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05-019 277 AUDUBON RD BP- 2011 -0847 GIs #: COMMONWEALTH OF MASSACHUSETTS N Bloc 05 - 019 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: roofing BUILDING PERMIT Permit # BP- 2011 -0847 Project # JS- 2011- 001395 Est. Cost: $3400.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BOB THIBODO ROOFING & SIDING 065699 Lot Size(sq. ft.): 273992.40 Owner: CARNES RICHARD CHARLES & EMMA JANE Zoning: RR(100) / /WP Applicant: BOB THIBODO ROOFING & SIDING AT. 277 AUDUBON RD Applicant Address: Phone: Insurance: P O BOX 201 (413) 527 -7663 O WC NORTHAMPTON MAO 1061 ISSUED ON :412612011 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE FRONT ROOF 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 4/26/20110:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 phone 413- 587 -1240 Fax 413 - 587 -1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH LL G SECTION 1 - SITE INFORMATION 1.1 Property Address This s do to completed ;by o ce L , . ! 4DYAG tNSPCSttN�{ Unit Zone Overiay District .' l�� �S EIm.St atst�lct y CS District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: A l Name rint)� Current Mailing Address: _ S'? c) I��r Telephone Signature 2.2 Authorized Agent: Name (Print) Current Mailing Address: 1M�F S p C G Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) C7 O Check Number 3 3s This Section For Official Use Onl Date Building` Permit Number: 'Issued: Signature: 1 < Building Commissioner /inspectorof 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 I � F t £i S bac Rear ---- BkWirig Height Bldg. Square Footage Open Space Footage % (Lot area minus bldg & paved �� i L_�i -kin # of Parking Spaces Fill: volume & Location 1 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 ® DONT KNOW 0 YES 0 IF YES: enter Book o 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 ® Obtained ® , Date Issued C. Do any signs exist on the property? YES Q 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 i NO 0 IF YES, describe size, type and location: j 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 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 ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [E:3] Other [p] Brief Description of Propose Work: o • l\ Alteration of existing bedroom Yes No Adding new bedroom Yes No I s Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa. .tf+tw��llli " dcClor ;ec'11xior�s a.hf erns: 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 BU'1LDING'PERMIT' r I, Ne- (� �Ql� (-r1� S as Owner of the subject property hereby authorize 2,� ` ►�`, +� d to ct on my behalf, in all matters relative to work authorized by this building permit application. N L4 �- Signature of Owner Date 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 saand ' penalties of perjury. b \ Yl Print N ame Signature of Owner /Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of license Holder : _ �^� 1 ► 1 � ���� Cr License Number Address Expiration Date -- I Sig ature Telephone Hom m rdir taa fi� r _ .., w Not Applicable ❑ ComOWv Name Registration Number _► Address Expiration Date 1 Telephone _ 1f�oh� SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c, 162, §:26C(6));, Workers Compensation Insurance affi avit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building perm Signed Affidavit Attached Yes....... No...... ❑ r $ ifiv 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 buildine 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 � • T The Commonwealth of Massachusetts Department of Industrial Accidents Office of InvesfZ 600 Washington Street Boston, M4 02111 www.moss govldia - -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electriciam/Plumbers Aimlicant Information Please Print L � 'blv Name ( Business organiiation/Individual): . st Address: 1 CitylStatevzip: S fb Phone #: you an employer? Check the appropriate box: Type of project (required):. 4.. I am a general contractor and I 1. I am a employer with 6. ❑ New construction employees (fall and/or part time).* have hired the sub- contractors listed 2.. Q I am a sole proprietor or pttrtacr- d on the attached sheet 7• ❑ Remodeling and have no aloyees These sub-contractors have .8. ❑ Demolition working for me in any capacity. I9 - I Izaye wooers'. 9 B addition _. conip, tnsir-ance — L [No wo co=p. TnSfII 5. We are a corporation and its 10 Q Electrical repairs or additions required ] officers haveGercised their 1 L unpb repairs or additions 3.0 I am a homeowner doing all work t . right of exemptrori per MGL myself [No workers' comp 12.3.Roofrepairs msm -a= required.] t c: 152, § 1 (4); and we have no 13.❑ Other employees: [No workers' comp. insurance reg6ire&I "Any applicant that checks box #1 must.also fill out the section below.showiag dzir- orkas' compensation policy information t Homeowners who submit this affidavit.indicating they are doing 0 work and than hire outside contnetots must submit a new affidavit indicating such. 1 connactocs that check this box must. attached an additional shed showing the name of the sub - contractors aad state whetbe or aot-thwe entities have employers. Ifthe sub - contractors have employees, they mustp7ovide their workers' comp.,policynumber. l aw an employer that isproviding workers' compensation insurance for trey employees. Below is the policy and job site information. l Insurance Company A. Policy # or Self -ins. Lic. 11414 L) 1 © 0 Expiration Date Job Site Address'd� U ' \-� U r1 �`� . Ciodst2L Zip Attach a copy of the workers' compensation policy declaration page {showing the policy number and eiration date). Failure ta secure coverage.as required iun&ir section 25A I MGI:`c 152 can lead to the iuiposit<on of"cnt�l penalties of a fne up to $1,500.00 and/or one -year imptisonme�' as well as civil penalties in the form of a STOP WC?1ZK and-a fine of uup to $250.00 a day against the violator Be advised,1hat a copy of this statement maybe forwarded to the O ffice pf lnvestttations of flue bIA for uisnrance coverage verii3ca`tlon. - _ :. ..;_. _, ... . _ . , I do lcereby certify under the pains-and penalties ofperjwy dW - tlte informatfDn�rovided ubnv s� _androrrert -__ . Phone # , ' C'. Offrcial use only. Do not write in this are* to be completed by city or town official ,City or Town: _ Pt rmltUcense # 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 #: i * y 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 aour), 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 occupancv 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 "ts 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