Loading...
44-012 297 OLD WILSON RD BP- 2011 -1118 GIS #: COMMONWEALTH OF MASSACHUSETTS Map :Bloc 44 - 012 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Above ground pool BUILDING PERMIT Permit# BP- 2011 -1118 Project # JS- 2011- 001797 Est. Cost: $6000.00 Fee: $30.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 147276.36 Owner: EWING JOHN Zoning: SR(100) //WP/WSP II Applicant: EWING JOHN AT. 297 OLD WILSON RD Applicant Address: Phone: Insurance: 297 OLD WILSON RD (413) 584-2855 FLORENCEMA01062 ISSUED ON :613012011 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 21' ABOVE GROUND POOL 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 Sienature: FeeType: Date Paid: Amount: Building 6/30/20110:00:00 $30.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner t ' City of Northampton Building Department c2d 212 Main Street Room 100 ,' �� � lorthampton, MA 01060 - 587 -1240 Fax 413- 587 -1272 „a Im lit) APPLICATION TO N RUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING gUWNG IN ON � This sectiorrto be completed by office 1.1 Property Address � ' Map Unit 7 J� �,�, ��� zat�e ` ouerlay p�strtct "Elm st`btstrlct 'CB District :. SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record " Name (Print) Current Mailing Address: Telephone Signature l 3c) ` 3 4'/ 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 �— 4i47 Z 6. Total = 0 +2+3+4+5) Check Number 1 61 X6 This Section For Official Use Onl Date Building PPermit Number: Issued Signature: 0 - Of Building_ Commissioner /Inspector of Buildings Date a Section 4 ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete nformation i Existing Proposed Required by Z ing j This column to be Red in by Building Department Lot Size Frontage _ Setbacks Front ( ' -- Side Um R: L: ._...._' R: -- Rear -- Building Height Bldg. Square Footage " "' ` " "i % 3 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 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 Q .„.,�.. 3 �.«., f ............._. y............ ._..._ IF YES: enter Books Page, and /or Document # s _ _ B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES 0 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: 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,, e or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO *q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. t 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 [ [3] Decks [C] Siding [[3] Other [a Brief Description of Proposed Work: o f ��7GIi� 6L Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 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 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 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 ofperjury. Print Name Signature of Owner/Aiint Date t SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone Not Applicable ❑ 9.: leaistereclfrniirieiroeitierrLanratteia; PP Company Name Registration Number Address Expiration Date Telephone SECTION '10- WORKERS' C©MPENSATION INSURANCE AFFIDAVIT (M.G.L. e. 152, §; 25CM) 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 co nsidered 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 and State of Massachusetts General Laws Annotated. Homeowner Signature -- I R5 - r The Commonwealth of Massachusetts Department oflndustrial Accidents. . Office of Investigations 600 Washington Street Boston, MA 02111 wwx.mass gov /din -Workers' Compensation Insurance Affidavit: Builders/Contractors./Electricians/Plumbers Applicant Information Please Print Legibly 7� Name ( Business /Organiiation/ludividualY Address: City /State/Zip: AW dldl -'�hone. #: 3�-� ; . f Are you an employer?. Check the appropriate'box: Type of project (required)•, /f 1. ❑ I am a e Io. er with 4, E] I am a general contractor and I _ . mP . Y 6. ❑ N co nstruction --- -- - -- -- - - I - e fu11 and/or - arftiine :* - _-- havehired- the-sub- contractors— - - - - - -- emp Y ( P - ) - 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub - contactors have .g [] Demolition wor - for me in an aci employees and have workers' Y capacity. tY• # . 9: El Building addition [No workers' comp. insurance comp. insurance. 10.� Electrical repairs or additions required:] 5. F1 We are a corporation and its reP 3. I am a homeowner doing all work officers have zxercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.E].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 #I must also fill out the section below showing their wori= compensation policy information. t Homeowners who submit this affidavit indicating they are doing aD 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. Aram an employer that isproviding workers' compensation insurance for my employees Below is thepolicy andjoh site information. . Insurance Company Name: Policy # or Self-ins. Lic. #: Expiration Date: - Job Site Add City /Sta&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 i a the form o£ a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that acopy- of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under th ains-and penalties of perjury that the information provided abovo is true and correct Signa ture: Date: Phone #: Official use only. Do not write in this area, to he completed by city or town offwjaL City or Town: PermitUcense # Issuing Authority (circle one): .1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other L Contact Person: Phone in Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' cbmpensation for their employees. P ursuan t to this statute, an employee is defined as "..:every person in the service of another under any contract of hire, i express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation o; other legal entity, or any two.or more of the foregoing engaged in a joint enterprise,. and including the legal representatives of a deceased employer, or the j receiver or trustee -of an individual, partnership; association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of tire dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,' §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who. has not produced acceptable evidence of compliance with the insurance coverage required." lr. Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall / enter into. any contract for the performance .of public work until acceptable evidence of compliance with the insurance - -_ -- r equirements of this chapter.- have_ been - presented- to_the contracting- authority.' - - -- -----.--------_--- Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub- contiactor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insuran Limited Liability Companies (LLC) or Limited LiZility Partnerships (LLP) with no employees other than the 4 . members Or Partners, are not required to carry workers' compensation insuran If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed. below. Self-insured companies should enter their self- insurance license number on the appropriate line. City or Town Officials Please be sure.that the affidavit is complete and printed legibly. The Department has provided a space at the bottom Of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current Policy information (if necessary) and under "Job Site Address" the applicant should write ."all -locations'in (city`or town)." A copy pf the affidavit that has been officially stamped or marked by the city or town may be providedto the applicant.as proof that a valid affidavit-is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is. obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required.to complete this affidavit ' The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Department's address, telephone -and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investlgatlons 604 Washington Stmt Boston, MA 02111 Tel. # 617- 727 -4900 ext 406 or 1- 577- MASSAFE Revised 11 -22 -06 Fax # 617- 727 -7749 www.mass.gov /dia The State of Massachusetts allows the homeowner the right under 780CMR 108.3 A 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 dis ng,: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 „ _ persons) who seek to.use the ho ne per exemption, acct as °their own consftu�dpn supervisor; to be avoam that by doing so you become responsible for compliance with state building codes. and regulations. The inspection. process - requires that the.building Aepartment be called to inspect work at various stages, which include foundation/footing (before backfiln, sonotube !roles (before your), a rough building inspection (before work is concealed), insulation inspection fifnguired) and - a`final building inspection. The building department requires these. inspections before the work is concealed, failure. to secure these insuectians can result in far7ure 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 'ts 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 understand the above. (Home ow /resid is ' tore requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to Date .Address of work 0/� /�//'�"v location