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10B-110 dr r t� v Fri Jp! Ll f e J,v, 7 a 11 a N ct Vic.•-�s "�—...., �xita tt�"�3 G UF3L�D ✓'✓T���-?� �I" r�k-�� G�.-,r�t'r�' %vr r5 S3ux �ir3Y1G�Tic �JLL;e°T� �ZrST%nt�. (�'��.vi r-rr `fe)'`Pr ELM v - 1 E�6 4E o 7- i'x L4 6v "K'i- Tie-, I rJ y L. t)C-Yj F7 17 L-V, I ,1 14 T le 06 ` 'Db(, cj>'� R 41joop --KI—�{ Fo C,-P r--'6 7 LAC'�i-3- lam' "--� ��y �! ILA L--� -Z 4 L/ k4l or,, 7-L/ X 1 a 'Lr L Vi lkic, Lv L") I 2-2 OO I_of 2 za,3y2 S,IF, If Suer •� 34�•"^� f 2,6 V� F ("u SST h�ou sE M I CeNC I c Evev-Green Road EtiTRGY CONSERVATION APPLICATION FORM FOR LOW-RISE RESIDENTIAL NEW CONSTRUCTION and ADDITIONS 780 CNIR Appendix J Applicant Name: ._` r! l Z IE)"7 / Site Address: Applicant Address: E7' !f-G-XQv 2 City/Town: t—1 t75 Use Group: Date of Application: Applicant Phone: l& ct r 3 f`� 3/�/ e Applicant Signature: Compliance Path(check one): ❑ Prescriptive Package(Limited to 1- or 2-family wood frame buildings heated with fossil fuels only) Package(A through KK from Table J5.2.1b): Heating Degree Days (HDD,,,)from Table J52.la: (For items d. through i.,fill in all values that apply from Table J-52.Ib:) a. Gross Wall Area sq.ft f. Wall R-value R- b. Glazing Area' sq.ft. g. Floor R-value R_ C. Glazing%(100 x b_a) % h. Basement wall R- d. Glazing U-value U- i. Slab Perimeter R- e. Ceiling R-value R- j. Heating AFUE ❑ Component Performance: "Manual Trade-Off' (Limited to wood or metal framed buildings only) Climate Zone(from Figure J622) ❑ Zone 12 ❑ Zone 13 ❑ Zone 14 Attach Trade-Off Worksheet from Appendix J, [and HYAC Trade-Off Worksheet, if applicable] ❑ MAScheck Software Attach Compliance Report and Inspection Checklist printouts ❑ Home Energy Rating System Evaluation Attach Home Energy Rating Certificate (IRS rating score must be 83 or higher) ❑ Systems Analysis OR ❑ Renewable Energy Sources Attach Mass Registered Architect or Engineer Analysis ALTERNATIVE FOR ADDITIONS ONLY: a. Gross Wall +Ceiling Area ( sq.ft. b. Glazing Area' 12 Ig_sq.ft. c. Glazing%(100 x b:a) 2� % 41 ADDITION with Glazing % (c.) up to 40%may use 780 CIVIR Table J1.12.3.1 below: vL-AXLML'N1 U-value I NE IEM M R-Values Fenestration' Ceiling' Wall Floor I Basement Wall Slab Perimeter,De th 0-39' R-37 I R-13 R-19 R-10 R-10,4 ft I Glazing Area maybe either Rough Opening or Unit dimensions. Based onNFRC listing. Applies either to every unit or to area-weighted average of aIl units. 3 R-30 ceiling insulation maybe used in place of R-37 if the insulation achieves the full R-value over the entire ceiling area (i.e.-not compressed over exterior walls,and including any access openings.) ❑.-"SU�R04 I dditiaa- greater than 40%gkzin -to-wall and ceiling gross area) Attach"Consumer Information Form"from 780 CMR Appendix B. Official's Name: /a)X%iG� OfciaFs Signature: Application Approved ® Denied ❑ Date of Apprcva]Denial: _ J Reason(s)for Denial: (provide additional details as needed on back side) r Ilk- HOME OWNER EXEMPTION ACECiOWLEDGEMENT 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 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 occupancv until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing& ga.$) 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 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. Date Address of work location Y he Commoiiwea, i aj llassacliusez Deparnmen£Of t:2diCSt:"Ial.'iCCiden£S Q o`Ia v es .v arior _ 600 VT"ashingron Sa ee£ Boston, 111-1 02111 - www.mass.gov/dia Workers Compensation Insurance Af da-dt: Build.-rs/ContractorsTlectricians,'Plumbers Anulicant Information PIease Print Legibly �'3i�lZ(Business/0-ganiza*ion�'Tndividual): �p�'�`� �- ZIE�"(/r�SSIG/ c`SL,C4t,D�'�-'��• Address: ©D1j City,State/Zip: ,� <t"7�1 �z e A/o 38 Phone rt: y13 '�t Are you an employer?Check the appropriate box: Type of project(required): 4. I am a general contractor and I I am a employer with � � 6. ❑tiew consuuction � employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or parmer_ listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g_ [-1 Demolition worizg 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 10.17 Electrical repairs or additions ❑ I am a homeowner doing aE 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.]' c. 152, §I(4), and we have no employees. [No workers' 1-,.7 Other comp.insurance required.] 