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24D-066 r w 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 • .1 • 1, - . - .so socess 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 jjf 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 __— _____ perms -in- conjunction to_ the_ buildi .ng_ermit_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. —mate Address of work location A The Commonwealth of Massachusetts Department of Industrial Accidents RPM Office of Investigations • a _ , � • 600 Washin Street Boston, MA 03111 www.mass.gov /dia - Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb ers Applicant Information Please Print LegibIv Name (Business/Organization! Address: 13•=%X- 6q City /State/Zip: � ) ) L c3 Phone.. #: L/r3 5 gY Olt Are you an employer? Check the appropriate b o x : T y p e ofp oJect (required): 1. ❑ I am a emplo with - 4.. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub- contractors 2. am a sole proprietor or partner- listed on the attached sheet 7. [I] Remodeiing ship and .have no. employees These sub - contractors have . 8. ❑ Denioi±tion ki for in an capacity. employees and have workers' working Y P tY• 9. ❑ Building addition c . . [No workers comp. insurance off' insurance. 10 Electrical r airs or additions required] _ 5. ❑ We are a corporation and its ❑ rep 3. I am- a- homeowner-doing all work _ - o cers lave_ ,er_cis their _ -11.0 g ingrepairs or additions right of exemption per MGL myself [No workers comp. 12. gloof repairs insurance required.] t • c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comp. insurance requited. *Any applicant that checks box #1 must also fin 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: Policy # or Self-ins. Lic. #: . Expiration Date: Job Site Address: City/State /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 criminal penalties of a fine up to $1500.00 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. 15e advised that a copy of this statement may be forwarded to the Office of Investieations of the DIA for insurance coverage verification I do_kereby certify under the pains and penalties of perjuly that the information provided _ above_is_true_audcorrec.z __ _ Signature: Date. 1 Phone #: i4/3 Official use only. Do not write in this area, to be by city or town off ciaL 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 Contact Person: Phone #: • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Lam / Name of License Holder :✓>7.✓ J ✓ / Cv ✓ /�j� License Number ( C Y i % /V 4 - �5 -/z Addr Expiration Date St Q�.i' Telepho l 9.; ReaistereFtbme °tmroYerr►Carttrarcfor:< ., „� ..,,.N. �.._ ,,.r �: Not Applicable ❑ // ' Company Name Registration Number 7 ' Address fn Gals l/ Expiration Date 1 Aid- C ' �-” D L 64 Telephone f /, 3 6 / 7I4 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 it. Signed Affidavit Attached Yes No ❑ 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. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton "UrdmanceS; State - andtocat` - orting taws -and -S • - - • • ■ -tts- General- Laws - Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [I_] Siding [D] Other [DI Brief Description of Proposed 0 Work: S k"p I C lol � PO(� i G' VLS J I / I Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative . Renovating unfinished basement Yes No Plans Attached Roll - Sheet ;f teii r[ iifatf t ititicirtrtru aking hods itig riiript to tie f�tfcivvrrti 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 � 7 v y , as Owner of the subj ect property hereby auth e to act on y behalf ' I afters relative to rk authorized by this ing permit application. / 110 Signature o wner Date 1, L-4 , as Owner /Authorized Agent he reby Clare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pal and penalties of perjury. ) Print Na �.. / / d Signature • owner /Agent Date A r ft 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 _ 1 fi ...__. ; Frontage t Setbacks Front I -, Side L.._ .... _. R _ .. ___ L: R. "_, _._... _ ._ ._ Rear Building Height "` Bldg. Square Footage d ° " "' Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: -_ (volume & Location) ,--------, . _ .,__.. A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW (3 YES IF YES, date issued:. IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page` _ and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 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 NO IF YES, describe size, type and location: -- D. Are tfiere any - proposed changes to or actions irsigns intended for the property ? YES NO IF YES, describe size, type and location: E. W+ll 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton • �errn Building Department 212 Main Street s t I 4 _ Room 100 , Northam pton, MA 01060 phone 413-587714.1-0 2 A r ax d 5 97 ' Li1 „'� y , �=c:.a,�z r� z�.