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35-241 (3) 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: L4 L �' The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant � �� Date C�, _\ \ S Signature of Permit Applicant City of Northampton f � Massachusetts t DEPARTMENT OF BUILDING INSPECTIONS K nx,t . r ✓ 212 Main Street • Municipal Building 6r« Northampton, MA 01060 SsWyy y7�1� 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 I 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 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/Indivi dual): \ ► l�� l Address: _ C City/State/Zip: Phone #: "� '� G L Are you an employer? Check the appr priate box: Type of project(required): 1. I V am a employer with 4 ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑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. insurance. $ 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 11.0 lumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.M 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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. \ ` Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date:_2 - Job Site Address: �� Ci State/Zip: Q Attach a copy of the workers' compe sation 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 tt h-e;pains and penalties of perjury that the information provided above is true and correct. Siznature: I ��, Date: 4 Phone#: S7 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#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable £ Name of License Holder License Number Address Expiration Date Sign lure Telephone 9.Registered Home Improvement Contractor Not Applicable £ '� Company Name Registration Number Ad r ss Expiration Date Telephone, SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance idavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the uilding permit. Signed Affidavit Attached Yes.... . £ No...... £ 11. --Home Owner 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 Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature, SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks Siding [❑] Other[❑] Brief cription of Proposed Work ``1 O V-R, &WA 90i-ox -� ► A \ � ��= �-�l�k S Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa. 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 r as Owner of the subject property hereby authorize --R - ' to act o my be ' all matters relative to work authorized by this building permit application. _ a I - I Sign ure o wner Date I, r.b 0 , as Owner/Authorized Agent hereby dec are 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 Nafntf Signature of OAFEA3erR Date . � Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This colurnn to be filled in by Building Department ' Frontage Setbacks Front Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bIdg&paved p king) ft of Parking Spaces (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? �� NO \_�� DON7KNO0/ x�� YES x�� IF YES, duteissued:| � IF YES: Was the permit recorded at the Registry ofDeeds? NO K J D ES �� IF YES: enter Book Page and/or Oocument# �� B. Does the site contain a brook' body of water orwetlands? NO �_�� DON7KNOV/ «�/ YES �~J IF YES, has a permit been or need to be obtained from the Conservation Commission? Needstobeobtained �~\ Obta�ned »~� Date�~/ ' . C. Do any signs exist on the property? YES �^�� NO �.�� J 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: E. Will the construction activity disturb(clearing, gradingexcavation, or filling)over 1 acre orinit part ofa common plan ' that will disturb over 1 acre? YES NO K ) ~~/ IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Deparfiner�t use only City of Northampton Status of PermitA� N k [P4 r1� Building Department Ctrrh CuT/DrircewajrFermt# 4 i 212 Main Street SewerlSepfleAvalrab�t�ty ' 6 , W " S i 1u7'' APR z 1 2015 ' Room 100 �IVater/VtrellAvatlafillity k L` ",Northampton, MA 01060 !TWO Sets;of Structural Plans t _Ps 41 -587-1240 Fax 413-587-1272 P[of/Slte Flans " Electric. Fi nr,ng&Gds Inspections z` ' Northampton,MA 01060 Other Specify + . APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE,INFORMATION - 1.1 Property Address: Thls sectwn to be completed by office I Map Lot Unit c. L� �' Zone Overla District y Elm St :District..... 68 District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 1 LCA , ame(Print) ,---- Current Mailing Address: Telephone Si a ure 2.2 Authorized Agent: V-) n Name(Print) Current Mailing Addressss:� (� 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 Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) C Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: _ Building Commissioner/fnspector'of Buildings Date 43 LADYSLIPPER LN BP-2015-1003 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35 -241 CITY OF NORTHAMPTON Lot: -00 1 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2015-1003 Project# JS-2015-001924 Est.Cost: $10500.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BOB THIBODO ROOFING & SIDING 065699 Lot Size(sq. ft.): 45302.40 Owner: BLAIR DANIEL E&DEBRA A Zoning: Applicant: BOB THIBODO ROOFING & SIDING AT: 43 LADYSLIPPER LN Applicant Address: Phone: Insurance: P O BOX 201 (413) 527-7663 O WC NORTHAMPTON MAO 1061 ISSUED ON:412212015 0:00:00 TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE ROOF 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 4/22/2015 0:00:00 $35.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner