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43-065 BP- 2010 -0894 GIs #: COMMONWEALTH OF MASSACHUSETTS :Block: 43 - 065 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categor BUILDING PERMIT Permit # BP- 2010 -0894 Project # JS- 2010- 001324 Est. Cost: $1100.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 15507.36 Owner: OLMSTED ROBERT E Zoning SR(100 /� II Applicant: OLMSTED ROBERT E AT. 56 DUNPHY DR Applicant Address: Phone: Insurance: 56 DUNPHY DR (413) 687 -1812 O FLORENCEMA01062 ISSUED ON :411612010 0:00:00 TO PERFORM THE FOLLOWING WORK.- 10 X 10 SHED 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 4/16/2010 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo File # BP- 2010 -0894 APPLICANT /CONTACT PERSON OLMSTED ROBERT E ADDRESS /PHONE 56 DUNPHY DR FLORENCE (413) 687 -1812 Q PROPERTY LOCATION 56 DUNPHY DR MAP 43 PARCEL 065 001 ZONE SR(100)/ /WSP II THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid Typeof Construction: ERECT 10 X 10 SHED New Construction Non Structural interior renovations Addition to Existin Accesso1y Structure Buildiniz Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: V 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 41 I by 10 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. yr- . City of Northampton try Building Departments 212 Main Streetx ,1 Room 100 rR� Northampton, MA 01060 phone 413 - 587:1240 Fax 413 - 587 -1272 $' g a � f 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 Proper Address map Lot Unit F M i M 6 010 Zgne Qverlay District �� t `81i St CB District SECTION i':2 - PROPERTY" OWNERSHiP[AUTHORIZED AGENT 2.1 Owner of Record Name (Print) Curren�t Mailing Address. L LE 3 �- Telephone Signature 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONST RUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit appli cant 1. Building l ec ) (a) Building Permit Fee � l 2. Electrical (bj Estimated Total Cost.of Constructionfrom 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) «00 Check Number lop This.Sectian For Offrcial Use Onf Rate Building Permit Number Issued` Signature: Building Commissioner/lnspectorof Buildings Date I 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 :.--- Rear Building Height Bldg. Square Footage Open Space Footage % (Lot area minus bldg & paved p arkin g ) .. _........... _........ # of Parking Spaces Fill: (volume & Location A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON KN OW YES IF YES, date issued:' IF YES: Was the permit recorded at the Registry of Deeds? NO _0 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 (P DONT KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued:} C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: fliere any propased' cfianges to or a (tons of ignsinteQd the property ? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb telearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 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 Alteration(s) ❑ Roofing ❑ Or Doors 1 Accessory Bldg. Demolition ❑ New Signs [0] Decks [C] Siding [o] Other [EI] Brief Description of Proposed ( Work: t — 5 - p . A L 6"31 Vin(( °�, C'Ua ^d+�n S�� T' C�tt0. Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa in .ift.fiiotseldMor �tcitf" xfiadstrrg3siicl .copretrfifis}rig: 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 - T0:1 CO MPLI =TED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT' 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 I, 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 igna ur Owner /Agen ate SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9.,:Rectisterei3. Home ;:linpr�rr+�iiettfGar%tcaetor' Not Applicable ❑ D .,..x �, >,,. >a..� .�,, >, >.az �,xva .�,,. , Company Name Registration Number Address Expiration Date Telephone S ECTION 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 ex tended 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 consid 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 m . o7 owner Signature The Commonwealth of Massachusetts Department of Industrial Accidents , Office of Investig, ations a 600 Washington Street Boston, MA 02111 www.massgov /dia -Workers' Compensation Insurance Af ldavit: Builders / Contractors /Electricians/PIumbers Applicant Information Please Print LegIbIv Name (Business/organization/individual): Address: City /State/Zip: Phone. #: Are you an employer? Check the appropriate box: Type of project (required).. 