23A-093 (15) 17 FAiRFIELD AVE BP-2017-1486
GIs#: COMMONWEALTH OF MASSACHUSETTS
Man:Block:23A-093 CITY OF NORTHAMPTON
Lot:-001 PERSONS CON FRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:Bath reno BUILDING PERMIT
Permit# BP-2017-1486
Project# JS-2017-002480
Est.Cost: $11500.00
Fie:$75.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
use Group: KIM RESCIA 022464
Lot Size(sq. e.1: 13242.24 Qwner: GOTTLIEB SETH G&JENNIFER N
Zonine URBti00X Applicant: KIM RESCIA
AT: 17 FAIRFIELD AVE
Applicant Address: Phone: Insurance:
311 Locust St (413)320-1831 O
FLORENCEMA01062 ISSUED ON:6112I2017 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE TUB, SINK, TOILET IN BATHROOM
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: Qin 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 6/22/2017 0:00:00 $75.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-1486
APPLICANT/CONTACT PERSON KIM RESCIA
ADDRESS/PHONE311 Locust St FLORENCE (413)320-1831 p
PROPERTY LOCATION 17 FAIRFIELD AVE
MAP 23A PARCEL 093 001 ZONE URB(I00)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMI 7 (CATION CHECKLIST,
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 2 -)i
T BeaConstruction: REP ACE T $'INOILET IN BATHROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 022464
3 sets of Plans t Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOR ATION PRESENTED:
pproved 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
D-• olition Delay
t(—"77
Signature of il.ing 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 40& Contact Office of
Planning&Development for more information.
t !
City of Northampton . u. �' ^� c
Building Department 3 i®l = N' ` ,
212 Main Street 1,7.-- -
Room 100 - v ''
Northampton, MA 01060 4jja of Stfacturai Plans _
phone 413-587-1240 Fax 413-587-1272 Pin III4',,k4S r
tter 'Mt:III
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: 1Q
This section to be corn leted by office
`Map 0254 Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
A2.1 Owner of Record:
Name(Print) Current Mailing Address
-- - I . -c
Telephone
Signature
2.2 Authorized Anent:
-E I 3 / l ti id_ l .�
Name(Print) - Current Mailing Address:
le ( �(t. )(T./fief % � e3 3za lK3l
Signal e Telephone
SECTION 3- TIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building g coo Q (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
I 5 00 C U Construction from(6)
3. Plumbing 6 �d ,
Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection Ii
B. Total=(1 +2+3+4+5) I I S QC) r 0(' Check Number ZC,C, Y/,Se
This Section For Official Use Only
Building Permit Number DIssued:
ate
Signature:
Date
Building Commissioner/Inspector of Buildings
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
.. . Existing ..... NMI Required by Zoning
Eq.
Thisolmm to be fined in by
Building Depammeatmcnt
Setbacks Front
Side ......_..._
Rear
Open Space Footage .
Qat area minus bldg&paved
• kin:)
#of Parkin S.aces
1.11111.1
A. a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page ! and/or Document#... .
B. Does the site contain a brook, body of water or wetlands? NENg DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist an the property? YES NO
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 O
IF YES, describe size, type and location:
E. Valll the construction activity disturb(clearing, grading,excavation,or Ring)over 1 acre or is it part of a common plan
that will disturb over I acre? YES O NO're
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) Roofing ri
Or Doors D
Accessory Blc�dg. El Demolition CI New Signs [0] ID,V�Decks (I/I= Siding[0] Other[0]
Work: 1Bnef -e �
.[Lo L — fJ/ lf' 1roc7u\
Alteration of existing bedroom No Adding new bedroom Yes �o
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa„itNewhouse`and,iiiadditionito 'bush.coinotete 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
. , as Owner of the subject
property �{/!/QJ
hereby authorize 7.j /Iv / \L-Sc/
to act on my behalf, in all matters relative to work authorized by this building permit application.
r
Signature of Owner . Date
t
/1vt P , as Owner/Authorized
Agent hereby declare that the s atements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains penaltiesfof perjury.
\. sy
Print Name ”
/// • _a /
Signature•-O ner/A ent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: t Not Applicable £
Name of License Noide(: 14}1,„ tG C,( ( C _ •-
peens-ens- Num,-r
Ufa
Address .' -bon ime
_'-" . K1 A'"2 C-e'4 3 c? —/ g- .3/
Si 'tture Telephone
677 /7/
B-Regtisteied Nomeardent Contractor: Not Applicable £
AOAv ' eAccaly<e/ 7a
Company Name1 Registrati n Numbe
'a Cedbf f -EJ 31 I ! g �(/
Address Expirat Dale
Telephone
SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.O.L,c.152,§25C(Sy)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the Issuana@of the building permit.
Signed Affidavit Attached Yes £
1t:-Home Owner Exerptitin
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 1083.5.1_
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-tear 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
' The Commonwealth of Massachusetts
Department of Industrial Accidents
Ire-1E Cl Office of Investigations
• rt=
,__q600 Washington Street
1p= Boston, MA 02111
.g
....*� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 7 Please Print Legibly
Name (Business/Organization/Individual): 7 j)'9 fes( Q
Address: 3 1 1 JC,LLJ ti---
City/State/Zi ----.
i---City/State/Zip. ' , , J 1J 6 a Phone #:_ L3 320 /E, 3
Are you an employer?Check the appropriate box:
contractor and I Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general
\ ,�, employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
2`11 I am a sole proprietor or partner- listed on the attached sheet. •� Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance? 9 ❑ Building addition
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' 13.11I 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.
tContractors 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.
1 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 ins to c' -ra:e verification.
1 do hereby certify u - the pains,a,-, .enalties of perjury that the information provided above is true//////aaa���n^^^d correct7
Signa / 't .‘1' /O9(J./a Date: /�//
Phone#: / //3 ' 3Zc, --/f3 I
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
Y NR
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Massachusetts $ r
( t DEPARTNENT OF BUILDING INSPECTIONS p
\ a 1 212 Main Street • Municipal Building
-- Northampton, MA 01060
IDISPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXTMPTION 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)
I 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 fined b MG c 111, S 150k
Address of the work: 12 ' b2. 1 (/t
The debris will be transported by: IL 6-s
The debris will be received by: - P
_ .
Building permit number:
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Name of Permit Applicant AlL ?tit SC ( Cti
c'M 7
Date Sig ,:turf ermit Applicant