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43-098 (2) BP-2011-0428 GIS #: .. COMMONWEALTH OF MASSACHUSETTS "''_ 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- 2011 -0428 Project # JS- 2011- 000700 Est. Cost: $2100.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 72309.60 Owner: CELENTANO JOHN J & GEOFFREY W LOCKE Zoning: SR(100) //WSP II Applicant: CELENTANO JOHN J & GEOFFREY W LOCKE AT. 19 WHITTIER ST Applicant Address: Phone: Insurance: 19 WHITTIER ST (413) 582 -0078 () FLORENCEMA01062 ISSUED ON :11 1512010 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL FIREPLACE INSERT 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 11/5/2010 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner City f Northampton tY w Building Department r _ 212 Main Street J Room 100 Northampton, MA 01060 phone 413 -587 -1240 Fax 413 - 587 -1272 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 141a6 Lot Unit 42 Zone; Overlay Dlstnct Ern► St` Drstrt � CB i)lstrtct SECTION -2 - PROPERTY' OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record Ce le h fa >7 v Name (Print) Current Mailing Address: Telephone Signatu/ — DD 2.2 Authorized Aoent: 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 ] e2D G `7 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Bullding!Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total= 0 +2+3+4+5) Check Number This Section For Official Use Onl Date Building` Permit Number: Issued: Signature: Building Commissioner/Inspectorof Buildings Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Informa'Cion ^ , Existing Proposed Required by Zoning , This column to be filled in by Building Department Lot Size v �_ ___.1 Frontage Setbacks Front Side L: L--- J R L: I R: Rear Building Height�� Bldg. Square Footage i_____ % Open Space Footage _ % (Lot area minus bldg & paved p arkin g) F # of Parking Spaces }- --- Fill: volume & Location A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KNOW 0 YES 0 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 r Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued:y _...._a. C. Do any signs exist on the property? YES 0 NO Q 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 Q 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. 1 r 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 [(_] Siding [tom] Other [[I Work: efDescription of Proposed S U l r� ��J �u �!�/S�Y �- c� �! �1 G' Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa, � y ot� i "i d> o 1 axis a r na; qtr t t I t war Cl: 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. Wif .building conform to the Building and Zoning regulations? Yes No. I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION TQ BE COMPLETED 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 /'evt fatly 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 Sign r of Ow r /Agent Date r SECTION 8 -CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone �.r k R "" " " 2 6 Not ❑ REI'IS, terf ln:111 ©�lIt311'+`Dtlr*i1 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 consid a homeo 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 orthampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature The Commonwealth of Massachusetts Department of Industrial Accidents " Ai Office of Investigations ' 600 Washington Street Boston, AM 02111 www.mass govI&a - Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb.ers Applicant Information Please Print LegibIy Name ( Business /Org=zation/Individvai) . Address: City /StatelZip: Phone. #: Are you an employer ?.Check the appropriate'box: F 4.. I am a general contractor and I Type of project (required):. 1. E I am a employer with ❑ g 6. F] New construction employees (fall and/or part time). * have hired the sub- contractors 2. E I am a sole proprietor or partner- listed on the: attached sheet 7. ❑ R modeling ship and have no =Tloyees These sub - contractors ha ve. .8. ❑ Demolition working for me in any capacity. employees and have _ workers' [ workers' 'comp filsu anct - C4II7p. m¢rrranra _ ❑ afldltt required.] 5. ❑ We are a corporation and its 10 ❑ Electrical repairs or additions I am a homeowner doing all work officers have exercised their 11. Plumbing g ❑ g or additions myself [No workers' comp right of exemption per MGL 12. insurance required.] t c: 152, § 1(4), and we have no employees. (No workers' 13.E Other comp. insurance required.1 *Any applicant4hat checla box #I mcst.also fill oat the section belowshowing theirwork=1 compensation policy information: t Homeowners who submit this affidavit. indicating they are doing an work and then hire outside contractors must submit a new affidavit indicating such: IContactars that check this box must.attached an additional sheet showing the name of the sub - contractors and state wheihc ornot those entities have employees. "If the sub - contractors have employees, they must provide I= 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 Sit Address: City /stawZip: ` Attach a copy of the workers' compensation oli decraf on ire showin the 9h number and exp iration date . P... �' la :...._....per_ (. . g p: cy , mb _ ��_ Failure to secure coverage. as required under Section 25A`ofMGZ "c 152 caa lead'to die imposition of crimmal penalties 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 ORDEK and a fine of up to $250 00 a -day against the violator. Be advised that a copy of this statement maybe forwarded to t O ffice of _ .__= InvestiQatioris of tt c'DIA for msuraace coverage verification I do hereby certify under the pairu penalties ofperjury.tltaftlte in fornutdonprovrdedRbove_tslrue an"Orrect _.. -:ate ...- . A tore: / p . Phone #: Official use only. Do not write ui this area, to be completed by 0 __ r town official .City or Town: PermitUcense # Issuing Authority (circle ane): J. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other F Contact Person: Phone #: f 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 backfilI), 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 mad I, under_ stand the above: me ner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued tome. Date Address of work location