1. El am a employer with 4. E] I am a general contractor and I employees (full and/or part-time)-* have hired the sub- contractors 6. ❑New construction 2. Ell am a sole proprietor or partner- listed on the attached sheet: 7. Remodeling ship and have no e=ployees These sub - contractors have. .8. Demolition working for me in any-capacity. employ a nd have workers' 9. ion -- - -- [No workers' comp. insurance p insimance.� . __ - _.. -.... . required] 5. e a corporation and its 10.❑ Electrical repairs or additions I I a-m- a -homeowa doino all werIt — - r��a dJ�iL _ �1 � ]?lambing repairs or additions myself fNo workers' comp. right of exemption per MGL 12.Q Roof repairs insuran required] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below.showing their workers' compensation poficy information. t Homeowners who submit this affidavit indicatiag they are doing alt work and then hire outside contractors must submit anew affidavit indicating such. ZContractors 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 numbs. I am an employer that is providing workers' compensation insurance for my employee& Below is the policy and job site Lf 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 capitation date). Failure to secure coverage as required under Section 25A ofMGL c. 1 can lead to the imposition of criminal penalties of a fine up to $1, 500.00 and/or one - impriso 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. lie advised that a copy of this statement may be forwarded to the Ofti'`ce of Investigations of the LIA for insurance coverage verification I do_hgreby certify under the pains penalties ofperjury that the information prov ded -above &-true andcorrect tore: ate .. . - Official use only. Do not write vi this area, to be comp ed by city or town ociaL City or Town: Per-mitUcense # Issuing Authority (circle one): I: Board of Health 2. Building Department 3. Ci Town Clerk 4. Electrical I nspector 5. Plumbing Inspector . - - - - - -- 6. Other Contact Person: Phone #- J 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 Th_ election process_reauir that the building department be calle to inspect work at various stages, which include foundation /footings (before backfdl), 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 ------ ,- - - -pe, t s-in -con} unction,- to Ahe- buildingp- ermitissued,_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 understand the above. .(Home owner /resident's signatur requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. v Address of work location —NOTE — THIS PLAT IS COMPILED FROM DEEDS, PLANS AND OTHER SOURCES AND IS NOT TO BE CONSTRUED AS AN ACCURATE SURVEY AND IS NOT TO BE RECORDED. BUILDING LOCATION ACCURACY IS NOT GUARANTEED 97.61'± to 10 to BOOK 4172, PAGE 68 PLAN BK. 88, PGS. 60 -61 LOT #16 ±I ±I NOTE: SUBJECT TO EASEMENTS AND Ln RIGHTS OF WAYS OF RECORD. I [77777777 - -; r #56 2' WIDE UTILITY EASEMENT 100. 994 DUNPHY DRIVE TO: BANK OF CANTON & FIRST AMERICAN TITLE INSURANCE COMPANY TO THE BEST OF MY INFORMATION, KNOWLEDGE AND BELIEF I HEREBY REPORT THAT I HAVE EXAMINED THE PREMISES AND BASED ON EXISTING MONUMENTATION ALL VISIBLE EASEMENTS, ENCROACHMENTS AND BUILDINGS ARE LOCATED ON THE GROUND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY WITHIN THE LOT LINES, EXCEPT AS NOTED. I FURTHER REPORT THAT THE PROPERTY IS NOT LOCATED WITHIN A FLOOD PRONE AREA AS SHOWN ON FEDERAL FLOOD INSURANCE MAPS FOR COMMUNITY #250167 —NOTE — SURVEYO R(J�ir.Sl_��Q Z . 2 9� THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY -- AND DOES NOT CONSTITUTE A PROPERTY SURVEY - OF µ4s — MORTGAGE LOAN INSPECTION PLAT — s q� NORTHAMPTON, MASSACHUSETTS o RAKE. �-4 PREPARED FOR v IZER y ROBERT E. OLMSTEAD #35032 SCALE: 1 " =40' AUGUST 27, 2009 R O � HAROLD L. EATON AND ASSOCIATES, INC. REGISTERED PROFESSIONAL LAND SURVEYORS 235 RUSSELL STREET — HADLEY — MASSACHUSETTS