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46-046 121 ISLAND RD BP- 2009 -0444 GIS #: COMMONWEALTH OF MASSACHUSETTS Map-Bloc 46 - 046 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) B UILDING UILDING PERMIT Permit # BP- 2009 -0444 Proiect # JS- 2009 - 000599 Est. Cost: $35000.00 Fee: 210.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JAMES HELEMS 093395 Lot Size(sa. ft.): 5488.56 Owner: SARGENT CATHERINE E Zoning: SC(100) / Applicant JAMES HELEMS AT. 12 ISLA RD A'DpZcca rldctress: - - - 'Phoney P O BOX 625 (413) 246 -6506 SOUTHAMPTONMA01073 ISSUED ON. 1012212008 0:00:00 TO PERFORM THE FOLLOWING WORK: REPLACE SOME INTERIOR WALLS, INS ULATION,DRYWALL & NEW FLOORS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. _ Building Inspector Underground: Service: �r� Meter: Footings: Rough: Rough:., House # Foundation: Driveway Final: Fivat:eln )� final: 3 9 io _ (ovdtL Rough Frame:�� Gas: Fire Department Fireplace /Chimney: Rough: ` Oil: InsulationeK Ja^ Final: q" f ul"r- ; moicc: Final: 4 K -7 ,26. &c7 THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLAT / OF ANY OF ITS RULES AND REGULATIONS. Certificate of f� OCCUranCL/ _ Signature: FeeTyne: Date Paid: Amount: Building 10/22/2008 0.00:00 $210.001018 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Couunissioner - Anthony Patillo log � TG� e,or���0) 11 � t File # BP- 2009 -0444 APPLICANT /CONTACT PERSON JAMES HELEMS ADDRESS/PHONE P O BOX 625 SOUTHAMPTON (413) 246 -6506 PROPERTY LOCATION 121 ISLAND RD MAP 46 PARCEL 046 001 ZONE SC(100)/ 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: REPLACE SOME INTERIOR WALLS,INSULATION DRYWALL & NEW FLOORS New Construction Non Structural interior renovations Addition to Existin Accesso1y Structure Building Plans Included: Owner/ Statement or License 093395 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF91MATION 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 jo 1 Signature of Building Officid 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. t [Separtmenn ease only City of Northampton Status of Rerm►t 2, Building Department CurtrCtat�f7ciey Per 212 Main Street SeweelSepftcAarlatultt Room 100 ater/tltetlAva "ial Northampton, MA 01060 Twc�Sets,QtuStl'rotutt Ptarrs phone 413- 587 -1240 Fax 413- 587 -1272 Pht/51te Prams Other Specify r ,3 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 Y� c {t t �► t� vh ? t c m f� is I (j,b Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record Nam (Print) Current Mailing Address: Cam Telephone Signature r 2.2 Authorized Agent: f`�Z � !-Zz�- ,c9tl,`�►� 7_ � �! �o .Z J �G..iN,��,,,��1 v v� � Name (Print) Current Mailing Address: b i 0 L!, 1 — 7 nature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only com feted by ermit applicant 1. Building yl3 j- vim. C (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) s, CC' C - C? 0 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 Frontage _ _. _...... _........_ Setbacks Front Side L: ........... R. Rear Building Height Bldg. Square Footage % _._.._,...._, __.. . Open Space Footage ° (Lot area minus bldg & paved p arking) eP – -- # of Parking Spaces Fill: (volume & Location) —t" - . .... ...... .....__.___. _ _,,.,,_ A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO DONT KNOW YES 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 DON KNOW 0 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, 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. r ` SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition Replacement Windows Alteration(s) ® Roofing F7 Or Doors 0 Accessory Bldg. ❑ Demolition El New Signs [❑] Decks [Q Siding [❑] Other [o] Brief Description of Proposed _ Wor f) r.3 , lc��; � )� �¢ 1 NZ 1-2 1 _ - "a ' 'o. i a %t r- t1Cw N A wfiL J7 � 'F1ocaLs Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing complete the folFowing 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 stones? 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 1 1 k i'l (, ; Ct ,j' C �� V as Owner of the subject property hereby authorize L—�2z ► L �.� r. S t a2 v c �F Z z N. a w 1 : �S. LLC to act on my behalf, in all matters relative to work authorized by this building permit application. Sig ure of Owner , Date C ` as Owner /Authorized Agent hereby declare tha the statemen 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 Nam g Signature of Owner /Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor ]� Not Applicable ❑ _ Name of License Holder -� vh ' S rl e Yv� S S 3 3 � " License Number 5 3 G - I1„., zo i L,, 01v 13 ? - 16 -2 a Address Expiration Date nature Telephone &. Registered " Home, lmpirovemerif "C ©ntracfir Not Applicable � ., [ ❑ C II = Y�I� L C �5 1�✓G1�V:l "+i1Lw L-LC Company Name Registration Number So, ;�L,.,? i �� ,M1 n1t ay_ey -/ 0 Address Expiration Date Telephone W 3 " Z 4/1., -4 S , SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.E. c. 152, § 25C(5)) 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....... 19 No...... ❑ 11. - .Nome = w>i;rer Egeloboon 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 and State of Massachusetts General Laws Annotated. Homeowner Signature The Commonwealth of Massachusetts Department of Industrial Accidents t ,�- Office of Investigations 600 Washington Street - Boston, MA 02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors/EIectricians /Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): z i 'r C n Y,� tt �� i �� aZ z . >� �1, , L L L Address: 0 �-, x 1: Z 5 — City/State/Zip: Sc, , ii k A , ? ' D. [-,a vin 13 Phone #: Lt i 3 - 2'-1 b _ G: Scl G� Are you an employer? Check the appropriate box: Type of project (required): 1. ® I am a employer with 3 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.7 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.7 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 employees. 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: In �,(ZiA"N C r- Policy # or Self -ins. Lic. #: 2 o O 4, '- i�- 2 `/ Expiration Date: ' 2 ° o Job Site Address: R l s l a fl U � City /State /Zip: �� � A %_ �)! on 1 v A v l o t, b 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 criminal 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 fore 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature:- — Date: Phone #: 4 3 L Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit /License # Issuin, 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 OWNED 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 I 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 s Z Z P � v W i Cl) O w r ` w 250 a a0 Cf) LL � M O co p �. � cri W r 0 kZ �r D O = Q m o J � s O J L,9 .r U O J LL 5.£ w C) � W Q — ZM - O U z N lV116 LL ti I Q J W M O � � � Y ti 0 Z Q J o O O J LL 0 Z O U W U) Apr 22 09 06:28p Jim Helems 413 - 529-0101 p.2/0 ,di / j APR- 23 -200si O5:340 FROM- C21 T -702 R_101 F-917 514 h" I MAIN b I t t, VV= F r1eLu, nrw u I V00 (413) 58448190 _ Wod Apr 22 17.1539 This Pro}ect emnot be prkmd because not ail Irrafin WE we carried In stock. See Skwo Amodate for prices on nonoatock hems shown In O"WaterUft. JAMES HEI,EMS CREATIVE CONSTRUCTION 1, ApR 2009 . C j� A � THY DECK DESIGN 3D Vlew 4 1 k a rvi a� s . 4 4 e a o v► a � J 7 ` R _a t L•d 6040-6ZS-Uv SW918H wiP d8Z :90 60 ZZ add w • o-.� , %� I � „� -. ...., .....__..,,, k.