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31B-187 (4)
The structure I propose to repair appears to be greater than 35,000 cubic feet and requires controlled construction, however because the work appears to be minor in nature and will not affect health and safety issues we can accept a request for a waiver from controlled construction however the letter needs to come from a registered design professional,Architect or Engineer. See text below. I request that you grant a modification to waive the requirement for control construction for the project at xxxx in Northampton because the work is of a minor nature,will not affect health, accessibility, life and fire safety,or structural requirements and is impractical in that the cost of control construction is considerable when compared to the cost of the proposed work. ((I have provided a letter as a licensed construction supervisor in support of this request.))Thank you for your consideration. Respectfully, Jesse Montgpmey r4CM 'ome Imp. Northampton Ma.01060 °-,, The Commonwealth of Massachusetts Department of Industrial Accidents . il,— u 0"---,:" .' Office of Investigations µ w 600 Washington Street ' Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/PIumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 0-7e.S5--e Ikl o✓l-I0'IC` I Address: 0 041- S 4—. J City/State/Zip: F t(yL v'C /!l 4 0106 2 Phone#: Lit 3° 5 P d2 Li.d'2 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 4. [] I am a general contractor and I f have hired the sub-contractors mployees(full and/or part-time).* 6. ❑New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have g, 0 Demolition working for me in any capacity. employees and have workers' 9. El Building addition [No workers' comp. insurance comp.insurance,$ required.] - 5. 0 We are a corporation and its io.0 Electrical repairs or additions 3.0 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 Zoof repairs insurance required.]f c. 152, §1(4),and we have no employees. [No workers' 13.❑ 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. 1 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$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 certify under the ,ins a ' enalties of perjury that the information provided above is true and correct. ■Sicnature_,//ff Date: (f/6 b /1.3' Phone ". J 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): I.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Version1.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No 0 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT hereby authorize es5e 711 cOrl. me act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Own-' ,00r Date I, _ e„cp--1_,_„. ....„„,z-c56e / 073._ ,as Owner/Authorized Agent hereby declare that the statements an information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains andsanalties_ofertum____ Print Name 'I'. c5 s 6 i - - Signature of Owne., gent late SECTION 12-CONSTRUCT!, SERVICES 10.1 Licensed Construction Supervisor: Not Applicable El Name of License Holder. 07 Li ( License Number 5-k---- vt-e (114 0106 /,2 - Address ■41.111111111 Expiration Date ses Telephone SECTION 13-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 0 No Version1.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION-SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR'.116(CONTAINING MORE THAN 35,000 C.F.OF EN.LOSEDSPACE) 9.1 Registered Architect: w.._...._._.__._....__._._._._ ._..____...._ ____ __.... . _._ ___ _ _ Not Applicable ❑ Name(Registrant): Registration Number Address -------7 7 Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address 6 RegistrationiNumber Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date ... _.. . 9.3 General Contractor 4J C.w. `r` n" _..._. ._._ __. Not Applicable ❑ Company Name: Responsible In Charge of Construction o oc(< s+, . rlotce._ . __ dl o6a ._.. . .. Address �: y/ -. x.3" 9 Signal Telephone • Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by zoning This column tore filled in by Building Department Lot Size Frontage Setbacks Front Side L... Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg&paved parking) .�,..�,.,� u.�........,. .T�.�.�d ...,...,_..,�. #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding been issued for/on the site? NO 0 DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Regi of Deeds? NO 0 DONT KNOW YES IF YES: enter Book PagewM- _ and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained (j 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, exca n, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Version1.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ DemolitionD RepairsAdditions ❑ Accessory Building Exterior Alteration ❑ Existing Ground Sign❑ New Signs 0 Roofing❑ Change of Use❑ Other 0 Brief Description Enter a brief description here. e er ■e ecnoF Of Proposed Work: //L°c.tS c. -�� j � e ,p0�� Ll ✓ © ►� SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A � ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B r ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-i ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: -_ , _ S Special Use ❑ Specify: , COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: w Proposed Use Group: Existing Hazard Index 780 CMR 34): ,W Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1st 2nd 2nd 3rd3rd ;_.._,....................... ..... .._......_.._......._...�.,.........„ „, .. _._...,.—,.�.�n 4th 4m I Total Area(sf) Total Proposed New Construction(s Total Height(ft) Total Height ft 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone Outside Flood ZoneD Municipal El On site disposal system Version1.7 Commercial Building Permit May 15,2000 fil r�(� }per 15 y/ _ Departmeftt ttsetonJy ( 5 > E.�<� - F S Y ea d 9z °�- k/ City of Northampton stair s of 0erit►t i- 4 �. ` Building Department CrJf©nueway perntt 'i S* x ' -6 2013 212 Main Street SeiveriSepficAuaiab►tity t Room 100 U1/ate.,WWJIMMartab►rtyr# DEPT.07 EJTE6lik-Z i�SPE(;TI S rthampton, MA 01060 Two Sets crf_Strt etu a PIaats a ;v NORTHAMPTON MA s �De 41 -587-1240 Fax 413ONE O TWO Plotfsite Plans Other Specify APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION opertYAddress This section to be completed by office iri ....• c\ - be // �`� • - Map Lot Unit A/O It Irlc...,.•.,f+O ' /14• DI O O© Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: g------ -_ �, ,.: g n -,- :_..: A.crle) _._,_ rte! bi I . _.. '._ Name Print � ) Current Mailing Address: Signature " Telephone 2.2 Authorized Agent: ess e o - p r „r771__ �!® I S e.I or r!CC !'i f))0G 2 Name(Print) Current Mailing Address: --- LlI 3 ` C�5......:.c `Li PcQ_.... Signat _„� / Telephone SECT1O '. ' _._ CONSTRUCTION COSTS 1 Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building i 1.,/ 0(90 (a)''Building Permit Fee 2. Electrical (b).Estimated Total Gost of Construction from(6) _.._. ......_. _.. ... ,.._....... 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) _... ..__... _. ......_._......._—,.__..:,___ . 5. Fire Protection ,.. �. . 6. Total=(1 +2+3+4+5) ! D OCR Check Number d D 5 71 ,5- - This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-0142 APPLICANT/CONTACT PERSON JESSE MONTGOMERY ADDRESS/PHONE 40 OAK ST FLORENCE (413)585-8482 PROPERTY LOCATION 26 TRUMBULL RD MAP 31B PARCEL 187 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out G96 j 6 $5'.5"$5'.5"Fee Paid Typeof Construction: REPAIR VARIOUS DECORATIVE TOOF AREAS&REPLACE PORCH ROOF New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 077410 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ■WetiriON PRESENTED: L pproved 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 r- .�. ' i•• 5el. 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. 26 TRUMBULL RD BP-2014-0142 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B- 187 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-2014-0142 Project# JS-2014-000272 Est. Cost: $4000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JESSE MONTGOMERY 077410 Lot Size(sq. ft.): 6185.52 Owner: MONGEON EUGENE J&BEATRICE F GARY E MONGEON&GREGORY A MON Zoning:URC(100)/ Applicant: JESSE MONTGOMERY AT: 26 TRUMBULL RD Applicant Address: Phone: Insurance: 40 OAK ST (413) 585-8482 FLORENCEMA01062 ISSUED ON:8/9/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:REPAIR VARIOUS DECORATIVE bOF AREAS & REPLACE PORCH 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 8/9/2013 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner