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35-005 (36) 92 TURKEY HILL RD BP-2019-1405 cls#: COMMONWEALTH OF MASSACHUSETTS Map:Block:35-005 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category Above ground pawl BUILDING PERMIT Permit# BP-2019-1405 Proiect# JS-2019-002268 Est.Cost:$5000.00 Fee:$40,00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use croup: Homeowner as Contractor_ Lot Siu(sa. R.): 135340.92 Owner: STEFAN CECILE 1&DONALD W zoning: Applicant. STEFAN CECILE J & DONALD W AT. 92 TURKEY HILL RD Applicant Address: Phone: Insurance: FLORENCEMA01062 ISSUED ON.61712019 0:00:00 TO PERFORM THE FOLLOWING WORK.ABOVE GROUND POOL 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 OccuoancY signature: FeeTYpe: Date Paid: Amount: Building 6/7/20190:00:00 $40.00 212 Main Street.Phone(413)597-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File q BP-2019-1405 �' 1 APPLICANT/CONTACT PERSON STEFAN CECILE 1&DONALD W Q ADDRESS/PHONE FLORENCE PROPERTY LOCATION 92 TURKEY HILL RD 1, MAP 35 PARCEL 005 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid TvceofConstruction: ABOVE GROUND POOL 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 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 Management Demolition Delay �� 67 / Signature of Building 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. City of Northam n RECEI -sem Department use only erm i Building DepartL Curb Cut/ ve ay Derma f 212 Main StraJUN _ s er/s tic ailabilty - Room 100 rnv 11 Av lability .\ Northampton, MA Two Be of s cb ral Plans phone 413-587-1240 Faxans RTHAMPTON. ecl APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION t-SITE INFORMATION 1.1 Address Property AddresThis section to be completed by o T-2 o2 TuR J(,'/ //'W Rd Map Lot 07S Unit FJorLnCGI rnp. Zone Owday District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: NameW) Current wang A9AX — �•�� /�u Telepnore l J �l Signature 2.2 Authorized Agent: Name(Print) 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 �1 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cast of Construction from 6 3. Plumbing — Building Perrrlh Fee 02 - 4 Mechanical(HVAC) 5. Fire Protection S. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date Issued' Signature: Building Commissionenlnspedor of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to bm fined in by BuiNing Depanmat Lot Size Frontage Setbacks Front -"-" ---- __ Side L: R: LR Rear Building Height Bldg.Square Footage . Open Space Footage (Lot area minus bid,&pave 4ofParkin Spaces tFill: wlume&Locatimm A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DON'T KNOW O YES O 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 If B. Does the site contain a brook, body of water or wetlands? NO O 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 IO , Date 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 O NO O 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 I© IF YES,then a Northampton Storm Water Management Permit from the DPW is required. IPTI N FPR P EDW RK check all applicable New House ❑ Addition ❑ Replacement❑Windows Alteratlon(s) ❑ Roaring ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ �New Signs [0] Decks [p Siding[0] Other[O] Brief Description of Proposed TOOL REP/ltifi me� Work: !! Alteration of existing bedroom_Yes No Adding new bedroom.Yes No Narrative Naetive Renovating unfinished baseent Yes No Plans Attached Roll -Sheet ea. 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 c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stones? I, 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 R. 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 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 OEM- I, 1��7'/I/q LQ as Owner/AuNonzad 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. 0 ONpL 1 S l!Lai PrintNa rf� Y Signature of Owner/Agent Dale SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable O Name of License Halder: Licerme Number Address Expiration Data Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152,S 2SC(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.. .. ❑ City of Northampton j Massachusetts Sv`- D&PARTFII:Nr OF BDILDING IN"WrIOM 212 Main atreat • Municipal suiltlinq C Northampton, as 01060 .� AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction,alteration,renovation,repair, modernization, conversion, improvement,removal, demolition,or construction of an addition to any preexisting owner-occupied building containing at least one but no more than four dwelling units....or to structures which are adjacent to such residence or building'be done by registered contractors. Note:Lf the homeowner has contracted with a corporation or LLC,that entity must be registered. Type of Work: Est. Cost: Address of Work: Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): —Job under$1,000.00 _Owner obtaining own permit(explain): Building not owneroccupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: 1 hereby apply for a building permit as the agent of the owner: Date Contractor Name HIC Registration No. OR: Notwithstanding the above notic I hereby apply for a building permit as the owner of the above property: -7-i9 Z".I/ 2,4go/ Date Owner Name and Signature City of Northampton Massachusetts DEPARTl16'NT OF SOILDING INSPECTIONS 212 Min Stmt • e icipal Building � Nort pton, NB 01060 Y "pac Massachusetts Residential Building Code Section I IO.R5.1.2 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. Section 110.115.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.115, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. 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. City of Northampton •'P � Massachusetts c DA'PAa216NT OF BM=I= Z8 E`CTIONs t � 212 Main 6t—t atau,icipal Building Northampton, MA 01060 Debris 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 property licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from construction work being performed at: (Please print house number and set name) Is to be disposed of at: ,per (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: A (Company Name and Address) Tads/ ".- /frr/r Signature f Permit Applicant or Owner Date If,for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. The Commonwealth of Massachusetts Department of IndustrialAccidents ! Congress Street,Suite 100 Boston,AIA 02II4-2017 www-massgov/dia VIA orkers'Compensation Insurance Affidavit:Builders/Contraeton/Eleetricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lesibly Name(Busmcss/Otgaa.anoNlwh,iduaU: Address: City/State/Zip: Phone#: An you an employer?Check the appropriate box: Type of project(required): 1.❑1anaemployer with cmvloyecs(billwaterran-limey' 7. New construction 2.[]]me a sale prapsoci r or partnership and have no employers working fm are,en 8. ❑Remodeling any capacity.[No woskn s'comp manatee ots w ll 3711 an a Iwncownm doing oil work myself[No worker'camp.wnancemvtrical 1• 9. ❑Demolition 4,a1 an is homeowner and way be boost contractors W conduct wok on my properly. I will 10❑Building addition umthat an comm�orscither m.e workers compensation immnnremae xnm I1.❑Electrical repairs or additions pmptiemrs with no cmpWyces. 12.❑Plumbing repairs or additions 5.[]I an a genal connector and l have hired the subcontractors lisad on mmworanazMd sheet, l3.❑Roof repairs Them su -cons have employees mW have wakens'con,imus 6.❑W'e anaanpontiov and i6 off ars hevc cxaciacd Ween right ofexempnw per MGL c. 14.[—]Other 152,1114),and we hoc no employees.IN.woken'comp.imurance,ralobekl 'Any applicant Wat checks box#1 mast also fill out We section below showing Wen workers'compensation policy infomutum s Bomeowmrs who submit this affidavit indica ig they we doing all wok and Wen hire outside connncton mast submit a new affidavit twheatthg such. 4bntraemrs that check this hos most attached an additional them showing the name ofdo,sub-contactors and tam whether or not those entities have employees. If dm subconnucmrs base employees,they must provide their cookers comp.W licy number. I am an employer that is providing workers'compensation insme nce for my employees Below is the policy and job.site information. Insurance Company Name: Policy N or Self-ins.Lic.u: Expiration Date: Job Site Address: City/Slate/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and exp-nation date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby Acer underr the pains and penaldes of�i erjury that the information provided6 - 7 - /9 above^u7true and correct Signature: lf+— -�1�j t� .5//�idT�J Date: 6 — / - /S Phone# Official use only. Do not write in this area,to he completed by city or sewn official. City or Town: Permit/License p Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.Cityrfown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone N: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,anemployee 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,MGL 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-contractors)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 maybe 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 bas 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 fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permitAicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia -��� �� �N� ;oG �.n�� 0�� soO1 *�91 ���d� d