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31A-274 15 DRYADS GREEN ST BP- 2011 -0696 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A - 274 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit # BP- 2011 -0696 Project # JS- 2011- 001148 Est. Cost: Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ED LENNIHAN 042506 Lot Size(sq. ft.): 12240.36 Owner: IVES PETER B & JENIFER FLEMING -IVES Zoning: URA(100)/ Applicant: ED LENNIHAN AT: 15 DRYADS GREEN ST Applicant Address: Phone: Insurance: 76 Bancroft Road 587 -0437 NorthamptonMA01060 ISSUED ON:2/28/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: REPAIR WATER DAMAGED INSULATION & CEILINGS ON 2ND FLR 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: FeeType: Date Paid: Amount: Building 2/28/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner • File # BP- 2011 -0696 APPLICANT /CONTACT PERSON ED LENNIHAN ADDRESS /PHONE 76 Bancroft Road Northampton 587 -0437 PROPERTY LOCATION 15 DRYADS GREEN ST MAP 31A PARCEL 274 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out + ,�- r �r- Fee Paid 4 ∎7 Typeof Construction: REPAIR WATER DAMAGED INSULATION & CEILINGS ON 2ND FLR New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 042506 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOIIATION PRESENTED: pproved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Peinut from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay 4Z$, jf Si nature of Building 0 cial Date g g 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. i � �►'�: City of Northampton ° = � � j.� . \ : ui lding Department °_ 2 212 Main Street s - R ��, Room 100 ��`� �� r�� `� F 1 ampton MA 01060 » �� ' � ,1 :,;. , ,,,,,, --- '''''''13-587-1240 Fax 413- 587 -1272 ,„ � n, d 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 , 7.1.e y,t75 -- ,�r Map L'ot,` Unit A7 ■ Tli, " t ,71 p +3 • 1 i a 1 , 'a Zone Overlay Diets= Elm St. District CB District' SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 ner f Reco Name (Pi Current Mailin �e s: r � /' — IFpm/li �/ •i�► Telephone S c7 (� S 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 27 0c, 0, _ 1> (a) Building Permit Fee 2. Electrical (b) te ii- (b) fro Cost (6) of 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection r1'' '' e �r 6. Total = (1 + 2 + 3 + 4 + 5) g . 1; )'.), Check Number �(� / � b � j C This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date % P l Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This columnrto he filled in by Building Eitipartment f'14 t Lot Stze 4� r Frontage 1 i I Setbacks Front Side L: R:- �..,.. L:= 1 R: w t Rear = Building Height ( _ � _" i Bldg. Square Footage [] 1 % f 1 1 Open Space Footage i % (Lot area minus bldg &paved [__ __ ( ? ___. j . parking) # of Parking Spaces i Fill: 1 1: - ..... � T m ___ i � (volume & Location) l t A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 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 0 i IF YES: enter Book 1 i Page! ! and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: I D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 IF YES, describe size, type and location: F 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 0 NO 0 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 El Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [IZI Siding [D] Other [ J] Brief Work: e l /74, e Proposed ii 4 mac' Zw /.. /4s ,A. i• u /mil r (.:' t', !.:/ 1 2 J i,),<- 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 et ifN [ew hou .. nd a� ' adddttien ' ..xelliffir a: iit -,coi iie h Alf64AfF! 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 AUTHO TION'- TO BE COMPLETED WHEN OWNE T OR CO R APPLIES FOR BUILDING PERMIT', I, ' )r 2Y _ tt , as Owner of the subject grope it' here• , a horize J a o► n v r A) I /' to - on behalf - II m.- rs relative to work authorized by this building permit application. i -. at : • Owner • 4, Date • 1, I- di 4v4 d 7) . 4 if- , N , as- w►Rer /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. / c-Jn J d 7) . e.., 1-7. ✓ >JiH'9 Print Name 9 ') i2- L /25 //1 Signature of -ewner /Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : t cIn /1‘• ymil ). /N 4 ./ CS 92 SJ �. License Number 7l. ' -. ,t 2-7 A/3 / c'T —2 , i✓t a, G) IZS �L rL Address Expiration Date '1,. 4 i /3^ Se? - T3W37 Signature Telephone ec# sletat3 >obnitriirettlen�ortracir. Not Applicable ❑ / , i // Company Name Registration Number o //JJ L CD 6/IS12JiL Address Expiration Date 7 '13 A4'6 , c - f , ;, •cl ,27. ,J, ev /n,-,ovi -r, ,, 4Telephone '//3 527• 3 7 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 1g No ❑ ��% �ll �t �� t I Il 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 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 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 .