„ ;�' I .JIIVII f"QJ1�13-JV / - FAO t APPLICATION TO CONSTRUCT. ALTER. REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION -1 - SITE INFORMATION This section to be completed by office 1.1 Property Address: Map Lot Unit Zone Overlay District Eim St District CB. District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: -- ► cTf- __ _ 26 te4C(i s f E :::::: • ressy 2.2 Authorized Agent: �� '� � x / ��` J 7)10/11 � ice- 1 Name ' ) Current Mailing Address: - 3 1?7. floc Signature Telephone • SEC ON 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building QdJ (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) 1, �u Check Number J //3 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 28 PERKINS AVE BP- 2010 -0424 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:alppk 24D - Q 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 -0424 Project # JS- 2010 - 000577 Est. Cost: $2000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: TIMOTHY J LUCE 100515 lot Size(sq. ft.): 5183.64 Owner: FINE JUDITH I Zoning: URB(100)/ Applicant: TIMOTHY J LUCE AT: 28 PERKINS AVE Applicant Address: Phone: Insurance: P 0 BOX 14 (413) 387 -9800 LEEDSMA01053 ISSUED ON:10/20/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP,PLY & SHINGLE PORTIONS OF ROOF 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 10/20/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo 2662 I O ,_._ 36" 21" 00 n � 9' -1 " "' BATH 36" � . 36 " zo 0 i 36" I. f © 30" 24„ 24 K ITCHEN Li J 2465 I i— I 24" 1 15 "FH 6' - 10" Ceiling Height _ 9 „ 30" 36" 14'_5" / — — ° 30 " „ / 12” 24 I __ 2865 UP PROPOSED PLAN 1 NOTES: All allowances on proposal subject to change. Customer to empty contents out of the kitchen, bathroom and attic areas. Plumber to redue basement waste plumbing and washer machine drain. (ABS) Add $95.00 for water to refrigerator for icemaker. (1) Toilet and (1) Disposal fSunnlied By Owner). Does not include any heating, other than the bathroom ceiling heat, supplied and installed by the electrician. Bathroom door and jamb are primed white. Kitchen entry door and window to remain. All trim is to be stained and urethane. Opening to dining area is to be trimmed out in pine. Does not include Pulls or knobs for kitchen cabinets. Countertops Granite Uba Tubaj$4,032.00 tax included) Solid surface corian countertops Choice of color by owner. ($5,200.00 tax included) Silestone "Group B" Material allowance of ($5,095.00 tax included). Custom wood edge laminate counter tops per dimensions, loose backsplash, choice of standard stock colors, ($1,907.00 tax included). Painting/stain /urethane: All New interior walls to be painted one coat primer and two coats finish paint. Bathroom door and jamb to be painted two coats finish. All pine trim to be stained and urethane. Kitchen Cabinets : Wellborne forest Classic Series "Chiswick II" in oak with available stains Upper cabinets to have a crown molding installed. Add $500 for full extension with soft close drawer slides. Does not include pulls or knobs. Countertops : ($4,032.00 tax incl.) Granite "Uba Tuba" countertops installed to kitchen area. Cut out for sink, standard pencil edge treatment, template, delivered & installed. Flooring Vinyl: (Material & Labor Allowance of $400) We will install vinyl sheet goods to the bathroom area. (color by owner) Flooring Wood: (Material and Labor Allowance of $8$0) Install 2.5" strip oak flooring to the kitchen area, sand, coat with 3 applications of urethane finish. 6 Floorin ,---) (BY OTHERS) n Aaaliances: cl �fr We will install owner supplied microwave hood, vented to the outside. x1 ci ` We propose to furnish the material and labor necessary for the completion of the above stated work for the sum of =.� = _ x,. ::.� ::::•: ::;5.