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16B-044 253 NORTH MAIN ST BP- 2011 -0791 GIs #: COMMONWEALTH OF MASSACHUSETTS Map :Bloc 16B - 044 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category: replacement windows /siding BUILDING PERMIT Permit # BP- 2011 -0791 Project # ``' JS- 2011- 001305 Est. Cost: $27000.00 Fee: $70.00 PERMISSION IS HEREBY GRANTED TO: Const. Cla ss: Contractor: License: Use Group: TIMOTHY SENEY 061088 Lot Size(sq. ft.): 12893.76 Owner: LAFLAMME JEFFREY & TERRY Zoning: URB(100)/ Applicant TIMOTHY SENEY .-ice: n "< A IQ - -,RT -; 1 '9 0 Applicant Address: Phone: Insurance: 43 COUNTY RD (413 66 -0230 HUNTINGTONMA01050 ISSUED ON :4151201.1 0:00 :00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS /SIDING 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: NJ THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AN GULA ONS Certificate of Occup � si nature FeeTyue: Date Paid: Amount: . Building 4/5/20110:00:00 $70.00 212 Maui Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner 253 NORTH MAIN ST BP- 2011 -0791 GIS #: COMMONWEALTH OF MASSACHUSETTS Map.-Bloc 16B - 044 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate og ry: replacement windows /siding BUILDING PERMIT Permit # BP- 2011 -0791 Project# JS- 2011 - 001305 Est. Cost: $27000.00 Fee: $70.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: TIMOTHY SENEY 061088 Lot Size(sq. ft.): 12893.76 Owner: LAFLAMME JEFFREY & TERRY Zoning: URB(100)/ Applicant: TIMOTHY SENEY AT: 253 NORTH MAIN ST Applicant Address: Phone: Insurance: 43 COUNTY RD (413 ) 667 -0230 HUNTINGTONMA01050 ISSUED ON :41512011 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS /SIDING 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 4/5/20110:00:00 $70.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner City of Northampton GEC Building Department 212 Main Street =� Q 2 � , Room 100 N hampton, MA 01060 -587 -1240 Fax 413- 587 -12726 .� 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 Zone Overfi` D'istnct Elm St. 'District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record - - - -. Name (Print) Current Mailing Address: Signature Telephone 2.2 Authonze Aaent: 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 Law 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) I zew, o'' Check Number ply This Section For Official Use Onl Building Permit Number: Date Issued Signature: Building Commissioner /Inspector of Buildings Date f Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incompletelinformation Existing Proposed Required by oning This column to lent, filled in by Building Dep Lot Size m Fronta e Setbacks Front Side L: __.._ R: Rear Building Height — I�. Bldg. Square Footage --- % -- Open Space Footage (Lot area minus bldg & paved - p arkin g) # of Parking Spaces Fill: 7 volume &Location A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO n DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON KNOW 0 YES Q IF YES: enter Book Page and /or Document #' 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: mm ^~ 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 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 0 NO Q 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) E] Roofing Or Doors iR1 Accessory Bldg. ❑ Demolition ❑ New Signs [[] Decks [M Siding $4 Other [ [:7] Brief Descn tion of Proposed Work: -i YMfe4x ,wa,2 i7�/�L�4 i /��✓ Q ,�N,7 S �f / /2/c 5�i�h' �� /fOLlt /fl�r:�5� Alteration of existing bedroom Yes No Adding new bedroom Yes K No Attached Narrative Renovating unfinished basement Yes _ No Plans Attached Roll - Sheet sa Ife hciseranctrord'rtric�n tci exr"tlna losrdQrarfete hI foltc>vtEia 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 as Owner of the subject property hereby authorize f pv✓r e ,�/' to act on my behalf, ' all rp6tt s re tive t work authorized by this building permit application. Signature of Owner - Date I, 1lNL ��,C„JiCy as Owner / A 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 pedury. .mac 7 V Print Name ::�6 3 A.? � /'� Signature of Owner /Agent Date SECTION 8 - CONSTRUCTION'SERVICES 8.1 Licensed Construction Supervisor / Not Applicable ❑ Name of License Holder f0 771Y 1 l� y ��Q I License Number ✓iJ � N "7.