-..: • 4... 7 ' • ' .. The Commonwealth of Massachusetts Department of Industrial Accidents . 0 1, 7.... .• ... =,-7.."•=-. ay Office of Investigations 1_,—= i 600 Washington Street ... .7...# Boston, MA 02111 www.mass crov/dia • .. -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers - - Applicant Information Please Print Legibly . , . Name (BusinesS/Organiz ation/Individnal): 7)c 4 */L (1 ,S-i.e. (..,.. 4/cri , 4 c' (..: • Address: 7 6- "atiAit -,, e 7/ k"? . ,. • .. - City/State/Zip: /\/.),C, -771/41-11 M- ,), Phone.#: '.'t f 3 -ce 7 - o V $ 7 il Are you an employer? Check the appropriate box: Type of project (required): . 1. 0 I am a employer with / 4.. 0 I am a general contractor and I 6. 0 N • co 'on have hired the sub-contractors employees (full and/or part-time).* listed on theattached sheet 7• E] Remodeling 2. 0 lath a Sole proprietor or partner- ship and have no =ployees These sub-contractors have .8. 0 Demolition eimloyees nd have workers' . . . - working for me in any capacity. 9 - 033iiilding . aZdiliiin _ comp..insunmce.L . [No workers' comp. insurance 10.0 Electrical repairs or additions , . 5. 0 We are a corporation and its 3. 01 am a homeowner doing all work officers have4xercised their . 11.0 Plumbing repairs or additions I myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs . - insurance required.] t ,c. 152, §1(4), and we have no 1 2:1 Other /NA's le. t' - '• 4 : i 4 .16e employees. [No workers' 13.1 , . comp insurance reqUired.j. - / e e 7 At 0 f 5 *Any applicant -that checks box ftl-nsust also fill out the section below show;mg their ivoricers comixnsation policy information. t Homeownera who subrcit this affidaVit inc4cating they are doing all work d then hire outside ecatraCtors must submit anew affidavit indicting such. :Contractors that check this box must attached an additional sheet showing the name of the sub and state whether-or not those entities have employees. If the sub-contractors have employeee, they must provide their workers' comp. policy number. Jam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. . , Insurance Company Name: - "Te. 4 tk Ex.! S . - Policy # or Self-ins. Lic. #: 7P-71/3 - -15 / I -1 Expiration Date: - ioST /24-/// Job Site Address: IS Dieri:4-).s _ , CitY/StateZip:' /v.> e. , ti/b71 PCT) V 4 ivi 4 73 i ),i..,j Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requited Meer Section ofMGL c 152 can lead to the imposition Ofainthrij Penalties of a fine up to 51,500_00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER anda fine of up to $250.00 a day against the violater. Be advised 'that a copy of this statement may be forwarded to the Offi'se of Fifeitiiiiiiinisof the for insurance C6iiiiii _. - • '. _. - .. 11 -:::-- ,.„. -:---- ::- ' tile' heraiyceriihitiik.ia. the Pa&s•an d pentilti;...i ofiirjurythat the itifOrnuttiOnpritvitiiii_Waire: e -- _ $itmature: C. -7 ) • 1 -e--,-- . path; 2/4 A/ • . , Phone ii: '/ /3 -- Se 37 / . . - , • . - Official use only Do not write in this area, to be completed by city or town'ojficiaL • • City or Tovvri: "- Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Eleetrical,Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 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 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 ermits 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, 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 Date Address of work location VDAC TRAVELERS WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (7PJUB- 0545N13 -1 -1 0 ) RENEWAL OF (7PJUB- 0545N13 -1 -09) INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA NCCI CO CODE: 13579 1. INSURED: PRODUCER: DELONG CONSTRUCTION LLC WHALEN INSURANCE AGENCY 76 BANCROFT ROAD 71 KING STREET NORTHAMPTON MA 01060 NORTHAMPTON MA 01060 Insured is A LIMITED LIABILITY COMPANY Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 05 -26 -10 to 05 -26 -1 1 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA t ��1 B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 1000000 Each Accident Bodily Injury by Disease: $ 1000000 Policy Limit Bodily Injury by Disease: $ 1000000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: o COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A NIMINNOM 0 _.... D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 0 -- 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 04 -22 -10 WC ST ASSIGN: MA OFFICE: DIRECT ASSIGNMENT 701 PRODUCER: WHALEN INSURANCE AGENCY 28LKF 001822