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18D-053 (18) control 1 request that you grant a modification to waive the requirement s of for or n turenstr not aff r the project at SO Damon Rd. #5102 in Northampton because the work health, accessibility,life and fire safety,or structural requirements is imprad work. Thank you forf ctical in that the cost control construction is considerable when compared to the cost the your consideration. Respectfully, Tim Daley Jr. Pres. MZM Enterprises Inc. 13 Hyde Hill Rd. Williamsburg, MA 01096 D [EdW OCT - 7 2014 EteotrlC,Plumbing&Gas inspection w Nort hampton,MA 01080 1 J City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: 80 by�ec\ The debris will be transported by: The debris will be received by: ©d\ bov'x�? Aer-> Building permit number: Name of Permit Applicant �. P Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizationlindividual): AZIm �my-jen -trvc- _ Address: ( _-�> 043C VV\\ City/State/Zip: uv,ll'c�w.7�u Y►1 D l Phone#: 4 i 3 30v 568'-/ Are you an employer?Check the app priate box: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ l am a sole proprietor or partner- listed on the attached sheet. 7. [Remodeling ship and have no employees These sub-contractors have g. F1 Demolition working for me in 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.❑ 1 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.❑ 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. 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$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 cerd u er the pains andpenalties ofperjury that the information provided above is true and correct. Si ature: dry''rr Date: Phone#• y l J`3 0; —6-e t 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: Not Applicable ! Name of License Holder:---r;'w�,®i-\ c' C`J©-161 License Number 13 N�vse \:\\ ' a < C-)Ipq(p 08 log/ ;CA Addres Expiration Date Signature Telephone 9.Registered Home Improvement Contractor: ! Company Name Registration Number t- .V u,:\� W�. 81141 ae)c-s Address Expiration Date W4Wl"NdS�- r ✓k 0 Telephone y►3-3�y �S€i�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 Attache Yes.. .... ! No...... ! 11. - Owner Exemption The current exemption "homeowners"was extended to include Owner-occupied Dwellings of o or two(2)families and to allow such homeown o engage an individual for hire who does not possess a license, ded that the owner acts as su rvisor.CMR 780 Sixt dition Section 108.3.5.1. Definition of Homeowner:Person ho own a parcel of land on which he/she ' es or intends to reside,on which there is,or is intended to be,a one or two famil elling,attached or detached s res accessory to such use and/or farm structures.A person who constructs more tha ne home in a two- r eriod shall not be considered a homeowner. Such"homeowner"shall submit to the Building O 1,on a fo acceptable to the Building Official,that he/she shall be res onsible for all such work rformed under the b rmit. As acting Construction Supervisor your presence a jo ' e will be required from time to time,during and upon completion of the work for which this permit' sued. Also be advised that with reference to C er 152(Workers'Compensa' and Chapter 153(Liability of Employers to Employees for injuries not resulting' eath)of the Massachusetts General L Annotated,you may be liable for person(s) you hire to perform work for yo nder this permit. The undersigned"homeo r'certifies and assumes responsibility for compliance wi a State Building Code,City of Northampton Ordin s,State and Local Zoning Laws and State of Massachusetts Genera aws Annotated. Homeowne ignature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Ef Roofing ❑ Or Doors !] Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[L7] Other[DJ Brief Description of Proposed ^� Work: Ra'-'Wek wCDE�►.r. C�ravale cJ „�r�\\ �:,�Q�es�er S4��xJC t Ae--J Alteration of existing bedroom Yes No Adding new bedroom Yes f No Attached Narrative Renovating unfinished basement Yes ✓ No Plans Attached Roll -Sheet 6a.If New house 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 —, vuk 1:v Nw- VV� --t' line 1 to act on my behalf, in all matters relative to work authorized by this building pe it 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. Print Name Signature of er/Agent 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 Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg.Square Footage % 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 O DON'T KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DON'T KNOW ® YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW ® YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® 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 O NO 0 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 O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit p d IF- 212 Main Street Sewer/Septic Availability. QRoom 100 Water/Well Availability. OCT _6 rthampton, MA 01060 Two Sets of Structural Plans on -587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify N ow VTOCONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: T s section to be completed by office Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �lcg. 'A\'.�ezn D.- v� ` �t�5. �u•�ctir�Rt! �� !� - n, Md OKY� Name rin) Current Mailing Address: Telephone Signature 2.2 Authorized Anent: T-7w. .N. c 1 1\.�i�c 1 V�� 3:►;11:cxvy,�lac�c�� ©IG t(� Name Current Mailing Address: rya- c4,,3-,?q0- Sign re Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 7, co 4!u (a)Building Permit Fee 2. Electrical , (b)Estimated Total Cost of t X73 Construction from 6 3. Plumbing ter, Building Permit Fee LJ 7 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) 01 (0(0" E'° Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0393 APPLICANT/CONTACT PERSON TIM DALEY JR ADDRESS/PHONE 13 HYDE HILL RD WILLIAMSBURG (413)320-5884 PROPERTY LOCATION 80 DAMON RD#5102 MAP 18D PARCEL 053 000 ZONE GI(88)/SC(12)/WP(12) / THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Tvneof Construction REMODEL BATHROOM(DRYWALL FLOOR&VANITY) New Construction Non Structural interior renovations Addition to Existiny, Accessory Structure Building Plans Included: Owner/Statement or License 76752 3 sets of Plans/Plot Plan THE FOLL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: 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 Demolitio elay Signature of Building ffici 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. 80 DAMON RD 45102 BP-2015-0393 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18D-053 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2015-0393 Project# JS-2015-000710 Est. Cost: $2466.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group TIM DALEY JR 76752 Lot Size(sq. ft.): Owner: DUNN MARIANNE F Zoning: GI(88)/SC(12)/WP(12)/ Applicant: TIM DALEY JR AT: 80 DAMON RD #5102 Applicant Address: Phone: Insurance: 13 HYDE HILL RD (413) 320-5884 WILLIAMSBURGMA01096 ISSUED ON:1011612014 0:00:00 TO PERFORM THE FOLLOWING WORK:REMODEL BATHROOM (DRYWALL,FLOOR & VANITY) 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 10/16/2014 0:00:00 $55.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner