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43-016 File # BP- 2009 -0877 APPLICANT /CONTACT PERSON THEWS PETER A & REBECCA C CASTRO ADDRESS/PHONE 273 CRESCENT ST ff2 NORTHAMPTON (413) 552 -6556 Q PROP TX LO THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT - Fee Paid Building Permit Filled out Fee Paid Typeof Construction: DEMOLISH BARN New Construction Non Structural interior renovations Addition to Existing - Accessory Structure -- Building Plans Included• Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PI RENTED: 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 . "20 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. Iity,of Northampton m Building Department 21 Main Street evrer b�r ��� Room 100 iatet ilraab zs �� a, Nompto�i, MA 01060 7wEa a �at� s phone 413 7 -12 Fax 413 - 5871272 P© ;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 Map Lot Unit Zone Overlay District Elie St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT.' 2.1 Owner of Record Id Nam Current Mailing Address: Telephone Signature 2.2 Authorized Agent: r /V 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 Q ja) Building Permit Fee: 2. Electrical / (b) Estimated Total Cost of Consfn'btion #rom 6 3. Plumbing :Bullding Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = 0 +2+3+4+5) Ctieck Number This ,Sdctidh For.,Dfflciit Usef. Oni Date. Building Permit Number. Issued: Signature: Building Commissionertinspector of 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 ' by Building Department Lot Size Frontage _.. _,_ ._.. _.._. _. ._. _.,_.._.__._ m Setbacks Front Side L. R. L R: Rear Building Height Bldg. Square Footage % ` Open Space Footage % (Lot area minus bldg & paved arlcin i # of Parking Spaces Fill: volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO D ONT K NOW YES 0 W IF YES, date issued:! IF YES: Was the permit recorded at the Registry of Deeds? NO 0 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 0 DONT KNOW 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 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, excav , or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Ae� NO 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 Alterations) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition L"1 New Signs [O] Decks [(] Siding [0] Other [p] Brief Description of Proposed Work: 1)v�06rff Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and: or.'add' tion to' ez>IStingvhousincl , _6 �fete the: ollciwin!g: a. Use of building: One F milt' Two Family Other b. Number of rooms in each w ily unit: Number of Bathrooms c. Is there a garage attached? M d. Proposed Square footage of new constr ii ct on. 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 . f wetlands? Yes No. construction within 100 yr. floodplain Yes No j. Depth of basement -or cellar floor below finished grade k. Will building, onform to the Building and Zoning regulations? Ye No . I. Septic Tank City Sewer Private well City water Supply SECTION. 7a - OWNER AUTHORIZATION TOPE I COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIESFOR BUILDING.PERMIT as Owner of the subject proporty hereby authorize to act on my behalf, in all matters relative 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 Na Signature of Owner/ gent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor r Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9:: RegisteredHorrioprovernenfCnn #t a'i�for4..,,.�! NotApplicable ❑ .�... .��..._ ., MEN Company Name Registration Number Address �1- � �x iration Date Telephone SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L: 6 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...... ❑ 1 aloe >e 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 -vear 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 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 an State of Massachusetts General Laws Annotated. Homeowner Signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations t 600 [Fashinaton Street Boston, MA 02111 1 I www.mass.gov /dia Workers' Compensation Insurance Affidavit: Build ers / Contractors /EIectricians /Plumbers Applicant Information r Please Print Legibly Name ( Business /Organization/IndMdual): Pte( _7'7 <' 5 1t) J _ Address: City /State /Zip: Phone #: ss — S� Are you an employer? Check the appropriate boy: Type of project (required): 1. ❑ I am a employer with 4. [ I am a general contractor and I 6 F� New construction employees (full and/or part- time).* have hired the sub - contractors 2. F I am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling ship and have no employees These sub- contractors have g. emolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ re ed.] 5. ❑ We are a corporation and its 10.0 Electrical: repairs or additions - officers have exercised their 11. ❑ Plumbing repairs or additions , .E9 1 1 1arn a homeowner doing all work myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *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 employee`s. If the sub - contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy 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 c rimina l 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 fine 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 Investigations of the DIA for insurance coverage verification. W'd I do hereby cethe pains an penalties of perjury that the information provided above is true and correct Signature: Date: 2_Y / Phone #: Official use only. Do not write in this area, to be completed by city or town official Citv or Town: Permit/License # � Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town CIerk 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 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 inspec 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 occupa 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 h 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. Date Address of work location Northampton, MA Pro perty Detail Page 1 of 2 City of Northampton, MA: Residential Property Record Card New Search Property Type Classification Code Reference Card 1 of 1 Parcel - Location - Zoning - Assessment Map -Block -Lot 43 Zoning: Assessment: Location: 248 PARK HILL RD Neigborhood: 2 Land: 115,300 #Living Units: 1 Deed Book: 3895 Building: 100,500 Class: R -101 Deed Page: IL Total: 215,800 Dwelling Information Building Sketch Style: Conventional Year Built: 1720 Story Height: 1.5 Attic: None Descriat Basement: Full A :.5Msl1 N Total Rooms: 6 720 sgft B :1 Fr/B Bedrooms: 2 12 288 sgft Full Baths: 2 W ood Deck C :Wood D i 2 ' 1aa 132 sgft Half Baths: 0 D: 132 D .. 144 ' Exterior Walls: Brick 30 12 sgft Unfinished Area: 0 Ground Floor Area: 720 Wood Deck �4 24 _5Ms11Ms1B 1Fr1B Total Living Area: 1548 13Z Finished Basement Living 0 X 0 Area: Basement Recreation Area: 0 X 0 Woodburning Fireplace 0/0 Stacks /Openings: Metal Fireplace 0/0 Stacks /Openings: Heat/Central A/C: Basic Heating System: Hot Water Fuel Type: Oil Addition Information: Quality Grade: C Physical Condition: Average Interior /Exterior: Better Condition/Desirability/Utility: FR Lower 1 st Story 2nd Story St ory Area Vacant/Dwell /Oby Status: Dwelling One Story [Half Story Additional Features: Basement Masonary Masonary 720 Brick Trim: 0 X 0 Basement one Story Frame 288 Stone Trim: 0 X 0 lWood Deck F 132 Remodeling Data: I n http: / /www.northamptonassessor.us/ noho /propertydetail.php ?map_no =43 -016- 001 &pagecard =l 4/27/2009 Northampton, MA Property Detail Page 2 of 2 Year Remodeled: 86 Wood Deck I 1 144 Kitchen Remodeled (Y/N): Bath Remodeled (Y/N): Land Data Outbuilding Info Square Foot Type Utilities Type ]F t Value no no information � Q ��� information T e t ear ize 1 Size2 Grd Cond AB2 1 1901 Acreage Type Street/Road Type Ecgj Value no information Home Site 1.00 115,250 Sales Info Permit Info Date Type Price Validity Date Permit # Price Purpose Ino information Ino information http: / /www.northamptonassessor.us/ noho /propertydetail.php ?map_no =43 - 016 - 001 &pagecard =l 4/27/2009