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37-128 38 BLACK BIRCH TRL BP- 2012 -0035 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Bloc 37 -128 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:BASEMENT RENOVATION BUILDING PERMIT Permit # BP- 2012 -0035 Project # L'' JS- 2012 - 000059 Est. Cost: $24300.00 Fee: $145.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: INTEGRITY DEVELOPMENT & CONSTRUCTION INC 118041 Lot Size(sq ft.): 14679.72 Owner: JACKSON BENITA SIBIA & SAMUEL GAHAN RUHMKORFF zonin :gSR(100) Applicant: INTEGRITY DEVELOPMENT & CONSTRUCTION INC AT: 38 BLACK BIRCH TRL Applicant Address: Phone: Insurance: 110 PULPIT HILL RD (413) 549 -7919 AMHERSTMA01002 ISSUED ON. 7115120110:00. 00 TO PERFORM THE FOLLOWING WORK.- Basement, Renovations 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 7/15/20110:00:00 $145.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner File # BP- 2012 -0035 APPLICANT /CONTACT PERSON INTEGRITY DEVELOPMENT & CONSTRUCTION INC ADDRESS/PHONE 110 PULPIT HILL RD AMHERST (413) 549 -7919 e PROPERTY LOCATION 38 BLACK BIRCH TRL� MAP 37 PARCEL 128 001 ZONE SR(100) THIS SECTION FOR OFFICIAL USE ONLY: Z•W ,Q�G 1���(" PERMIT APPLICATION CHECKLIST U ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid ' uildin Permit Filled out tJ se�Paid Z01 O U - 0 Typeof Construction: Finish Basement, Renovations New Construction Non Structural interior renovations ( (/ Addition to Existing Accessory Structure Building Plans Included: .. I ilk Owner/ Statement or License 118041 3 sets of Plans / Plot Plan t/ THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: pproved Additional permits required (see below) Q K , PLANNING BOARD PERMIT REQUIRED UNDER:§ ,� I r l ' �l «t 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 , d =7:�p 7 lS LI 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. ED ty of Northampton Sf�tus of PenrirY B Tiding Department curk ;Gut/Diiveu�a rmit f 212 Main Street g Sewerft �lirarla il�t 1 2 011 Room 100 3 €velvet I x FOP b , o ampton, MA 01060 ���,,� 3- 7 -1240 Fax 413 - 587 - 1272 NORTHAMPTON MA 01060 Q � , APPLICATION TO CONVkUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address ACS .�•� This section to be completed by office 3$ SEk�,(C., �lQ� ! �-• ,Map Lot Unit Zone` ��" Overlay District Elm St District M CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record ,C3( TX AIL P.v Name (Print) Current Mailing Address: Telephone Si ature 2.2 Authorized Agent: f Name ) Current Mailing Z"AfRIf A Address: Si at a Telephone S CTION 3 - ESTIMATED CONS TION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building iy �W (P) Building Pen Fee 2. Electrical (b)'Estimated To Cost of 1 Construction from 6 3. Plumbing building Permit Fee 4. Mechanical (HVAC) r S 5. Fire Protection / 7J 6. Total = (1 + 2 + 3 + 4 + 5) Z 3Q� Check Number p �/ This Section For 'Of icial`Use Onl y____ Building Permit Number: Date Issued: Signature: 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 : t A, This column to be filled i4$y Building Department Lot Size f.�,„.. 5 .....� .._.,...._...,,... -..r. Frontag Setbacks Front ( .)• Side L: i_—I R. Rear Building Height +" Bldg. Square Footage % — I Open Space Footage % (Lot area minus bldg & paved p arkin g) # 4Parkjng Spaces Fill: _ _. volume & Location — A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO. _ .DONT KNOW ® YES 0 IF YES, date issuedn IF YES: Was the'perrriit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES 0 IF YES: enter Book Page, and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Q Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 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 0 NO 9 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 D Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [M Siding [❑] Other [E3] fDescription of Proposed , 1 5 ! , Work Alteration of existing bedroom Yes X_ No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement X_ Yes No Plans Attached Roll - Sheet Ga. 'If New house and "or i diAM66'fo eAiSit °l ouslng,` complete the following: a. Use of building : One Family 7C Two Family Other b. Number of rooms in each family unit: Number of Bathrooms� c. Is there a garage attached? N d. Proposed Square footage of new construction. Dimensions 3 3 ) e. Number of stories? . f. Method of heating? 