� Oa✓ ' !Q U .�'�� Address Expiration Date Signature Telephone REt ItL: d=' llClinIt11pT t81Xt811hf3 i.. a,�,... _.. Not Applicable ❑ loll Company Name Registration Number sr�M� 1v z,<1 u 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...... ❑ y U O'n 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 Investigations 600 Washington Street Boston, MA 02111 www.mass gov /dia - Workers' Compensation Insurance Affidavit:.Buiiders/ Contractors /Electricians/Plumb.ers Applicant Information Please Print Legi l Name ( Business /Orgaair�tion/lndividual): AeA4 YCi✓Xe Address: City /State/Zip: , 5!,,j22V AvW, 0106D Phone. #: 1 //3 /71 Are you an employer ?.Check the appropriate'bor. T e of project r 1.0 I am a loer with 4.. E3 I am a general contractor and I Y 6. El New coistiuction . employees (fall and/or part time)." have hired the silt- contractors 2 I am a 'sole proprietor or partner- listed on attached sheet 7. ❑Remodeling ship and have no loyees These sub - contractors have. .8. E] Dcaolit on worldrig or me m an ad e l and have workers' Y P . tY sdit a difion [NO wa*lqrs f,. I�S1iIaliGe, - ..GOIap. �__ .'. ... require&] 5. �]. We are a corporation and its 10 Q IIectrkal repairs or additions 3. ❑ I am a homeowner doing all work Of have xercised their l L - Phnabing repairs or additions myself [No workers' comp. right of exemption per MGL 12: Roof repairs � 152, 1 , and�we have no - insurance rt34 c: ] t . (� 13.0 Other ' /Gl� 4 r /� employees. [No workers'. camp. Insurance requii�l 'Any applicant Shat chec3a box #Lmnst.also fill out ffie section b loo showing dx cornpesation policy informadaL t Horneownes who submit this affidavit:inacatiag they = doing aR work and the hire outside contractors mwt submit a mw.affrdavit indicating sock. 1 Coatt2ctor3 that check this box mustanached an additional sbect showing the name of the sub - connectors and slate whedwror notthose-eatities have employees. If the sub - contactors have employees, tliey must.pmvide their wozi=' comp.po n urnbcr . . 4m an employer that is providing workers' cantpensatian insurance for. my employees Below is the policy and job site information. Insurance Company Name: . Policy # or Self ins. Lic. A Expiration Date. Iob Site Address: C' /Stir ` - — t P= • Attach a copy of the workers'" compensation policy declaration page'(showing the policy number and _ezptratiou date). Failure. ta secure covers e;as re under.Secttoa "13A ofIVIGL`c: T52 can lead to ffie '- sitiim of " -' g 4 �o crunmmI pe aIhes of a fine up to $ 1,500.00 and/or one- year as well as civil penalties is the foam of 11 STOP WDRK QRD£R and a fie o up t o $250.00 a day against, the violator Be advised that a copy of this statement may be forw to the Offi 'cc, -of Tnvestigattoiis of the D A for "u surance'coveraze verification _do hereby certify under thep enaltres o. fperftpy41& - t a irrforma:ran�rovrded av "ifs _aadcorret _. _. Si tare. Phone # O use oril . Do not write in this fficrdl y area, tb be completed by city or tower offictaL City or Town: Permit/Llcense # _- Issuing Authority (circle one): .'I. Board of Health 2. Building Department 3. City/Town CIerk .4. Electrical Inspector 5. Plumbing Inspector 6. 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 homeowner." The building department for the City of Northampton wants persons) who seek to use the home owner exemption; - to act as their owrr 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 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 �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 DIELAY 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 lime: Date Address of work location