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31A-009 (4) 281 ELM ST BP-2017-1288 GIS7: COMMONWEALTH OF MASSACHUSETTS Mao:Block: 3I A-009 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Bath reno BUILDING PERMIT Permit a BP-2017-1288 Protect JS-2017-002141 Est. Cost: $40825.00 Fee: $266.50 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: use Group: Homeowner as Contractor Lot Stanton. D.): 29620.80 Owner: DARDANO KRISTIN L& LILIBETH K DENHAM TRUSTEES Zoning: URB(100)/ Applicant: DARDANO KRISTIN L& LILIBETH K DENHAM TRUSTEES AT: 281 ELM ST Applicant Address: Phone: Insurance: 281 ELM ST NORTHAMPTON MA01060 ISSUED ON:5/9/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:BATHROOM RENOVATION 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: FeeTvpe: Date Paid: Amount: Building 5/9/2017 0:00:00 $266.50 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-1288 APPLICANT/CONTACT PERSON DARDANO KRISTIN L& LILIBETH K DENHAM TRUSTEES ADDRESS/PHONE 281 ELM ST NORTHAMPTON PROPERTY LOCATION 281 ELM ST MAP 3IA PARCEL 009 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERM ' PPLI ION CHECKLIST CLOSED REQUIRED DATE ZONING FORM FILLED OUT ` Fee Paid 4 Building Permit Filled out {i tit Fee Paid Tvpeof Construction: BATHROOM R ! TION 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 LOWING 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 tc-917 S o Bu' ding S icial 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. ` z' ' z peparfr� n usepn�Y ..-, J City of Northampton i,.�h[ �fPann '�'t n ,, i�3: Kt ,y,I iii / Building Departmentiii 4ircut/Dn` Fi PeE"m,�rt *&' f' Cb 212 Main Street k {ii bibaabiilrC �f1t t a zr '§:em" Room 100 4040:040)--,y ` '� `I Ti Northampton, MA 01060• '(Wo Bad e£5tr ratPtaos,e' phone 413-587-1240 Fax 413-587-1272 p9tlsrte Nanst ''i OtherSPe907F .. i APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: ., Th_[Istsect7onto becomptefed bbfyy+{yoficg o9 0l f i/ t, /J..- ,r— Map d fes ° Lot € Unit ,1 2, —zi.+r,•e. V /Mill / Zone Overlay DfstHM -Elm Si.district CS Disfrict SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: G/44067# K ar ri/k l t OW/ , (VT-- Name(Print) CurrentM4�Ytress: /Z/Zo7G..„37 `x. T.__ Telephone Signature 2.2 Authorized Agent: 64. ,e'OX y /1. /77/ /5'71 C.�" r, c7/i/ae, i aZ Name O Int Current MaThng Address: �'. . /9 12 4'xlJ aq/J02- Sig ature / Telep ane SECTION 3-ES !MATED CONSTRUCTION COSTS Hem Estimated Cost(Dollars)to be Offiaa(Use Only completed by permit applicant 1. Building (a)Building Permit Fee /1;COO2. Electrical //3 (b)Estimated Total Cost of 1 {'J Construction from(6) 3. Plumbing J D�`9 Building Permit Fee 4. Mechanical(HVAC) DCS r 5. Are Protection --- 6. Total=(i +2+3+4+5) , �6 (,'(Check N�Um / r oa ,66-0 This Section For'9fFe'raYOse O y r Building Permit Number: Date at eG Signature: _„- Building Commissioner!Inspector of Buildings Date • Section 4. Z ING All Information Must Be Completed, Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filed in by r Building Department Lot Size i i Frontage Setbacks Front (__J C I Bale 1.,:1 RI ....... I L:r ' RI i i . I 1 Rear . ... . I r' Building Height --"'I I nn Bldg.Square Footage I I t_i - % F-1 '- t I f--1 • Open Space Footage % — ^^� (Lou area minus bld8&paved t_._� l._.____I ,1 I parking) s if of Parking king Spaces I ' i i -__z Fill: I (vobune&Loc timn) ---- A. Has a Special Permit/Variance/El ding ever been issued/f^o^r�/on the site? NO 0 DONT KNOW (41V YES IF YES, date issued:: IF YES: Was the permit recorded at the R-tistry of Deeds? NO O DONT KNOW t:/ YES Q • IF YES: enter Book I _ Pagel and/or Document N __ B. Does the site contain a brook, body of water or w=tlands? NO `Pt DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained rom the Conservation Commission? Needs to be obtained Ll Obtained t, C. Do any signs exist on the property? YES Q NO 0 IF YES, describe size, type and Location: I D. Are there any proposed changes to or additions of signs intende. •or the property? YES © NO +s IF YES, describe size, type and location: ;' 17 E. Will the construction activity disturb(clearing grading,ex valion,or filling)ove\bi acre or Is it pad of a common plan that will disturb over 1 acre? YES Q NO R4 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 El Addition ❑ Replacement Windows Alteration(s) Q Roofing El Or Doors D • Accessory Bldg. El Demolition ❑ New Signs [I7] Decks [q Siding[O] Other iX Brief p: i.tion •f• o•ase• ♦ 7/t1ff rt $ fiT� y' f� �^�, Work: if !