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11A-028 (2) BP- 2010 -0691 GIs #: COMMONWEALTH OF MASSACHUSETTS 1Mc.11A -02$ CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0691 Project # JS- 2010 - 001016 Est. Cost: $11000.00 Fee: $66.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: STEVEN OLIHAN 045567 Lot Size(sq. ft.): 27399.24 Owner: EVER ELIZABETH R & KEVIN HALE zoning: URA(100)/ Applicant: STEVEN OLIHAN AT: 17 CHESTNUT AVE Applicant Address: Phone: Insurance: P O BOX 86 (413) 268 -0005 () GOSHENMA01032 ISSUED ON :112812010 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMODEL 2ND FLR EXISTING LAUNDRY /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: (tough: 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 1/28/2010 0:00:00 $66.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo File # BP- 2010 -0691 APPLICANT /CONTACT PERSON STEVEN OLIHAN ADDRESS /PHONE P O BOX 86 GOSHEN (413) 268 -0005 Q PROPERTY LOCATION 17 CHESTNUT AVE MAP I IA PARCEL 028 001 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 Fee Paid Tveof Construction: REMODEL 2ND FLR EXISTING LAUNDRY /BATHROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/ Statement or License 045567 3 sets of Plans / Plot Plan THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION 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 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 Northampton" ro1 Building Department C Ctzt`Diaveua t 21.2 Main Street Se acit� ��.. Room 100 N'gl­Oiarnpton, MA 01060 phone 413- 587 -1240 Fax 413- 587 -1272 �r�� 5 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address Map Lot Unit i7 C OVUT t � Zone Overlay District L..CEvS Eim St District GB District SECTION r2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record - vk Name (Print) /� 7 - / Current Mailing Address: U Telephone � _ -] C) l Signature 2.2 Authorized Agent: Name (Print) Current Mailing Address: 03 Sig ture Telephone SECTION 3- ESTI MATED '.? CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building ja J v J (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) / C7vJ Check Number — — - - -� - This Section For Official Use Ong Date Building Permit Number. Issued: Signature: Building Commissioner /Inspector.of Buildings Date 0 - 1 1A Section 4. ZONING Alt 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 Frontage Setbacks Front Side L: 3 Rear Building Height - Bldg. Square Footage % Open Space Footage % (Lot area minus bldg & paved ......., p arking) # of Parking Spaces Fill: (volume & Location) ='-.- —� -• _ _... A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW YES IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YE S 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 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 0 NO IF YES, describe size, type and location: z_ °`: - ire f�iere any p>ropo" she changesto or�lca it�ons signs infened 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 Q 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 [0] Decks [0 Siding [0] Other [O] Brief Description of Proposed �L �-- OAW Work: y���� ��5��7 Alteration of existing bedroom Yes X , No Adding new bedroom Yes No Attached Narrative N�)N'r Renovating unfinished basement Yes _ No Plans Attached Roll - Sheet sa: Ni ho%lse.an t ar" acts lrtlnn =to "exists rg'fivusinc ; coriiplefe't le.follouvinca: 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 99 hereby authorize y V to act on my behalf, i II m ers relativ to work authorized by this building permit application. 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 and penalties of perjury. Print Name Signature of Owner /Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder : � 1 1" V 2 X (0 License Number 3_5 Q/T) I /// Address Expiration Date ignatur Telephone 9:..Reviste 'red Hdme,,lmprovemeniContractor . Not Applicable ❑ ill'7b�i2 Company Name Registration Number l d� Address Expiration / Date A 5 ��'� 11r- Telephone _ SE CTION 10- WORKE COMPENSATION INSURANCE AIFFIDAVIT',(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....... No...... ❑ :� i , o , J " rt -The-current-exemption for. "homeowners" was exten 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 referencerto 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 r rnances;` a e o tts General-Laws- Annotated. Homeowner Signature The Commonwealth of Massachusetts Department oflndustrial Accidents - Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumb.ers Applicant Information Please Print L 'blv Name ( Business/ Organization /Individual): Address: _t7 •7� 3� �44 L:L ?S City /State /Zip: M)k V o Z_ Phone-#: �) 3" a Sv ^ 2 2 cj Are you an employer? Check the appropriate box: L7Re jf project (required).. 1. Fj I am a employer with 4., � I am a general contractor and employees (full and/or part-time).* have hired the sub- contractors ew construction 2. I• I am a sole proprietor or partner- listed on the attached sheet emodeling ship "and have. no. _ r ployees These sub - contractors have. Demolition working for me in any capacity. employees and have workers' [No workefs' comp. insurance comp. insurance.$ Building addition required] 5. irs We are a corporation and its lectrical repa or additions 3.0 I am- a- homeo-wner- d6ing�l-werk - - -- - –Q tea- Iurnbing repairs or additions myself [No workers' comp. right of exemption per MGL oof repairs insuran required] t c. 152, §1(4), and we have no employees. [No wo ther comp. insuran required}. "Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who subnrit this affidavit indicating they are doing all 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 notthose entities have employees. If the sub - contractors have employees they must provide their workers' corm. policy number. lam an employer that is providing worke:x' compensation insurance for my employees. Below is the policy and job site formation. 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 crimin4l 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 , ne of up to $250.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the Office of Investieations of the DIA for insurance coverage verification I do hereby _certify under the pains and penalties ofperjury that the information provided above -i - &ueard - correct Si ture: ; . ate. Phone #: – • sJ Offcidl use oriDy Do not write in ffiis area, — to be completed by city or town official City or Town: PermitlLicense # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical 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 - reg ulations The in be calle 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 - - - -- per-nii in- c©n}unction_to the_ building permitissued, _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, 7` & 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. Address of work r location j �- G /Le� ems& �