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35-091 (2) 1181 BURTS PIT RD BP-2017-1421 claim COMMONWEALTH OF MASSACHUSETTS Man:Block:35-091 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:replacement windows/siding BUILDING PERMIT Permit# BP-2017-1421 Project# JS-2017-002354 Est. Cost:$18900.00 Fee:$100.06 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Grouo. KEVIN AYER 061973 Lot Slxe(sd. ft.): 8929.80 Owner: ZEITLER CYNTHIA zoning Applicant: KEVIN AYER AT: 1181 BURTS PIT RD Applicant Address: Phone: Insurance: 1192 WHATELY RD (413) 369-0078 () CONWAYMA01341 ISSUED ON:6/72017 0:00:00 TO PERFORM THE FOLLOWING WORK:SIDING &WINDOW REPLACEMENT POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Budding Inspector Underground: Service: Meter: Footings: Rough: Rough: Housed Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Insulation: Final: Smoke: Final: Tills 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 6t7/2017 0:00:00 $10200 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck-Building Commissioner City of Northampton - -��—_ Building Department /' r 'S " ! 212 Main Street * n JUNI Room 100 6 ' Northampton, MA 01060 ;� phone 41 -587-1240 Fax 413-587-1272 g ISM 'uit „ APPLICATION TRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION Q P- I 1- 14At 1.1 Property Address: This section to be completed� by office l U ( nags s 7'r j) Map 35 Lot C5pl Unit 1/ II Zone Overlay District rCpfZeNet 1\6\p Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: N CYrid IA A ' ZEIrLER... i(gi BoRrs ?a Rb Name(Piiry% ///ill - Current Mailing Address: r/ ./ / ��a �,/� Telephone 413 , 584 - 38e Signature �t%" 2.2 Authorized Agent: KEui.0 AYEfg lI92- &WkrEt,/ /21) , CosJw1 Name(Print) r/ nn Current Mailing Address: ryl 413. 369- 00 9‘53 Signature /// Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 4112 6-60.00 (a)Building Permit Fee 2. Electrical t ,4 66 0o (b)Estimated Total Cost of ( Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6 ,/� r; /{j) 6. Total=(1 +2+3+4+5) 15, 100 ,60 Check Number (Z I 0(/ This Section For Official Use Only Building Permit Number IssuedDale : Signature'. (;# /Z. �� 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 •��. . _.,M30-5,r pA-` S. Frontage Setbacks Front _ Side L:- ._ R - . Li R:: _ . Rear 4Q. .. _..: Building Height 30' ,. Bldg. Square Footage gd0 to % Open Space Footage (L �33/ k^ rl f_ amt area minus bldg&paved 1Q parking) #of Parking Spaces L-- -- - - - Fill. Q (voiume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO © DONT KNOW 0 YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book . Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO j DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained © , Date Issued: C. Do any signs exist on the property? YES O NO 0 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 (QS 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 ty/ 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 endows Alteration(s) ❑ Roofing I Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Ip Siding” Other[01 Bnef Description of Proposed Work. SIDING, 4- WIPE iUi gEPc6Bl'^g, Alteration of existing bedroom Yes K No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roll -Sheet sa.SNew-houe a' .v "add'i��ion to'e*istincthousinq.complete the folloWh q: a Use of building :One Family Two Family Other b. Number of roams 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 CONTRACTOR1APPLIES FOR BUILDING PERMIT I, C �/ i N IPl/c A- Z Y 1 7-LG ? , as Owner of the subject property I, Pn hereby authorize k F j Ix it x- toy rbehal, n al tters relative to work authorized by this building permit application. ac Signa a Owner �`( a / �l Date I, K- �l f - A TY . , 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. k Qu-4 AyER- Print Name swot 6 -5-1417 Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Suoervlsor: /) j(p Not Applicable £ None of OcenseXeklap: V EVI ( /}ny Vg-- License Number 1HZ WHA-rtc9 Con14A<( (VIA CS -a6 -1973 Address Expiration Date , - 9,3 561- oa 48 Z 9 Z6, Signature Telephone L-177011/ /'£U/A 14(4tZ4? YfHOO . coal S.Renisteied Rome lmpmvement Contractor . , Not Applicable £ ``` Company Name Registration Number Ye OM ) }lqt",e,..- /28 9Zp AddressExpiration Date CQ/lj(-L/py /�/j,r Telephone l &%7 6. 9 -2o/ 7 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.6.L.c.152,§28C(8)) 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 Attach-.a..,, £ No £ .f ante" e•8, xe AUtton. 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 700, Sixth Edition Section 108.3.5.1. Definition of Homeowner:Person(s)who own a parcel of land on which hefshe 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 be/she shall be responflble for all such work performed under the buildinv 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 The Commonwealth of Massachusetts Department of Industrial Accidents • t.=zr e —7.-_" t: Office of Investigations 8_ 4 ton Street 600 Washington_i Ii1= Boston,MA 02111 '''•�s* www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): KC 1/4/ /4 A1/411 14 r� Address: IIgi WH-a'rlcy PD dop.1WA-aj rvIIk City/State/Zip: lCNWttf IMP 0134( Phone #: 4/6 -361 - 00 1) eg Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I rrr��r,,,employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. ]V, I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling t ship and have no employees These sub-contractors have g. ❑ Demolition workingfor me in anycapacity. employees and have workers' P $' 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.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 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 contactors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors 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: 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 forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct Signature: /OW 9tisr#// Date: 6"S' Z6/ / Phone#: q/3 - 36f- O07B 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#: Kew" City of Northampton �6. fir. Massachusetts * •'r� (4. 4 s DEPARTMENT OP BUILDING INSPECTIONS 212 Main Street a Municipal Building s• �' • Northampton, MA 01060 'r 6y.' A. 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) 1 will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location 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: IIB( +3ofp i sfelt g.* The debris will be transported by: t Et1 fU /4 of 6 F. The debris will be received by: VALLg i pea IONAL ReeICJN6 Building permit number: ' Name of Permit Applicant - Ed/ri1 A-ye 12- - —6620 (7 114,y0 Date Signature of Permit Applicant