�s r At)+77ai \ -ft 4," coCOY. .L' , • .46- Attarratbedroom Yes x No Adding newbedroom Yes /, by ffindesterY Se Attached NarrativeRRenovating unfinished basement Yes �Xl No jai Plans Attached Roil -Sheet ea If New fiouse and or'additlon to ezietitiq hou5inq, complete the follovginq: 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 f the subject property ,..,hRi'/ �T abaft— to hereby authorize i? C /4. act on my behalf, in all matters relative to work authorized by this building permit application, Signature of Owner1 \\ Date I, { C\; c i4. �t+n h 0..M , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best or my knowledge and belief Signed under the pains and penalties of perjury. { j to{SQ Print Name Ck/17 Signature of Owner/Agent Date • SECTION 8•CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable £ Name of License Holder: License Number Address Expiration Date Signature Telephone 9.Re [stored Home Imam meid'Contractor: •. NH Applicable £ F.:6i tC,( .lrr _: f{yBistration Numberl Company�^ �Na�m�e.,`/r/ /,��/ �r�-- �,, L'�,�t::"T 4 fi";�/!-t :M_acJ�/l. r //oar o�lS Address A244 I �pi��'y'}^'' y[/3 Expiration to 1.441'. %air✓ ✓r'// Q.w 0 Telephone at —.r 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 E No E 11.-.Home Ovater.Egemtttion The current exemption for"homeowners"was extended to include Owner-occupied Dwepines 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 1083.33. f?eflnition 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 accessary 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 ail such work performed under the buitdina 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 .�i ,asp-- • , City of Northampton icy"f / Massachusetts •w2> L ion ( pG.y. D212 Main S OF BUILDING al Building 311 Main Street o Municipal Building PECTIONS �J , ace' \..�� Northampton, MA 01060 rirr wojh. 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, Tic ---tn.he..._ 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 g /8--/17 Address of work location ate/ 57- .�. . The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 1 Congress Street, Suite 100 (d Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information W Please Print Legibly Name (Business/Organization/Individual): L1214//G/ yyti (/ayc, _ Address: 069( y, p�yt�V ,gyp ti 2e7 Li �(iL / Phone #: </O — t Are you an employer? Check the appropriate box: Type of project(required): 1.E 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. ❑New construction listed on the attached sheet. 7. .Remodeling 2.E I am a sole proprietor or partner- ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance P required.] 5. ❑ We are a corporation and its 10.X Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their I I.EPlumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.D Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any 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'camp.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: 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 S250.00 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. Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: ��—i J.ae'a� Date: (V/57//—) Phone#: 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#: 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: ..e1 (•-.727- �/ The debris will be transported by: &OFc /t 7 r The debris will be received by: Lilts ay Zt, e-7 47 de �1✓rJ6 Building permit number: Name of Permit Applicant G/Z-v,G'/ i- d( c/Sf/I7 Date Signature of Permit Applicant