=,...._ $20 633.00 Payment as follows: $10,000.00 upon start (Demolition), $5,000.00 upon rough inspections, $3,000.00 upon finished sheetrock and $2,633.00 upon completion of contract. All work to be completed in a workmanlike manner according to standard practices. Any alterations or deviations from the above specifications involving extra cost will be executed only upon written orders in the form of a change order , and will become an extra charge over and above the estimate . $40 per hour and 15% above material cost will be billed for the extras and credits. All agreements contingent upon strikes accidents or delays beyond our control. Owner to carry fire tornado and other necessary insurance. A certificate of workman's comp. insurance, liability insurance, license and registration will be presented upon signing. Respectfully Submitted by ` i' ,/ of Harlow Builders. ACCEPTANCE OF PROPO 1 accept the above stated prices, specifications an ' ondition You are hereb authorized to do the work as specified. Payme w' .. be ma I e as outline Date -5 / c = / 1 Signature _ Atk Signature _..� ... /.. . 1 Electrical: Disconnect & reconnect all existing wiring and re -feed as needed. Using existing 200 amp electrical service. Install (1) dishwasher circuit (1) microwave hood circuit (1) garbage disposal electrical hook-up (2) GFI outlets (6) outlets (5) Recess lights with switches, (1) 4' track lighting, (1) Fan/light/heat combination. (1) Vanity light with switch. (1) GFI. outlet. (Owner to supply decorative fixtures). Insulation: Exterior walls will have 4" fiber glass insulation (R -13) installed with a poly vapor barrier. We will install fiber glass insulation around window and door units. Sheetrock: 1/2 "gypsum board applied to kitchen walls and ceiling. 1/2 "moisture resistant gypsum board, applied to bathroom walls and ceiling. Sheetrock fastened with 1 "1/4 screws, taped, coated (3) applications, sanded to a paint ready surface. Interior Door: Install (1) 2466 Jeldwen solid core door and jamb to the bathroom area. (white door & jamb) 0 Painting/stain/urethane: (BY OTHERS) Interior trim: Baseboard, Casing, sills and Jambs to be, ix pine material. • 0 Kitchen Cabinets ; (MATERIAL BY OTHERS) We will install owner supplied kitchen cabinets to the kitchen area as per plans. Does not include knobs or pulls. Countertops : (BY OTHERS) Vanity Cabiget: ($350.00 Material Allowance) (1) 30" Vanity cabinet with two doors. Diamon cabinet with oak wood and natural finish. Vanity Top: ($160.00 Material Allowance) Cultured Marble top and bowl. Bathroom fixtures: We will install owner supplied towel bar, toilet paper holder and mirror to the bathroom area. (Does not include shower door) Underla vment: We will add 5/8" ulc plywood underlayment to bathroom area. Harlow Builders 336 Coles Meadow Rd. Northampton, Ma. 01060 (413) 586 -0465 Submitted to: 5/4/11 Doug Luce / Judith Fine (413) 320 -1829 28 Perkins Ave. • Northampton, Ma. 01060 Page 1 of 5 We hereby submit specifications and estimates for the renovation of the existing first floor Kitchen and bathroom areas. All materials and labor to complete. All permits obtained by Harlow Builders. All debris caused by construction removed by Harlow Builders. See attached drawings for details on framing and placement of fixtures. (Drawings by Scott Harlow Dated Feb. 2011) Owner to remove all contents of kitchen, bathroom and attic area prior to start. Demolition: Remove existing counter tops and kitchen cabinets. Remove existing tub, toilet and sink. Remove existing door, base, case and sills. Remove existing wall and ceiling finishes to framing. Remove vinyl flooring and underlayment down to sub - floor. Remove partial finishes and framing to enlarge the wall opening, in the dining area. Framing: Frame new bathroom / kitchen walls, 2x4 framing 16" O.C.. Frame new wall opening into dining area. Install micro lamb beam. All necessary framing as per plans for a complete job. Plumbing: Includes: Disconnecting and removal of existing plumbing fixtures. All new waste from the basement floor threw the roof. (ABS Piping) Copper and Pea water piping. Re- plumbing as needed to install a new shower, toilet, vanity faucet, dishwasher and kitchen sink. Re -plumb existing washer connection. Fixtures and faucets listed below, plumbing permit and labor. (1) Aker KDS3448 NS Whi 3 PC Shower W/ Delta # BT13210 Metal lever valve. (1) Delta # 2575 -MPU Leland Hi -arc 4 CC lavatory faucet. (1) Houzer MD -3109 undermount 31.5 "x 18" DBL. Bowl stainless sink. (1) Delta Addison 9192 -DST single handle pull down 1/3 hole kitchen faucet. Add $95.00 for water to refrigerator for icemaker. (1) Toilet and (1) Disposal (Supplied By Others) 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 fancily 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 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 jermits 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 Date Address of work location The Commonwealth ofMassachusetts Department of Industrial Accidents . Al, 9, —'W z.. Office of Investigation • , jj 600 Washington Street Boston, MA 02111 www mass gov /din -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print L blv Name ( Business /Organization/Individual): 1 11,O.