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15B-003 BP-2010-0118 GIS #: COMMONWEALTH OF MASSACHUSETTS " , 11* CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0118 Project # JS- 2010 - 000134 Est. Cost: $250.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 20995.92 Owner: PROPERTY GROUP INC THE C/O ALISON P CHILDS Zoning: URA(100)/ Applicant: PROPERTY GROUP INC THE C/O ALISON P CHILDS AT. 625 SPRING ST Applicant Address: Phone: Insurance: 625 SPRING ST LEEDSMA01053 ISSUED ON. 712912009 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL WOODSTOVE 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 7/29/2009 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo Dep rtment use only City Northampton tatus of Permit C't of � Building Department GurbCutl ©r+ewa. Peirni# 2,12 Main Street Sewer /Septic Availability ROOM 100 "er/Weil Availability "�,` Northa r ton, MA 01060 Two Sets of Structural "Plans phone 41 587 - 1,240 Fax 413 - 587 - 1272 Plot/Site Plans - Other Sectf�r _APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Propertv Address: This section to be completed by office (G S ') O , Map' Lot Unit � t Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record Name (Print Current Mailing Address: San Ali Telephone 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 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) Check Number /._ This Section For Official Use Onl Date _. Ruilding Permit Number: Issued. Signature: Building Commissioner /Inspector of Buildings Date r yy 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 Frontage Setbacks Front Side L _ ..,,, R' L ,..._,,.. ,_. R% _.,.... 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 DON'T KNOW 0 YES 0 IF YES, date issued`; IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW 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 , Date Issued: C. Do an y signs on the property? YES NO _ . IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 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 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. V 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 [0] Decks [Q Siding [O] Other [[3] rief Description of P po ed (� Work: i Y� h VV _Ay1 D - ee Alteration of existing bedroom l Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or, addition to existinrx housing ,complete the fo]lowing: 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 . 1. 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 r 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 Nye, 1 i o Signature of Owner /Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9 Registered 1­11=6 Improvement•Contractor. 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 to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ 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 jWorkers' Compensation) and Chapter 153 (Liability of Employers to Employees -for iTUuries not resulting, in Death) cif the Massachusetts General Laws Annotated, you may be liable fu> p%nsun(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 � A The Cormnonwealth of Massachusetts = = Department of Industrial Accidents „= Office of Investigations 600 Tf'ashington Street Boston, 1MA 02111 _ www.rnass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print LeziblN Name ( Business /Organization/Indivi dual): Address: City /State /Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 7 1. ❑ I am a employer with 4. F I am a general contractor and I employees (full and/or part- time). have hired the sub - contractors b. ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have 8. F� Demolition /ama for me in any capacity. craployecs aril Dave wurkCrs' 9. Building addition kers' comp. insurance comp. insurance.$ . 5. We are a corporation and its 10.0 Electrical repairs or additions 3. omeowner doing all work officers have exercised their 11.[I Plumbing repairs or additions myself 1 o workers' comp. right of exemption per MGL Y � 12.0 Roof repairs insurance required.) t c. 152 §1(4) and we have no employees. [No workers' 1 • ❑ Other 1 comp. insurance required.] (IV *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit 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 not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site information. 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 criminal penalties of a fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the fora: of a STOP WORK ORDER and a fine c,f ip to $ ?.50 00 a clay against the violator. Be advised that a copy of this. statement may be fonvarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c rtrfy under the pain penalties perjury that the 'nformation provided above Q is r true and correct. nature: �J Date`. t D Phone #: nffcial use only. Do not write in this area, to be completed by citJ1 or town uncial Citv or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector S. 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 permits 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 4 ' /I, understand the above. V ....,.(Home owner /resident's signature requesting exemption) I will cal. to schedule all required building inspections necessary for the building permit issued to me. Tate Address of work location 2 fi l