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44-012 (2) 297 OLD WILSON RD BP- 2012 -0005 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: Deck BUILDING PERMIT Permit # BP- 2012 -0005 Project # JS- 2012- 000011 Est. Cost: $5000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(s4. £t.): 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) 326 -3510 O FLORENCEMA01062 ISSUED ON. 7/7/2011 0:00.00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 8 X 24 DECK 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 7/7/20110:00:00 $50.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner File # BP- 2012 -0005 ' APPLICANT /CONTACT PERSON EWING JOHN ) ADDRESS/PHONE 297 OLD WILSON RD FLORENCE (413) 326 -3510() (��- `� �,►.�� PROPERTY LOCATION 297 OLD WILSON RD MAP 44 PARCEL 012 001 ZONE SR(100) //WP/WSP II THIS SECTION FOR OFFICIAL USE ONLY: �` A 6 PERMIT PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: CONSTRUCT 8 X 24 DECK 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 INF9RMATION PRESENTED: 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 (-� 1 716 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. --" Department use only City of Northampton Status of Permit: gilding Department Curb Cut/Driveway Permit IV 21 Main Street Sewer /Septic Availability, oom 100 Water/Well Availability rth pton, MA 01060 Two Sets of Structural Plans pho M 1 58 -1240 Fax 413 - 587 -1272 Plot/Site Plans OF Other Specify PTON AIA 7 APPLIC T, 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 j 91 00 (U / / S 0 - ' j � ff _D Map Lot Unit nt.Q�dU U— Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record -� Name (Print) Current Mailing Address: Telephone Ili Signature 2.2 Authorized Aqent: 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 J 0 -0D -� (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 = 0 + 2 + 3 4 + 5) sp D • — Check Number This Section For Official Use Onl Building Permit Number: Date Issued: Signature: Building Commissioner /inspector 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 in by Building Department Lot Size C A Frontage U s7 Setbacks Front q0 r r Side L: (4i R: � L: R: Rear Building Height '� b Bldg. Square Footage 00 % Open Space Footage p % (Lot area minus bldg & paved p arking) # of Parking Spaces Fill: volume & Location A. Hasa pecial Permit /Variance /Finding ever been issued for /on the site? NO DON'T KNOW O YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DON'T KNOW © YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO V DON'T KNOW O 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 0 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 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. a SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [ Siding [O] Other [c►1 Brief Description of Proposed p ,� _ � TR .� � 0 � Ov - � f� �� Work: 0 lleC& 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 addition to existing housing, complete the following: 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 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 1, , 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 Signature of Owner /Agent Date t SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9. Reaistered Home 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...... ❑ 11. - Home Owner Exemption 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 (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 . T The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigationg _ 600 Washin Street Boston, MA 02111 wwrv.massgov /dia = - -Workers' Compensation Insurance Affidavit: .Builders/ Contractors /Etectricans/Plumb_ers Applicant Information Please Print Lesibly Name ( Business /organiiadon/ln&vidvat): ✓✓ t/ =�•�/e r�' Address: a � �1,�s� �- A9 City /State/Zip: /d Phone. #: Are you an employer?. Check the appropriate'boa: -Type of project (required):. L I am a employer with 4.. ❑ I am a general contractor and I employees (full and/or part time). have hired the sub- contractors 6. New constGaction . 2_Q I mitt a sole proprietor or part acr- The listed on- the.attacheil sheet �. ❑.remodeling ship and. have no, =ployees s e sub - contractors have 8. [� Deaiolikion ' wo for -many �joyees atid3zave workers' rlring y capacity 9; ding aeon _ in'rtranr_P .. [No wO&ers' 'COMB- C CQ �' ' 5. �. We are a coipoiation and its IO.Q Electacal repairs or additions re4vired J I am a homeowner doing all work ocers have xercised their 11. Plumb' repairs or additions ffi 3. ; 0 . elf o workers' co right 6f exempdori per MGL 12. Roof airs insurance required.] t c: 152, § 1(4) and we have no 13.0 Other employees.' [No workers' comp. msurance regtired.. "Any appiicant Shat checks box #1: masE,aLw fill out the section below showing thee. vod=s'..compeasatian poficy information submit this affdavit,indicating they are doing all work and that bare outside contraeton must submit a new affidavit indicating such. Zconuactors that check this box must.auached an additional sheet.sbowing the name of the sub-corttactors and state wbed=-ornot3hose-entities have employees if the sub - c ont r actors h employees, toy mustpruvide them wmi=' comp•.poHcYnumbcr. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job: site inf Insurance Company Name: Policy # or, Self -ins. Lic. # Expiration Date. Job Site Address: City /State/Zip: r Attach a copy of the workers' compensation policy. declaration pade the policy number and expiration date). Failure_ for secure coverage as required unday Section' - - 25 ofMCL c: 1 can Iead t6 hie nnposrtton of crstn I perratties gf a fine up to $1,500.00 and/or one.- year as well as crvil penalties in the form of a STOP W ©RK -P1 ZDER and-a fine of up tor,$250.00 a day against the violator. Be advised'that a copy of this statement may be forwarde to the Office of Investzsations ofthe DIA for 'insurance covma a veriticafton _ I do hereby certify under the pains aid penalties of._pe> . at th the inforinii onivrovided abav . ' aadrorr ' Si tune: A/ . Date: Phone #: OffX M use only. Do not write in this area to be completed by city or town &kjaL 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 5.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, act as their own construction- sup&Wsor,'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 your), 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 O occu 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 ermits 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 L understand the above. .(Home owne signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to Date Gd I J Address of work ocation aj �9� $ln ----------- r4 - T #4 &T4Xs8 * Tx C ->Ovl2Ow OTTT►TT Or x§ O r x_ O r x 8, T � 2 6►1�M [9 VxCxTM -Q►• D 41 Ji .- � �� i i'� f `� � ... d_. _}� Q,) 4 ) � _�"' .`_.._... .....,ems r 3o Al -XI