( - st.0 ∎ ` • Address: `3 . a ( 2) v■ • _I M Mil City /State/Zip: t\ (o. Phone. #: 4( )) ' C" %-q r� Are you an employer? Check the appropriate box: Type of project (required): 11 1.0 I am a employer with 4, 0 I am a general contractor and I employees (fill and/or part-time).* have hired the sub- contractors 6. ❑New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have. n a o loyees .. These sub - contractors have. .8. 0 Demolition • working for me in any capacity. loyees_and have workers' u } -� [No worke s'' comp, insu a•nc:e _.. t'Alnp. incnranoe #., . 33.61 ne a iditlOIl requ:sed:] 5. 0 We are a corpora 10 . tion and its 0 Electrical repairs or additions 3. I am a homeowner doing all work officers have xercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs c. , §1(4), and we have no inciira�r. required.] t 152 � employees. [No workers' 13.0 Other r • comp. insurance required. }. * Any applicant that checks box #1-mrst.aiso fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit: indicating they are doing all work and than hire outside contractors must submit anew- affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether ornotthoseentities have employees. If the sub - contractors have employees, they must pravide their writers' comp. poky number. I am an employer that isproviding workers' compensation insurance for my employees Below is the policy and job site information (� ' Insurance . 1 � '3 .. 4 . 4 `\162-. f S ance Company Name: - , . � '.. • t� C. C. Policy # or Self-ins. Lic. #: ( sz? 3 .a a' O cD 4� y Expir Date: . ` I C 1 1 (i) Job Site Address: F c��� ✓1 � c City /State/Zup �'5 {"V .'p r..� q U I�l� Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure covera e - .o ge as requured'tmdcer Sectitm`25A: of1VIGI:'c 152 can lead the osution of " - " mzp cnmmai 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, Be advisedthat a copy of this statement may be forwarded to the Office of nvestteattons Oldie DIA for msuaa rice' coveraa a werzficatuon _ . ';, :._ .,.. .. .. ,. Iddoo. herel5y_ c ertify . under the p .. ; , en • : of A wy that the rnformatien provutedsrbov • andc arrert ' Si. : ture: ,410 ,-- o ate Ili%/ / Phone it: (Li ('' S fO'' Cf. :, : .. - • - Official use only. Do not write in this area, to be completed by city or town 'offciat • • City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical ,Inspector 5. PIumbing Inspector 6. Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder : S cam `� — 1� - a L 1 (") License umb Address Expiration Date Signature Telephone 9. Registered.Hti a "lrfiprcvemerit Contractar .. ,,, ,. T ,...w.. ,. r .. ...; . Not Applicable ❑ Company Name Registratiqn N ber Address Expiration Date Telephoned 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 ❑ 11r -,3 om 0: uex: gem£fititin 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 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 buildins 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House D Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors ❑ Accessory Bldg. D Demolition New Signs [D] Decks [p Siding [D] Other [G] Brief Description of Proposed r Work: e .. V L 1n / t • ' i , e t1.1 `„c 1 . % s ■ V A of existing bedroom Yes V No ' • dding new bedroom Yes ' No Attached Narrative Renovating unfinished basement V Yes No Plans Attached Roll - Sheet si :V eVtiiiii iiiini a liii iiiiti ialii uiiittaiiipiete' #k iI iiow hic 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? n b d. Proposed Square footage of new construction. c '-''H"e -- Dimensions e. Number of stories? S .- -Ar ► ∎9---- f. Method of heating? � 9-*r"' Q_ Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction W 0 �>Q i. Is construction within 100 ft. of wetlands? Yes .1 No. Is construction within 100 yr. floodplain Yes 1714o j. Depth of basement or cellar floor below finished grade 30"°`e---. k. Will building conform to the Building and Zoning regulations? N Yes No. ` I. Septic Tank City Sewer v Private well City water Supply 'v 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, I \t kVQCACZ=1 ,asOwner/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 pena ies of perjury. Print Name I x/../1 ' S /9 1 1 7 Signature of Owe %Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due T nco `aete Information Existing Proposed ,Iequire• by Zoning ;,. ' This col to be filledni try Building , epartInent 1 Y Lot Size I r '---- — - 42 Frontage _ Setbacks Front 1 1 i i 1 Side L: R ...... L: __. r I _ --; Rear . Building Height i ___ ] E Bldg. Square Footage % I. I Open Space Footage (Lot area minus bldg & paved , _ parking) # of Parking Spaces - -- Fill: (volume & Location) I , A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 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 0 IF YES: enter Book i i Page' and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0 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 Q NO Q ° __., IF YES, describe size, type and location: mm - -.__ D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO Q IF YES, describe size, type and location: 1 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. EN =attrrat� RE • ty of Northampton t u sf fr� B 'Iding D e p a r t m e n t 1 12 Main Street r Room 100 '� • • - pton, MA 01060 4.4.4 ss .a °; e 13- 587 -1240 Fax 413- 587 -1272 = i 6:k1 w ; � tag � 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 c:9 S P ns ( L' Zone Overlay Distric E lm S D istrict CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ,S cl\ ct k\\Q_, Name (Print) Currep ' y ailing Addr sus: a 9 Telephhone �r�4 1 Signature 2.2 Authorized Agent: S � — • \ k, c- 33-b Q) � �..� ) - Name (Print) 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 ' 3, `3 3 (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 S 6. Total = (1 + 2 + 3 + 4 + 5) 4E:; , (off , pp Check Number 1 �0� / This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date at> ( 3 3 7 S 1° s s File # BP- 2011 -0958 APPLICANT /CONTACT PERSON HARLOW BUILDERS ADDRESS/PHONE 336 COLES MEADOW RD NORTHAMPTON (413) 586 -0465 PROPERTY LOCATION 28 PERKINS AVE MAP 24D PARCEL 066 001 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 ` " j Fee Paid i fi ` r4 `' 1cJ S CI 3) Typeof Construction: RENOVATE KITCHEN & BATHROOM a/ S New Construction tat lgA. ff? 1 Non Structural interior renovations .5 Addition to Existing {e Accessory Structure Building Plans Included: Owner/ Statement or License 052460 3 sets of Plans / Plot Plan THE F OWING 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 Demoliti• Delay "1 Signature of Building • ficial 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. 28 PERKINS AVE BP- 2011 -0958 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D - 066 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2011 -0958 Project # JS- 2011- 001565 Est. Cost: $20633.00 Fee: $135.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HARLOW BUILDERS 052460 Lot Size(sq. ft.): 5183.64 Owner: FINE JUDITH I Zoning: URB(100)/ Applicant: HARLOW BUILDERS AT: 28 PERKINS AVE Applicant Address: Phone: Insurance: 336 COLES MEADOW RD (413) 586 -0465 Workers Compensation N O RTHAM PTO N MA01060 ISSUED ON: 5/20/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: RENOVATE KITCHEN & BATHROOM 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 5/20/2011 0:00:00 $135.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner 28 PERKINS AVE BP- 2011 -0958 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D - 066 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERIVIIT Permit # BP- 2011 -0958 Project # JS- 2011- 001565 Est. Cost: $20633.00 Fee: $1 35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HARLOW BUILDERS 052460 Lot Size(sq. ft.): 5183.64 Owner: FINE JUDITH I Zon_n : URB(1001/ Applicant: HARLOW BUILDERS AT: 28 PERKINS AVE Applicant Address: Phone: Insurance: 336 COLES MEADOW RD (413) 586-0465 Workers Compensation N O RTHAM PTO N MAO 1060 ISSUED ON :5/20/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: RENOVATE KITCHEN & BATHROOM POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: ervice: Meter: - i7 Footings: Rough: 6✓ /-5// - ' ought .- /rte - ) r House # Foundation: Driveway Final: Final: i (-( e.., Final: -31- l pVNf1 Rough Frame: 04 --17 " Liu/ - Gas: Fire Department Fireplace /Chimney: Rough: � � _ �/l Oii• insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. 1 4444:06 . hi cve t ramou d o Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 5/20/2011 0:00:00 $135.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck - Building Connnissioner