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307 ACREBROOK DR BP-2016-1424 GIs#: COMMONWEALTH OF MASSACHUSETTS Mao:Bock:29-372 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit4 BP-2016-1424 Protect 4 JS-2016-002449 Est. Cost: Fee:540.60 PERMISSION IS HEREBY GRANTED TO: Const.Class: contractor: License: use Oronu Homeowner as Contractor _ Lot Size(sq.b.): 10018.80 Owner: CASEY MARY E Tonin Applicant CASEY MARY E AT: 307 ACREBROOK DR Applicant Address: Phone: Insurance: 307 ACREBROOK DR (413)587-9749 O F LO R E N C E M A01062 ISSUED ON:6/1;2016 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 Finai: 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 611/2016 0:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-7272 Louis Hasbrouck—Building Commissioner 7 Deparbnent use only City of Northampton Status of Remit Building Department Curb Cut/Driveway Permit ;/ ' - 212 Main Street Sewer/Septic Availability r , Room 100 WaternNelI Availability s a9';�� Northampton, MA 01060 Two Sets of Structural Plans E,' phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans "o 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 3�711C1tCB`ok.�T- Map Lot Unit FI Dr,CAM-C-M0- V t 6(0 Z-. Zone Overlay District Elm St.DistrictCB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Curr 1 2.1 Owner of Record: ? C aLu — i J ..erect n-tik Name (Pa t) yn Current Mating/Addddress: -r ^� 1 £_ C. n_“,, Telephone .//3 fl' -3783 Signalur 'I -_ 2.2 Authorized Agent: ppep.,.ft $4 rs- 0;,7y, a (a., r-o S•oZ /tire& Name(Print) Current Mailing Address: /"`-' ,-� 2 - P/J -i2 7 __ Signature c Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant {a)Building Permit Fee Yo 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection _ 6. Total=(1 +2+3+4+5) Check Number /O$(/ 961416 This Section For Official Use Only Date Building Permit Number: Issued' Signature: ...,_ Budding Commissioner/inspector of Bnathnes Date Section 4. ZONING fro Information Must Be Completed. Permit Can Be Denied Due To incomplete information Existing Proposed Required by Zoning This column to he filled in by Building Department Lot Size .. _. _.... _.. Setbacks Front Side L: R: L: R: Rear Building Height Bldg.Square Footage % Open Space Footage °a _.... (Lot area minus bldg&paved parking) #of Parking Spaces Fill: voume&&Lccaa«;;—. —�..... ._...— A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW © YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , pate Issued: . C. Do any signs exist on the property? YES O NO O 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 C> IF YES, describe size, type and Location: E. VOX 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 O NO O 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) E Roofing n Or Doors 0 Accessory Bldg. D Demolition ❑ New Signs [O] Decks IC Siding(o] Other[C] Brief Work Description of Proposed 57, p- � r n r S y _ fR ....0 _� Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement _Yes _,TNo 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 a 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_u g Energy Conservation Comohance. 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 1.370,34' (lee ia.S as Owner of the subject property hereby authorize +' i Q-C 4 C & r C to act on my behalf, in all mattert relative to work authorized by this building permit application.•Signatu urre . • Date I, •V ...nvr a"e'a'^' as Owner/Authorized Agent here 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. J,-)Or.c ISS aaardiea� Prin Name `___ R ✓fes+++�-^"'-_� —IF Signature of Owner/Agen e9, 4, L—diel A J Date 5— / ts' _ / (y SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: License Number Address Expiration Date Signature telephone 9.Registered Home Improvement Contractor: Not Applicable 0 Company Name Registration Number Address Expiration Date Telephone_ SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MCI.e.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 ❑ 11. — Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 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 ander 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,vett 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 Slate Building Code,City of Northampton Ordinances,Staleaand Local Zoning laws and State of Massachusetts General Laws Annotated. Homeowner Signature _ 1 j O.gct{} . �,,. et_A...0 ._......_...... ....... The Commonwealth of Massachusetts W Department of Industrial Accidents •E� t Office of Investigations (`= 1 Congress Street, Suite 100 Set Boston, M4 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizatio&Jlndividual): Address: City/State/Zip: _ Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. 0 I am a general contractor arid 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 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.* required.] 5. D We are a corporation and its 100 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. workers' right of exemption per MOL 7 [No comp. 12.9 Roof repairs insurance required.] " c. 152, §1(4).and we have no employees. [No workers' 1 -0 Other comp. insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers compensation policy information, 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 shoving the name of the sub-contractors and state whether or not those entities hae employees. If the sub-contractors have employees,they must provide their uerrker comp.policy number. l 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: Job Site Address: City/State/Zip: 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 fhrwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by dty 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 fi.Other ...... Contact Person: Phone 4: 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: !' —7 _ t - ,r, rtin k A 0064-, The debris will be transported by: Q�� The debris will be received by: TT I: e c7 c/ . /19 rJ rc&1+Ie'bed Building permit number: 1/74-7 Name of Permit Applicant m a.r yp C 0.r r Date Signature of Permit Applicant City of Northampton Mrd .1?,,, Massachusetts e? ' • 4c ,r_,, D212 Main Os BUILDING INSPECTIONSing (19 ; tari. .,may 212 Main Sbreet a Municipal Minding �yS ..,s. \Vw'p°' „amu Northampton, mh 01066 INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner DOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 1083.4 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 Dourl a rough building insoectiyn.. (before work is concealedl,insulation inspection lit reguiredkand a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections canuesult in failure to obtain a ce. 'fice t • IR . r t :r r . 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 p-EL Y the project until such time as the proper permits and inspections are made I, E C. O c( / understand the above. (Home ow r/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date S - is--it i Address of work locations 3S?4C, e. ,1 ( k `' l cenC,r' 1'es .._ � Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as an individual, partnership.association,corporation or other legal entity,or any two or more of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership.association or other legal entity.employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance. construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MOL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and. if necessary, supply sub-contractor(s) name(s), address(es)and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary)and under"Sob Site Address"the applicant should write"all locations in _(city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617.727-4900 ext 7406 or 1-877-MASSAFE Revised 7-2013 Fax p 617-727-7749 www.mass.govidia