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••NSTRUCTION UNLESS AUTHORIZED BY WRITTEN AGREE- PRELIMINARY SET (NOT FOR CONSTRUCITON) SEPT 15. 2009 WIP
M: T BETWEEN THE OWNER(S) AND CLOD RESTORATION &
RE •VATION, INC. THE OWNER IS RESPONSIBLE FOR ALTERATIONS TO LENNOX RESIDENCE (PHASE 1) MARSHALL AUDIN / ARCHITECT PROJ: G116
OBTAINING ALL REQUIRED PERMITS & APPROVALS. 15 COLUMBUS AVE., NORTHAMPTON, MA GLOD RESTORATION & RENOVATION, INC./ BUILDER
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•ONSTfFUCTION UNLESS AUTHORIZED BY WRITTEN AGREE- PRELIMINARY SET (NOT FOR CONSTRUCITON) SEPT 15, 2 09 WIP
M NT BETWEEN THE OWNER(S) AND GLOD RESTORATION &
R OVATION, INC. THE OWNER IS RESPONSIBLE FOR ALTERATIONS TO LENNOX RESIDENCE (PHASE 1) MARSHALL AUDIN / ARCHITECT PROJ: G116
OB AINING ALL REQUIRED PERMITS & APPROVALS. 15 COLUMBUS AVE., NORTHAMPTON, MA GLOD RESTORATION & RENOVATION, INC./ BUILDER
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 pmces esquires that the building department be called to
inspect work at various stages, which include foundation /footings (before backlill),
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 i-n- 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.
Address of work
location
The Commonwealth of Massachusetts
Department of Industrial Accidents
�= =--14g.=.7,0 Office of Investigations -
, . _0. . - 1;
�l:l- -$ 600 Washington Street
r Boston, MA 02111
s � www.massgov /dia
-Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): �T� L.pN S`fC.CZf4T /0,4 I Z6-N00II-TraaJ
Address: . b , 3oi- 5 { i . c 3 L S3 /tit4SS'A-Pi - ( r 6 , 4 - 4 y ) b , SI G 3 te- - /t(4 01 V
City/State/Zip: Phone #: iTT in `i 0 83
Are you an employer? Check the appropriate box:
. Tyke of project (required): /)-
1. �-I am a employer with 2 4 . ❑ I am a g eneral contractor and I
have hired the sub- contractors
employees (full and/or part- time). * 6. ❑New construction
listed on the attached sheet. 7. ❑ Remodeling
2. El I am a sole proprietor or partner-
ship anti have. pa , --nploy ees These sub - contractors hav 8. 0 Demol on
working for me in any capacity. employees and have workers 9. ❑ Bufidinaddition
[No workers' comp: u ce Eon= *ns aace _.. _
required:] 5. ❑ We are a corporation and its I0.❑ Electrical repairs or additions
officers ve°exercjs d their
3. ❑ I am-a homeo- -w ner- doing-al -work — — 1 ❑ Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs
c. 152 4
insurance required.] t � ' 1 § O' and we have no 13.❑ Other.
employees. {No workers'
•
COIDp. insurance regt±ed.]
*Any applicant that checks box #I 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.
IContractors 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 Ls the policy and job site
formation.
Insurance Company Name: . " G
Policy # or Self-ins. Lic. #: C. 5 . - coi LF + I Expiration Date: et /IC
Job Site Address: 1 C.O LOvut 3■.3S / City /State /Zip y.lo `T1lRfjP)24y .) V`-&7
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 fine
of up to $ 250.00 a day against the violator. to advised that a copy of this statement may be forwarded to the Office of
Investinations of the DIA for insurance coverage verification _
I do hereby certify under the pains , penalties of pedury that the information provided .above.istrue_andcorrect
Signature: - Date, l ` v � (
Phone #: 4 - 4-i) 8o 4 0 6. -
Official use only. .Do not write i t his ar tube completed by city or town officiaL
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical_ Inspector 5. Plumbing Inspector
6. Other f
Contact Person: Phone #:
•
t
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : l �+ S C*- -L-/2b, 5 T7
License Number
4 5 - 2- Mdiss/ 'c C - U. ( De/4.7 t..6 1 4 - 2 z -1b
Ad ress c 1 e) 4. - Expiration Date
,QI i q U^S1 g- )'-4 a t i-05t50 Lit S'3,C...