017 Ni r WQd � p12!!4 ireplaces 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 g k. Will building conform to the Building and Zoning regulations? x Yes No. I. Septic Tank City Sewer K Private well City water Supply SECTION 7a.- OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 ' e�GIGSO�'► as Owner of the subject property hereby authorize .1- VeVU� G s vdl G to act on my behalf, in all matte relati a to work authoriked by this building permit a pli ation. 7 Si ature of Owner Date as Owner/ uthorized ge ereby declare that the statements d information on the foregoing application are true and accurate, to the best of� elief. Signed under the pains and penalties of perjury. X55 � Pdnf Name Date Signatur of n ge SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone .9. Rea Contractor: .. ..., _ ,., ..r;r . .,, ......,... Not Applicable ❑ Company Name Registration Number Address 'Expiration Date Telephone 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 td provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ 1Z w Hom�,.wrir:Ezempti ©ri 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 The Commonwealth of Massachusetts Department of Industrial Accidents . Office of Investigations 600 Washing, ton Street Boston, MA 02111 www.massgov /dia - Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/PIumbers Applicant Information Please Print Lejibly Name (Business/organization/individual): Address: City /State/Zip: Phone. #: Are you an employer?. Check the appropriate bog: Type of project (required):, I. ❑ I am a employer with 4.. E] I am a general contractor and I 6. New construction employees (full and/or part-time). * have hired the sub- contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet 7. [ Remodeling ship and have, no e45 1oyees These sub - contractors have. .8. 0 Deao;itron working for me in any capacity. employees and have wooers' 9 3uil a�ditidn No workers' cornp. insuran - comp. insuacnce #_. Q — . required ] 5. We are a corporation and its 10 .0 Electrical repairs or additions 11 officers havegxercised their Q g epairs or additions 3.0 I am a homeowner doing all work 11. PI irabin r myself [No workers' comp. right of exemption per MGL 12:Q.Roof repairs ins,,, - c: 152 ' § 44Y, and we have no an ce required.] t 13.[� employees. [No work= comp. insurance required]. *Any applicant that checks box #d must also fiII out the section beiow.showing theirworkers' compensation policy information_ t Homeowners who submit this affidavit.iadicatinj they are doing an work and then hire outside contractors must submit a new affidavit indicating such :Contractors 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 bave employees, they must provide their workers' comp. policy number. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job: site in fo rmation Insurance Company Name: . Policy # or Self-ins. Lic. #: Eimiration Date: Job Site Address: City /State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the p94cy number and eapirahon date). Failure. to' seciu a coverage:as requirei under.Section 25A'of1VIGL c. 152" can lead to the imposition of criminal peiialhes of a fine-tip to $1,500.00 and/or one. -year imprisonment, as well, as civil penalties in the form of a STOP WORK -ORDER and-a fie 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 an j tieatioris of the MA for' nsurance coverazYe verification I d _ker0_Y certify under the pains : and penalizes of perjury ` drat the informatiosprovufed -above ittnce_aruLcorrect —__. _.._. Si�nattu e: bate• Phone #: — Official use only. Do not write in this area, to be completed by city or town ofj7cW City or Town: Permit/License # Issuing Authority (circle one): J. Board of Health 2. Building Department 3. City(lown Clerk .4. Electrical Inspector 5. Plumbing In pector 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 hvo 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 rou building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires tlse 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 t&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. 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