'Any aaoiicant that checks box=.`1 must also fill out the section below showing their worke s'compensation policy information. Homeowners who submit this afxdavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet shcwire the name of the sub-contractors and state w--,,ether or not those entities have employees. If the sub-contractors have--m.lovees,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 inform ation. ^� insurance Company game: 5&(G,? Policv:ii or Seif-ins. Lic. #':I,JCGTOO 600 VC, 12 (; G oy Expiration Date: � 3 D8 Job Site Address: 1 &2 D L ^` ` 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 vIGL c. 152 can lead to the imposition of criminal penalties of a tine up to S 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 3250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DL4 for insurance coverage verification. I do hereby terrify under the pains and penalties ofperjury that the information provided above is true and correct Signature: Date: Phone i 0 jicial use onlh. Do rot write in this area, to be completed by city or town oJjzciaL City or Town: Permit-'Licenser I issuing Authority(circle one): I L Beard of Health 2.Building Department 5. Ciry/Town Clerk 4'.Electrical Inspector 5. Plumbing Inspec tor 6. Other i Cont2ct Person: Phone =CTION 8 -CONSTRUCTION SERVICES E.1 Licensed Construction SuoerAsor�: Not Applicable ❑ Name of License Holder: /4 . 2 � License Number 110 C� ( Jl7D 4L( ,Caress Expiration Date !3 3ignatur r Telephone 1-.Realstered Home ImQroverrrentCantractor Not Applicable ❑ :omoanv Name Registration Number ddress Expiration Date Telephone ECTION 10-WORKERS'COMPENSAT10N INSURANCE AFFIDAVIT(M.G L.c. 152,§25C(6);) +orkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result the denial of the issuance of the building permit. fined Affidavit Attached Yes....... No...... ❑ n . 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 730. SLYth Edition Section 103.3.5.1. 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-vear period shall not be considered a homeowner. Such"homeowner"shall submit to the Building OfEcial,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 undersimed"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Norrhampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature .a+ a., SECTION S-DESCRIPTION Oi PROPOSED WORK(check all a!)aiicabie) New douse f7 Addition Replacement Windows Alteration(s) C Roofing Or Doors Accesso ry Bld g. El Demolition ❑ New Sign s [01 Decks [I� Sidine[=j Other I I i Brief Description of Proposed 2`X /�' /}�7ar;�.s.a S t�✓�Qov. c TC .��� a F V'Jcrk: 6C Alteration cf existing bedroom Yes ,X No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes >1 No Plan,s Attached Roil ---_She 6a.ff New:pause an " addition f0 existinq h6.6sIha.coma ete t,�-faffowin�: a. Use of building: One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms 2- c. Is there a garage attached? d. Proposed Square footage of new construction. / 9 2 Jr6 f Dimensions /2✓ �& e. Number of stories? 3 �1 tarayr !2 OG�/6°! f. Method of heating? ( ecyr c vla4 Gl��s« Fireplaces or Wcodstoves Number of each g. Energy Conser✓ation Compliance. Masscheck Energy Compliance form attached? h. Type of construction W Oo b i. is construction within 100 ft. of wetlands? Yes '� No. Is construction within 100 yr. floodpiain Yes No j. Depth of basement or cellar floor below finished grade 10 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 AUT}iOR1ZAT10N TO BE COMPLESE3TINFiEN OWNERS AGENT OR CONTFZACTOR APPLIES FOf2 BLIILDfNG.Pi ikNfiT C / _, as Owner of the subjec prcpe—,y herby authorize 2 to ac yin my behalf, in all m rs rla*�to ork 1,thorized by s building permit application. r Signature of G er Date I `.J C>l,� � c­i"i /--rs tc f as QmA;or/Authcrzed Agent hereby declare that the statements and info �ation on the foregoing application are true and accurate, to the best cf my krowiedge 1 and belief. Signed under the pains and penalties of perjury. _ _ I Fnnt iName 52t ion 4. ZONING I AU 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 Frontase Setbacks Front Side L:...9-- R ._ L li.. R J—'— Rear 0° 3c> Building Height Bldg. Square Footage % .- __ _.. _. Open Space Footage _ % (Lot area minus bldg&paved l Sc 1� 7�s�x 'Vr oarlanz) #of Parking Spaces - ~' Fill: (volume&Location) �� A. Has a Special Permit/Variance/Finding ever been issued for/on the site? AWN NO 0 DONT KNOW YES 0 IF YES, date issued:, IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0.., YFS IF YES: enter Book 5 Page; 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 0 , Date Issued C. Do an!y 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, excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES NO IF YES,then a Northampton Stom Wdtr -anM gemenf-Permit from the DPW is required. Department use only City of Northampton Status of Permit.- Building Department Cum Cut/Drveway Permit 212 Main Street Sewer/Septic.Availability Room 100 Wa€edWellAvailability Northlampton, M,A 01060 Two setsof'Structural Plans J U i� l jh&W 413-5$7-1240 Fax 413-587-1272 Plot/Si.te Plans Other Specify kPPLICATION TO CON§TRUCt,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Prooerty Address: Map. Lot Unit C� Zone Overlay District Elni St.'District CIS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name Tint) Current Mailing Address: c Telephone SOW Signature 2.2 Authorized Agent: Q -:YvYy--� d. -Name(Print) Current Mailing Address: c.4& yi3 3f�o Signatur Telephone SECTIO ESTIMATED CONSTRUCTION'COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant - 1. Building 8 2) W.Building'Permit Fee 2. Electrical U V v (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 19Z 7 60 This Section For Official Use Only .Date Building Permit Number' Issued: Signature: Building,.Commissioner/Inspector or w amgs ate r + File#BP-2008-1121 APPLICANT/CONTACT PERSON John Zieminski ADDRESS/PHONE 8 WOODRIDGE CIRC HATFIELD (413)247-9014 PROPERTY LOCATION 15 EVERGREEN RD MAP l OB PARCEL 110 001 ZONE URA 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: CONSTRUCT 12 X 16 SUNROOM TO REAR OF GARAGE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 017889 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO P ATION PRESENTED: . pNl_J _� oved i 1 lad Additional permits required(see below) l 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 041361.'o Signature of Building Of icial 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. BP-2008-1121 GIS#: COMMONWEALTH OF MASSACHUSETTS f4 - 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-2008-1121 Project# JS-2008-001645 Est.Cost: $30825.00 Fee: $96.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: John Zieminski 017889 Lot Size(sq. ft.): 20342.52 Owner: LEVAY BRADLEY J JR&ROSELYN S Zoning:URA Applicant: John Zieminski AT. 15 EVERGREEN RD Applicant Address: Phone: Insurance: 8 WOODRIDGE CIRC (413) 247-9014 Workers Compensation HATFIELDMA01038 ISSUED ON.613012008 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 12 X 16 SUNROOM TO REAR OF GARAGE 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 si nature: FeeType• Date Paid: Amount: Building 6/30/2008 0:00:00 $96.006860 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo �J �'i9 _ � 3g � � i 1�� 12`��-nJ �p� ��L 15 EVERGREEN RD BP-2008-1121 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: l OB- 110 CITY Or NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category:- BUILDING PERMIT �e Permit# BP-2008-1121 Proiect# JS-2008-001645 Est.Cost: $30825.00 Fee: $96.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: John Zieminski _ 017889 Lot Sizebq. ft�_20342.52 Owner: LEVAY BRADLEY 3 JR°e R^S3LYN S. Zoning URA � licant: .ioh:"1 Zie ?!!� E i Ai: 15 F_VERG!�EE'N R Applicant Address: _ Phone: Insurance: 8 WOODRIDGE CIRC ___(413) 247-9014 Workers Compensation HATFIELDMA01038 ISSUED ON.613012008 0;00:00 TO PERFORM THE FOLLOWING WORK:CONSTRUCT 12 X 16 SUNROOM TO REAR OF GARAGE POST THIS CARD SIT �. . ,.,,,,-:T .....:; �r47I-,.pry Inspector of Plumbing Inspector cf Wiring � i3.:`.�V. Buildaig inspLriux Underground: Service: Meter: d Footings:,Wdl- �7"© Rough: Rough- %y�U� House# Foundation: � A�`i/ Di iveway Final: Final: Final: 1T � V11f Rough Frame:Dk 74' L Gas: Fire Department Fireplace/Chimney: Rough. Oil: Insulation:c2ic V-�� Final: Smoke: Final: (I 1'� O g(OVo THIS PERMIT MAY BE REVOKED BY THE CITY OF'NOPT".'_MPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULAT'ONS. Certificate of Occu anc si nature:w FeeType• Date Paid: Amount: Building 6/30/2008 0:00:00 $96.006860 212 Main Street,Phone(413)587-1.240,Fax: (413)587-1272 Building Commissioner- Anthony Patillo