Signature Telephone
9. Registered.Home lmprovemeritContractor _ ... .,...,. .. Not Applicable ❑
A t') S. G Lbct3 i2,
Company Name Registration Number
T2- P40455A 43 /t . hv , s 'rl'4¢(.6_ Ma co8 9 - 1C . - )o
Address � Expiration Date
Telephone q T-� G <108 i
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 f4 No ❑
i i x �4 a f. x -
I � Owner xemp a�,c>t
The_current exemption for "homeowners" was extended to include Owner 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 1083.5.1.
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. . b'- " . t
The undersigned "homeowner' certifies and assumes responsibility for compliance with the State BuilciiigCdd`e, City of' .
`o amp on e r • inane , " a - a o a 2 m i . ,« - 6 - , . . - s- 6enera-1 -Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) 2 Roofing l i
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [C] Siding [ID] Other [0]
Brief Description of Proposed Al
/
Work: i Y� t`z.pi A L STfz0CTc,,2r4L, '0f STR F NL- f w�4 O1 /b Z�2 114.14/1(/ 34/`.
�3�S�iyfiNT
Alteration of existing bedroom Yes t No Adding new bedroom Yes X N
Attached Narrative Renovating unfinished basement Yes � No
Plans Attached Roll - Sheet
sa if Newhouse`arictoc, adiiition to':ezisfir qt ho islnq,,compiete the fa(lowlriq:
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 Ta - OWNER AUTHORIZATION w To BE C ®MPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
0J/• d k
as Owner of the subject
property
hereby authori -
to act on my •'half, in all atters relative to work authorized by this building permit application.
Signatu� Date
I, .,?A%/' at CS , 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
t'-
J
Signature of Owner /Agent �` Date f / C�
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.. ...__ _. _n____ _. _,. ..._
Frontage
Setbacks Front
Side L._ _.____. R::.___2 L :__ ,.,__..r R._....._,_ <'
Rear
Building Height
Bldg. Square Footage i-- -.-- -i
Open Space Footage
(Lot area minus bldg & paved _._ _ _
parking)
# of Parking Spaces — - -°
Fill: 1 .�..,��.._..��..� I �.._ . �..m. � �s.r......._
(volume & Location) tI ,----- •---•• -- --
R pig
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO (3 DONT KNOW 0- YES 0
IF YES, date issued:I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book i i Pagel i and /or Document #.
B. Does the site contain a brook, body of water or wetlands? NO 9 DONT KNOW 0 YES
lir IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location
__ D: — re tth re an ro - 5 — & — R Chan es to or a itio iTo si ns inten ed or the' property ? YES 0 NO
YP P g g P P Y•
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 Q NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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City of Northampton S tatus of Perntt
Building Department Curb Gut/I?nvewayermrf
212 Main Street SeeSepboAvarla4ff►#y� ���
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SGT p 413 - 587 -1240 Fax 413 - 587 -1272 'plot/Site 1 ?ran �
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APPLICATION TO' CONSTRUCT', ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
1.1 Properly Address: This section to be completed by office
1 5 V e) •n TS / Map Lot Unit
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
Signature 3 1
2.2 Authorized Agent:
C ? O, i � 1- 5q � d -( Si AfiSict Aftp_
Name (Pri Current Mailing Address:
Signature Telephone
SECTION 3.- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building q (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 (1 + 2 + 3 + 4 + 5) Check Number
This Section. For OfficiallyUse On1y
Building Permit Number. Issued:
Signature:
Building-Commissioner/Inspector of Buildings Date
File # BP- 2010 -0296
APPLICANT /CONTACT PERSON DAVID S GLOD
ADDRESS /PHONE PO BOX 590 DUNSTABLE (978) 804 -0836
PROPERTY LOCATION 15 COLUMBUS AVE
MAP 38B PARCEL 141 001 ZONE URB(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 0) 1°2
Typeof Construction: INSTALL FOOTING & WALL UNDER MAIN BASEMENT BEAM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 55077
3 set¢ of Plans / Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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
Demol' on Delay,.
_7:"/ •
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.
� r
BP- 2010 -0296
GIS #: COMMONWEALTH OF MASSACHUSETTS
s ; t,' k: 38H - 141 1 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- 2010 -0296
Project # JS- 2010 - 000392
Est. Cost: $9400.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DAVID S GLOD 55077
Lot Size(sq. ft.): 5924.16 Owner: LENNOX SARA J
Zoning: URB(100)/ Applicant: DAVID S GLOD
AT: 15 COLUMBUS AVE
Applicant Address: Phone: Insurance:
PO BOX 590 (978) 804 -0836 WC
DUNSTABLEMA01827 ISSUED ON:9/22/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL FOOTING & WALL UNDER MAIN
BASEMENT BEAM
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 9/22/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo