endorsement WC 20 03 06A D. This policy includes these endorsements and schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating plans. All information required below is subject to verification and change by audit, Classifications Premium Basis Rates Code Estimated Per $100 Estimated No Total Annual Of Annual Remuneration Remuneration Premium INTRA 362813 SEE EXTENSION OF INFORMATIGN PAGE Minimum premium $ 266.00 Total Estimated Annual Premium $ 1,742.00 As indicated interim adjustments of remium shall be made: Deposit Premium $ 1,800.00 Co Annually El Semi Annually D Quarterly ❑ Monthly MA Assessment Chg. $1,385.10 x 4.2000% $58.00 This policy, including all endorsements, is hereby countersigned by 10/01/2012 Authorized Signature Date GOV GOV KIND PLACING CLAIM NAME SAFETY White - Jubinville ins Agcy Inc STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP P 0 Box 789 MA 9014 2 707 - South Hadley, MA 01075 -0789 WC 00 00 01 A(7 -11) Includes copyrighted material of the National Council on Compensation Insurance, used with as permission. The Commonwealth of Massachusetts I Print Form I - -- Department of Industrial Accidents " " Office of Investigations ! 2 1 " 1 Congress Street, Suite 100 • Boston, MA 02114 -2017 • '= www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Leeibly Name ( Business /Organization/I Kelly M Kapinos dba Ace Chimney Sweeps Address :115 Main Blvd City /State /Zip:Ludlow, MA 01056 Phone # :413- 547 -8500 Are you an employer? Check the appropriate box: Type of project (required): 1. IS I am a employer with 3 4. ❑ I am a general contractor and 1 6. ❑ New construction employees (full and /or part- time).* have hired the sub - contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no chimney liner employees. [No workers' 13. Other comp. insurance required.] *My applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Assoc. Industries of Massachusetts Mutual Insurance Company Policy # or Self -ins. Lic. #:POL # AWC 7027806012012 Expiration Date: 10/08/2013 Job Site Address:7 Trinity Row City /State /Z i p: Florence, MA 01062 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi y under the pains and penalties of perjury that the information provided above is true and correct Si a ature. - - - -- ,‘■ a. � -- -- - - -- - - - - -- - - -- - - - -- — Date 11/02/12 Phone #: 413- 547 -8500 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: p PROPOSAL Page No. / of ! Pages 44- r 4:704 #1191'..is •(-7 LUDWV, MA 01056. (413) St/30 PROPOSAL SUBMITTED TO PHONE DATE 11„34, Julie Cafritz STREET JOB NAME 7 Trinity Row Same CITY, STATE and ZIP CODE JOB LOCATION Florence. hri 01062 Same ARCHITECT DATE OF PLANS, , tOftftlf:INE John J. Kaninos mot. We hereby submit specifications and estimates for: 7' UL Listed S12.10 SteziLl ::,,r7,7rwey "'. , . . • . .• :"" ' ;: We Propose hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: 7.1 Gne '5.,o'y 6'1 li''.;....1?• 6" dollars ($ ). Payment to be made as follows: All material is guaranteed to be as specified. Al! work to be completed in a workmanlike / manner according to standard practices. Any alteration or deviation from above specifications Authorized ; involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our 'Note:This firoiksal may be workers are fully covered by Workman's Compensation Insurance. withdrawn by us it no accepted within days. Acceptance of Proposal - The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the Signature e 1 • work as specified. Payment will 11 mad 1 as outlined above. Date of Acceptance: i e Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition [l Replacement Windows Alteration(s) [( Roofing ❑ Or Doors 0 Accessory Bldg. EJ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other (Mr Brief Descrip 'on of Proposed j 4 , m �Q� / Work: if15 (�� tit_ �-IS l SI old /C.4 Steel 1-/ nLr /h r K /5 /t ei • Alteration of existing bedroom Yes '/ No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes ✓ No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing. complete the following: 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 (1 ('.� �r 7L Z , as Owner of the subject property hereby : • - 'ze ,I 1 d• . t 1 • r /, .i // / !� to : on my ,, ehalf, in all matters elative authorized by this •u permit applicatio . !� 2// Signature Owner D e 1, J 5 4) i '1 v S 01 4a Act ' M /Kf keg keg S , as Owner /Authorized Agent hereby declare that 14 e statements and information on the foregoing af/plication are tilt a nd accurate, to the best of my knowledge an eUef. Signed under the pains and penalties of perjury. //V N f/Pdia6/.-- • gnatu • 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: L: R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 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 Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained a , 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 © 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. RECEIVED Department use only - City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 0\t • 8 2012 212 Main Street Sewer /Septic Availability Room 100 WaterMell Availability - 6.. ; , �,; - 67_ -,, _ 1 `FECTioNs orthampton, MA 01060 Two Sets of Structural Plans NORTHAMPTON, MA o; 3- 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans L Other Specify 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 - 7 7. dh } -l-1 Pb(A) Map Lot Unit /', /�� a // mfr O/ c 2, Zone Overlay District r ( Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 1,77.-ti r I 1(76e ma_e_10‘, ci ) Current Mailing Addre A � _ i V' 0 - G "y�r� f� �. Telephone Signatur 2.2 • thorized Ageltt. — . 4 r il ►1. ., . s_. • / • � i • //In ' 1 / 6 d .. i Nam (1 rrent Mailing Address: ature I Telephone • CTION - ESTIMATED CONSTRUCTION COSTS f Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building / 40'1 / D (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 y� 6. Total = (1+ 2 + 3 +4 +5) / '739 le .0 Check Number 29* ills S5 This Section For Official Use Only Building Permit Number. Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0543 APPLICANT /CONTACT PERSON ACE CHIMNEY SWEEPS ADDRESS/PHONE 115 MAIN BLVD LUDLOW (413) 547 -8500 PROPERTY LOCATION 7 TRINITY ROW MAP 23A PARCEL 103 001 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 �j ` Fee Paid LJ76 Typeof Construction: INSTALL STAINLESS STEEL CHIMNEY LINER FOR GAS HEAT 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 INF ATION 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 �•n delay . /715 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. 7 TRINITY ROW BP- 2013 -0543 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A - 103 CITY OF NORTHAMPTON Lot: -001 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- 2013 -0543 Project # JS- 2013- 000875 Est. Cost: $1720.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ACE CHIMNEY SWEEPS Lot Size(sq. ft.): 18730.80 Owner: LAWTON ROBERT W & JULIA CAFRITZ LAWTON Zoning: URB(100)/ Applicant: LAWTON ROBERT W & JULIA CAFRITZ LAWTON AT: 7 TRINITY ROW Applicant Address: Phone: Insurance: 7 TRINITY ROW FLORENCEMA01062 ISSUED ON:11/15/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL STAINLESS STEEL CHIMNEY LINER FOR GAS HEAT 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 11/15/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner