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29-046 15 PIONEER KNLS BP-2017-0937 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-046 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGLLcc.1144/2�A) Category: KITCHEN& BATH RENO BUILDING PERMIT Pe,mit# BP-2017-0937 Project# JS-2017-001599 Est.Cost:$4950.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor_ Lot Size(sq. ft.): 11979.00 Owner: PERRIER KEVIN Zonis : Applicant: PERRIER KEVIN AT:: 15 PIONEER KNLS Applicant Address: Phone: Insurance: P O BOX 778 (413) 527-4060 O EASTHAM PTONMAO1027 ISSUED ON:2/13/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACING CABINETS IN KITCHEN AND BATH 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 Si,nature: FeeType: Date Paid: Amount: Building 2113i20170:00:00 $65.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck-Building Commissioner File#BP-2017-0937 ,[� APPLICANT/CONTACT PERSON PERRIER KEVIN / d6` ADDRESS/PHONE P O BOX 778 EASTHAMPTON (413)527-6355 92 PROPERTY LOCATION 15 PIONEER KNLS MAP 29 PARCEL 046 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid 4I /6 Building Permit Filled out l' b/ Fee Paid Typeof Construction: REPLACING CABINETS IN KITCHEN AND BATH New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owned Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 001-0joliti. Delay t, o, /6 _ uilding 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) - - Deparhnent use only City of Northampton Status of Permit Building Department curb Cut/Dnveway permit 212 Main Street Sewer/Septic Availability ' Room 100 WaterNleil Availability d r i Northampton, MA 01060 Two Sets pfsfrugtirel P)ahs'� phone 413-587-1240 Fax 413-587-1272 PiotSite Plans Ltd "— Ot(ier 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 15 Pioneer Knolls Road, Florence Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Norwich Properties,LLC 123 Union St., Ste 200, Easthampton,MA 01027 Name(Print) Current Mailing Address: 413-527-0210 Telephone Signature 2.2 Authorized Agent: Name(Pont) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 4,000 (a) Building Permit Fee 65.00 2 Electrical 450 (b)Estimated Total Cost of 65.00 Construction from (6) 3. Plumbing 500 Building Permit Fee 4 Mechanical(HVAC) 65.00 5. Fire Protection 6. Total=(1 +2+3+4+5) 4,950 Check Number X373 This Section For Official Use Only Building Permit Number: Issu Dated: Signature: Building Commissioner/Inspector of Buildings 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 .28 i _.28 Frontage Setbacks Front Side L R:' _ L: .. . .FR:; Rear I_..._. Building Height I r_.. . Bldg. Square Footage -i % I,_ _.. Open Space Footage (Lot area minus bldg&paved parking) #of Parking Spaces _ --I - - Fill: - -- (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW 0 YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW ® YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW © YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO Q 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 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) m Roofing ❑ Or Doors Q Accessory Bldg. ❑ Demolition ❑ New Signs 101 Decks IM Siding ID] Other lm Brief Description of Proposed Work_ Rcmmnum efe,rseng Cat^nmm and kitchen Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes x No Plans Attached Roll -Sheet ba. If New house and or addition to existing housing, Complete the following: N/A 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 la-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 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 Licens4 older Kevin Perrier CS-085319 License Number 123 hi treet, Ste 200, Easthampton, MA 01027 1/13/2019 Addis It" Expiration Date 413-527-4060 Signature) I - Telephone 9.Re:is. Home Im•rovement Contractor: Not Applicable 0 Company Name Registration Number Address Expiration Date Telephone 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 it No 0 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 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 /rmit. The undersigned"homeowner"cert' s aassumes responsibility for compliance with the State Building Code,City of Northampton Ordinances, State— oc�ening Laws and State of Massachusetts General Laws Annotated. Homeowner Signature 1 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: 15 Pioneer Knolls Road, Florence The debris will be transported by: Complete Disposal The debris will be received by: Complete Disposal Building permit number: Name of Permit Applicant Norinto\ Pre?ec. C65 ) t_U,C. Date P.n .ture of Permit Applicant The Commonwealth of Massachusetts 414—fl Department of Industrial Accidents get= A 1 Congress Street,Suite 100 '4' Boston, MA 02114-2017 r x ir 4:1 www.mass.gov/din Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE TILED WITH TI IE.PERMITTING AUTHORITY. Applicant Information Please Print Legibly NameBusiness/Organiaadnr✓Individuap: Five Star Building Corp, Address: 123 union Street, Ste 200 City/State/Zip: Easthampton, MA 01027 Phone#: (413) 527-4060 Are you an employer?Check the appropriate box: Type of project(required): 9 1 am a employer with employees tall andlor part-rime}' 7. 9 New construction 7.0 I am a sole proprietor or partnership and have no employees Poring for me in 8. / Remodeling any capacity.[No workers'comp.insurance required 3 9 I am a homeowner doing all work myself Info workers'compinsurance required.[' 9. 9 Demolition 4E l am a homeowner and will be hiring contractors to IXIDdtxt all work on ray property. willIb Building addition ensu re Metall cnnna-torseiher hateworkers'camoenation insurance or are sole II.9 Electrical repairs or additions proprietors with no employees 12.9 Plumbing repairs or additions 5.®I am a general contractor and I have hired the sub-contractors listed on the attached sheet lip Roof repairs These sub-contractors have employees and have workers'comp.insurance': 6.0 We ere a corporation and its officers hase exercised their right ofexemption per MGL e. 14.9 Other_ 152,§1(4),and ue have no employee,.[No corkcrs'campinsurance required.) *Any applicant that checks box It I 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 indicant's such. :Contractors that check this box must attached an additional Sheet showing the name of the.subcontractors and state whether or not those entities ban employees. if the sub-contractors have employees,they must provide their workers'comp pokey number. 7 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: General Casualty Co of WI Policy s or Self-ins,Lia#: CWC1238432 Expiration Date: 5/9/2017 Job Site Address: 15 Pioneer Knolls Road City/State/Zip:Florence MA Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MOT c 152,§25A is a criminal violation punishable by a tine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the Kinn of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify ander the pains and penalties of perjury that the information provided above is true and correct. Signature: Kevin Perrier Date: February 7, 2017 Phone#: (413) 527-4060 Official use only. Do not write in ibis area,to be completed by rip"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 1 6.Other Contact Person: Phone#: City of Northampton �— := 4 Massachusetts Fyi• 4- e� • 9i W. z (1;1-4,t DEPARTMENT OF BUILDING INSPECTIONS �`• 212 Main Street a Municipal Building �Jy` CO "� Northampton, !Q 01060 J'-, o 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 Dour). 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 t e trades hired secure their proper permits in conjunction to the building permit issued, and that they i -t their required inspections. Failure of the individual trades to secure the permits and inspections 111. equired can PFLAY the project until such time as the proper permits and inspections are m _ I, // understand the above. (Home owner( .-'s2 ent's signature requesting exemption) I will call to sche/ le I required building inspections necessary for the building permit issued to me. Date 21''111"1 Address of work location 15 Pioneer Knolls Road, Florence ,® . Massachusetts Department of Public Safety Board of Building Regulations and Standards License.CS-085319 Construction Sppervisor KEVIN A PERRIER 120 UNION ST EASTHAMPTON MA 01027 %,GtG!oi� 0/cavy— Expiration: Commissioner 01/13/2019