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31B-296 (8) I. v.......... VN I I -0-11 ION 3. It 71. lit, lm 91 ........... A a. "MA :z J ................... 0 1" ............ TP ...... ...... ...... ................................................ It i f, x"u ............ ........... -7 4 ............. + 41 ............... lap 3 24 dk:�aG, k 1 Ali �{ �N y ......................... ............. it A "'11 1 Ilk. .......... 10 Ar R NO, �3 ....... ....... ............. Ft r 41 .......... .......... .................... .................... .......... ............... ct e", ........... ........ ............ ............................. ........... .................. ........... .............. Sackrey Construction Company, LLC John H. Sackrey Owner Date dafe '' ' �! �112� d° Date NOTICE: THE SIGNATURES OF THE PARTIES DOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE SETTLEMENT INITIATED BY THE CONTRACTOR. THE OWNER MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES. THE RIGHT TO INITIATE ALTERNATIVE DISPUTE RESOLUTION SHALL END TWO YEARS AFTER THE DATE OF THI AGREEMENT. MISCELLANEOUS: This Agreement is a Massachusetts contract, contains the entire agreement between the parties, any representations or warranties not expressly contained in it are not a part of the Agreement, and it is binding upon all heirs, executors, successors and assigns. This Agreement may be modified only by an instrument in writing signed by both you and the contractor. This Agreement is subject to and is intended to comply with the provisions of Chapter 142A of the Massachusetts General Laws and its corresponding regulation. LIENS: Under Chapter 254 of the Massachusetts General Laws, the contractor, and any subcontractor that he has written contract with, may obtain a lien, commonly known as a "mechanic's lien", against the property where the work is being performed. The 6 City of Northampton Massachusetts 3 Gr4 y t DEPARTMENT OF BUILDING INSPECTIONS �+ 212 Main Street • Municipal Building 9JS � 4 r Northampton, MA 01060 INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner 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 any 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 permits 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 1, 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. Date Address of work location 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: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): A C. _KJX, LM45T. Address: 2 -j S- W_Ar-*( City/State/Zip: SU-,-a &x_c4- p M-It- Phone #: `-t 13 Are you an employer? Check the appropriate box: Type of project(required): 1.[ I am a employer with 4. 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working or me in an capacity. employees and have workers' g y p tY• 9. F-1 Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.El Other Imo a V comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. tHo meowners 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. �A,� Insurance Company Name: � • � • ""\ � — i Policy#or Self-ins. Lic. #: A_W-•� yf.�— Expiration Date: 2 `k Job Site Address: T ��`i"'�' C�` 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 c under the pains and penalties of perjury that the information provided above is true and correct. Sip,n ature: Date: 2 2' V-1 Phone# 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#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: r' Not Applicable £ Name of License Holder: �1 O+V4 6� S License Number 3 s. . 101 of / Address Expiration tate 1-5 � -4 � (0 3 1 Signature I Telephone 9 egi Rstered H,ormelm_provm ee/nt Contractor .... Not Applicable £ l/►-Y Orr / (v —7 * 15 Ct Company Name ,,.y, en r^1 Registration Number D 3 vF- r/ � 1 1 Expirati Date Address 413-�`3,6G3� 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...... £ 1L: Ho-me Owner. Exemption. 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 buildine 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, r• 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 [❑] Decks [Q Siding[❑l Other[❑l Brief Description of Proposed Sit () _ 6 �� p Work: `'`hJ�lr C Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet ...., sa;`If Newhouse and or.addition.to existing housing;complete the following: 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 l ,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 Signature of Owner/Agent Date Section 4. ZONING ALI Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning ,,, AA nis coluznn to be filled Building Department Lot Size Frontage Setbacks Front Rear Building Height Bldg.Square Footage 01"o Open Space Footage % (Lot area minus bIdg&paved #of Parking Spaces Fill: r (volume&Location) A. Has a Special Permit/Variance/Rmding ever been issued for/on the site? »��v-� »�� NO ��/ DONT KNOW «�� YES «�� |F YES, date issue& / IF YES: Was the permit recorded at the Registry ufDeeds? NO K � DONT KNOW YES �� IF YES: enter Book Page and/or Document#11 �� B. Does the site contain a brook, body of water or wetlands? NO �~�� DONTKNOYY �~/ YES �~�� IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained �~\ Obtained x�\ Date Issued: �°� �~� ' . C. Do any signs exist nn the property �� YES �_� NO v�� /F YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0 IF YES, describe � ( ' E Will the construction activity disturb(clearing, gradingexcavation,or filling)over 1 acre orioit part ofa common plan thu1wi||dis�udbover1aona? YES NO � ' `~� |F YES,then u Northampton Storm Water Management Permit from the DPW iarequired. _ `'I ='-(__�/7 L ity of Northampton Status ofPermit k "� $r' r uilding Department Clxrt Cu#IDrt�ceuuay Perntt#', y �4 i �t 2 320 ' �� (t ;; 212 Main Street Sewerl6ep#icAvaiCa'bEl�ty Etectr, ± �•`�i Room 100 Waterlle�lAva�labtllty N�P'�ma G a -._� rthampton, MA 01060 TwaSets -fS#rtrctuTal PIaFlS mn.mP"r' r ,ii: ' r -587-1240 Fax 413-587-1272 PIotJSlte Plans ' a 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 L1'E.✓L L..� Map Lot Unit Zone. Overlay Distract Elm St;Dstncf CB;Dstnct SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: _T`1 �-1 C-( I R.�C�41N,�T,•-� Name(Print) Current Maili Address: `F 3 I 1 Telephone Signature 2.2 Authorized Agent: c Name(Pri Current Mailing Address: `fl-3- 54� - & L 3 9 Signature Telephone SECTION 3-ESTIMATE CONSTRUCTION COSTS. . Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Feb 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 Official Use Only Date Building Permit Number: Issued: Signature: - Building Commiss loner/Inspector of Buildings Date Q� File#BP-2015-0087 �z&AUe APPLICANT/CONTACT PERSON SACKREY CONSTRUCTION ADDRESS/PHONE 83 SOUTH MAIN ST SUNDERLAND (413)665-9995 Q PROPERTY LOCATION 3 TYLER CT �e MAP 31 B PARCEL 296 001 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 Fee Paid Typeof Construction: INSTALL 20 X 40 INGRROUND POOL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 040714 3 sets of Plans/Plot Plan T FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN ORMATION 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 Demolition Delay '.�.w�:o JV1,44 &tom a� 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. 3 TYLER CT BP-2015-0087 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 3 1 B-296 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Pen-nit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Inground Pool BUILDING PERMIT Permit# BP-2015-0087 Project# JS-2015-000150 Est.Cost: $30000.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SACKREY CONSTRUCTION 040714 Lot Size(sq. ft.): 13764.96 Owner: CHRISLER JENNIFER&CHERYL JACQUES Zoning. URC(100)/ Applicant: SACKREY CONSTRUCTION AT: 3 TYLER CT Applicant Address: Phone: Insurance: 83 SOUTH MAIN ST (413) 665-9995 () Workers Compensation SUNDERLANDMA01375 ISSUED ON.712512014 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 20 X 40 INGRROUND POOL 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 7/25/2014 0:00:00 $60.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner