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30D-010 r j 1 I i i i r 1 i i i j { l Aviv ' , J �1 -7 Lt 6 J 0 cL - City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: The debris will be transported by: Ge b&Li r The debris will be received by: ` Building permit number: Blame of Permit Applicant ZL 11V47— 113 C) 571 Date Signature of Permit Applicant City of Northampton S Massachusetts DEPARTMENT OF BUILDING INSPECTIONS :M 212 Main Street • Municipal Building Northampton, MA 01060 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 the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made 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 me. Date_ � Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents 1 Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 6-e it-zA,�. .c A"o-nAo- <,_ t-f Address:�t� , Yv�� r5 City/State/Zip: , G-- 0 1 33.. Phone #: 5 .5 '�L 7"-116 Are you an employer? Check t1fe appropriate box: Type of project(required): 1.9 I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. F-1 New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. tZ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. msurance.1 required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. tHo meowners 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins. Lie. #: \1 VU C (10 00 5 (1()9 a Expiration Date: 40/e" Job Site Address: ,�,;1�i" uf"5 ftl City/State/Zip: ftoirev►te Mei.01061'3600 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 certify under theejpains and penalties ofperjury that the information provided above is true and correct. Signature: r 6,J- Date: 27116_1 Phone#• 5� - 2 -7 Vzo Official use only. Do not write in this area, to be completed by city or town offciaL 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#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: �� 1 Not Applicable £ Name of License Holder: C Yzx�( lX /Xr t. 1` CS-010 7,0,8 License Number cu`3 I 1—S _I 7 Adclrr-Egs.s / Expiration Date Sig ure Telephone 9.;Registered Home Imp"rovement'Contract or „ . Not Applicable £ -teeVn -c 0", t 1n 99/ :?Company Name Registration Number �8 11--,2,2 15 Address Expiration Date Telephone aj Q, -7q 10 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)7 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...... £ 11. - Home Owrier.Exemption 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 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 al Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signatur SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[[I] Other[EJ] Brief Description of Proposed ��+�� j� �"t'�� '� Rea Ae over eau dl �Oc 3r Work: SE-�".__.. (o. \L( M -e CA(-,V-MA� Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes 7Z No Plans Attached Roll -Sheet sa:'If New and or addition to'exlstinq 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 as Owner of the subject property hereby authorize 61-e k:,, 1"�t-Gh vn�ct�" to act on my behal all matters relative to work authorized by this building permit application Signature of Owner l/ 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 ^� _ Ott � r- , Signatat�e of Owner/Agent Date , . Section 4. ZONING Ail Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning aj� This column to be filled in by— Building Department Frontage Setbacks Front Rear Building Height Bldg.Square Footage 0110 Open Space Footage % (Lot area minus bldg&paved ..........J #of Parking Spaces (volume&Location) A. Has a Special Permit/Vahance/Rnding ever been issued for/on the site? x�� -� NO «x~�� DONTKND\� �~� YES �~� IF YES, dateioued: IF YES: Was the permit recorded at the Registry ufDeeds? NO ~~K ) DONTKNOYY 0 'ES ^ IF YES: enter Book PageL 1 and/or Document# B. Does the site contain abrook, body of water orwetlands? NO 0 DON7KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs tobenbtained �~� Obtained �~\ Date Issued: ��' x_/ ' C. Do any d ��signs YES �~/ 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 0 IF YES, describe size, type and location: ' 1 E. Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre nriait part ofo common plan ' that will disturb over 1 acre? YES NO ) IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ^ ~ L w7 �� Department use only MICH.. orthampton �tatus,of Permtt r , Buil It Department Guru Gut/Dnveway Perrrttt r n F � 20J� 212' ain Street Sewer/SepticAyaira6tllty F7 om 100 WaterfWeltAW1 ablhty Electric. Plu ph Northam ton, � ton MA 01060 Twa Sets of S#ructurai Plans r " North n 240 Fax 413-587-1272 PIot/Site Plaris Other�Speo�fy' � 1 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 completetl by off ic e Map Lot Unit rernC-e �� G T fO� Zone Overlay Drstiict EIm St;Distract C8 Drstrtct SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 1 " V 2` 1'1O J J t�� e / yr^ rte Name(Print)„ Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Name(Print) p 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 ® a0 . 'co . 2. Electrical (b) Estimated Total Cost of o 0 0 �� ' Construction from 6 3. Plumbing 'i O 00 cr 4-a Building Permit 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: Building Commissioner/Inspector of Buildings Date File#BP-2015-0917 APPLICANT/CONTACT PERSON GERALD ARCHAMBAULT ADDRESS/PHONE 68 AMHERST ST GRANBY01033 (413)552-7410 Q PROPERTY LOCATION 326 BURTS PIT RD MAP 30D PARCEL 010 001 ZONE SR(100)/WP(26)/ 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 NEW BATHROOM IN EXISTINGARAGE&NEW ENTRY DOOR New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 010788 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO TION 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 Demolif n Delay 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. 326 BURTS PIT RD BP-2015-0917 GIs#: COMMONWEALTH OF MASSACHUSETTS MW:Block: 30D-010 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-2015-0917 Project# JS-2015-001775 Est. Cost: $15000.00 Fee: $90.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: GERALD ARCHAMBAULT 010788 Lot Size(sq.ft.): 257004.00 Owner: NUTTELMAN MELISSA A Zoning: SR(100)/WP(26)/ Applicant. GERALD ARCHAMBAULT AT. 326 BURTS PIT RD Applicant Address: Phone: Insurance: 68 AMHERST ST (413) 552-7410 O Workers Compensation GRANBYMA01033 ISSUED ON:41212015 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL NEW BATHROOM IN EXISTINGARAGE & NEW ENTRY DOOR 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 4/2/2015 0:00:00 $90.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner