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29-381 ' ,7 1 ('------ . P • i 1 ),,, to. i :-...41 -- 1, , , . , - r ' ...7""°""i I I \---) , C c.1-) , ; . . .... ' ; _.„...• 0 h , I - - - - ------ , ‘ &- "... / 3 -... , c ' , 1 1 - i \ . i _ ,,, ,..-. ....., .z,n,,, 3 a, 171 1/4 ?ILA ex„) 01 i ( ( ' ' j .,,,,t, .,•:,,,r, (C1 - It ei.o.) L ) „ i .t.„3,ifdo....),,,,1 D1 ci c'N ! ‘ 1 The Commonwealth of Massachusetts ,; ... Department of Industrial Accidents ( 0 1 Office of Investigations 600 Washington Street c ' • v, Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information � �9 Please Print Legibly Name ( Business /Organization/Individual): �,u,1.. BC re �3 e Address:.[ _ , �r +�► �° . ■('' 1 f11 City /State /Zip: Phone #: — l 0■—• Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part- time).* have hired the sub - contractors listed on the attached sheet. 7. ❑Remodeling 2. ❑ I am a sole proprietor or partner- ship and have no employees These sub - contractors have 8. ❑ Demolition working for me m any capacity. employees and have workers' 9 ❑Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.4Other A \IJ e. comp. insurance required.] yrri *My applicant that checks box #1 must also fill out the section below showing their workers' compensation policy in Lion. 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. Lie. #: 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 $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 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 certi under the pains and penalties of perjury that the information provided above is e and correct. Si i ature: t .441 Date: Phone #: 4/2- 09g_ /O Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 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 home owner." The building department for the City of Northampton wants person(s) who seek to use the hone 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 backfilll) 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 iermits 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 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 offfassachusetts Department of Industrial Accidents Office of Ini . 600 Washington Street • =re= 'd . Boston, MA 02111 www.mass.gov/dia . vs - , :.. -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information - Please Print Legibly Name (Business/Organization/Individual) " • Address: ,- - City/State/Zip: - . Phone.#: - Are you an employer? Check the appropriatebox: . Type of project (required): / • 1- 0 I a loyer with 4.. 0 I am a general contract° r and I • 6. 0 New coistraCtion. have hired the sub-contractors employees (full and/or part-time).* 2.0 I ani a sole proprietor orpartaer- listed on the sheet. 7. 0 Remodeling • ship" and have na employees These sub-contractors have. -8. Q Deirablition • • • employees,andhave workers : . - • , working for me in any capaCity. . 0 a&lifii5ii [No weirkere comp-. j]mmice 10.0 Electrical repairs or additions required.] 5 . 0 We are a corporation an d its 3.0 I am a homeowner dOing all work officers haVe4xeraised ;their . 11.0 Plunibing repairs or additiOns . right of exemption per MGL 1-1 myself [No workers' comp. . 12.0 Roof repairs . • insurance regnired t . . c 152, §1(4); and we have no • employees [No workers, 14.0 Other comp. instrance reqtrized.1. . • . • *My applicant-that checIts box #1: must also fill out the section belay/showing theirivixkers compensation policy informatiOn; ,--. t Homeownera who submit this affidaVitimficating they are doing all work and then hire outside contraatori must submit a new affidavit indicating such: . Icontractors that chick this box must attached an additional lieet showing the name of the subcontractors and state whether or notthose.entities have einployees. If the sub-contraitorshaie amployeeS, they must provide their wOriceis' comp policy number. .. - . . . lam an employer that is providing workers' co mpensation insurance for my employees Below is the policyand job information. : • • . - ' . • Insurance Company Name: - - " . • • . . Policy # or Self-ins. Lic. #: Expiration Date: . . . Job Site Address: : ' City/StaM/ZiP:' - . . . . • ' , - .• Attach a copy of the workers' compensation policy &clan:atm page (showing the p9licy nuinher and date). . Failure to secure coverage: as required taideit Sectrat'25Ar'OfY/IGL 152 can 1eatrt6 ihe IMPOSiiiiiti ofainiiiiiliiiiinliies of a fine up to S1,500.00 ancVor one-year implisonment; as well as civil penalties in the form of a STOP wopx-ORDER and a fine of up to $250 00 a day against the violator Be adyitedthat a copy Of this statement may be forwarded to the:Qtffce of BFeine cciviraieViritaitinE .. . _ - ' .... _7' ,... : - .,:"..'.1...,...: heiebypertifil under the pail' a peaalties ofperjary that the information providalabavelrfrue_andiorrec4 __:.... . . Signature: ' • - . . Da.te: . • . Phone 4: _ . . . _ . - Official use only. Do not write in this area, to be completed by city Or toWn offirial , ., . 1 City or Town Permit/License # : Issuing Authority (circle one): - '• • .1. Board of Health 2- Building Department 3. City/Town Clerk 4. ElectricalInmector 5. Plumbing Inspector 6. Other Contact Person: . Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 9 :;.Ri t+stered H`om lnitliiiieiinein > ra¢ tF r . idl u aa.. x_. _.. Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L 0. 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 ❑ 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding [0] Other I] F 00 \ Brief Description of Proposed ` i r/ Work: � ILCN -Q (t A1'1 c& � 4A 1 Alteration of existing bedroom Yes No Adding new bedroom Yes N `A�o Attached Narrative Renovating unfinished basement Yes ,/ No Plans Attached Roll - Sheet sa :[t use:' a aif+�n karats n�.ati : e1otirwtip: 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 to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date , 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. ki t:// L r122y. Print Na e L // — O Sig a . of Owng ent 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 NS E :_ ___ i Lot Size _ Frontage ? ? 1 ' .�._ Setbacks Front ! i Side L:' R L:i _' R:' Rear L Building Height t i r F Bldg. Square Footage "' �i - % 1 I 1 E Open Space Footage 1 % (Lot area minus bldg & paved I = i i i 1 i € parking) # of Parking Spaces L____ Fill: 1 € i (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for on the site? NO 0 DONT KNOW 0 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 1 I Page; 1 and /or Document # B. Does the site contain a brook, body of water or wetlands? NO !® DONT KNOW 0 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 0 NO i� 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 'tKi , 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 fi IF YES, then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton' x + ing Department 6 �: RECEIVED 2 2 Main Street r Room 100 :o! ( N rth - mpton, MA 01060 IA 41 58 -1240 Fax 413 - 587 -1272 0 bkpt. yr 6U i6 -IN6A • ' •°' s._u =I , ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: 1 �rco �x This section to be completed by office Map Lot Unit k r; Zone Overtay District Eire St District '+' CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: / c.9 h Name (Print) Current Mailing Address: Telephone ture 2.2 Authorized Agent: 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 (a) Buflding Permit Fee 2. Electrical 00 (b) Estimated Total Cost of �UV �� Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) r .7 Check Number (23 This Section For Official Use Only Date Building Permit Numb • - — Issued: .., -`sue Signatur �_��� Building Commissioner /Inspector of Buildings Date File # BP- 2012 -0058 APPLICANT /CONTACT PERSON NOBLE KAREN A & STACEY L NOBLE ADDRESS/PHONE 17 BROOKWOOD DR FLORENCE PROPERTY LOCATION 17 BROOKWOOD DR MAP 29 PARCEL 381 001 ZONE URA(100) //WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid /Building Permit Filled out vFee Paid ((✓' r 30 Typeof Construction: Above Ground Pool cf-- _ F(K)i -- PAW(' Rf9lA l(ZErA L S O C- New Construction j COGS Non Structural interior renovations R(� u�{ stew (LD(1' 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 INFQ- RMATION PRESENTED: L./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 71 1( 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. 17 BROOKWOOD DR • BP- 2012 -0058 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29 - 381 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Above ground pool BUILDING PERMIT Permit # BP- 2012 -0058 Project # JS- 2012 - 000089 Est. Cost: $5700.00 Fee: $30.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 15158.88 Owner: NOBLE KAREN A & STACEY Zoning: URA(100) //WSP Applicant: NOBLE KAREN A & STACEY AT: 17 BROOKWOOD DR Applicant Address: Phone: Insurance: 17 BROOKWOOD DR (413) 588 -1052 () FLORENCEMA01062 ISSUED ON: 7/26/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 24" Above Ground Pool; Pool must be inspected, barriers must meet building code requirements 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 7/26/2011 0:00:00 $30.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner