31B-162 (7) I _
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Work to be performed at 159 Elm st. Northampton Ma, 01.060
The following work by John Lebhar is part of the Kitchen remodel
Contracted by the homeowners Suelen Walsh and Bryant Rother. John
Lebhar is responsible for only the following and the Homeowners have been
instructed to secure their own building permit for the rest of the work.
Remove and replace existing double 2x 12 interior wall header with new
12' double 1-3/4 x 11-112 LVL's.
Homeowner has already demoed existing plaster wall and exposed the
framing.
Remove existing interior door and reframe opening to approximately
5'-0" with standard framing.
Prep all work for new plaster and replace crown moldings where
applicable
Prep existing Interior face of brick chimney for stucco. Homeowner has
removed the cabinetry that previously concealed the brick. The existing
framing on both sides of the chimney is in direct contact with the brick and
shall remain as such. Concrete backer board will be applied to the framing
and the brick for the stucco application.
l.
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 of 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 owh construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires hat the building department be called to
inspect work at various stages, which include oundation/footings (before backfilW.
sonotube holes before our a rou h buildline ins ection before work is
concealed). insulation ins ection if re uire and a final building inspection. The
building department requires these inspection 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 tjat 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
M �
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ar' Office oflnvestiaations
'= + g
600 Washington Street
i b
Boston, MA 02111
wwrv.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual): � H -
Address: G S�� �s`� G- i' 7` F� l^�L� !Vl /1—
City/State/Zip: /��f ili/' —� /' Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
4. I am a general contractor and I
1.❑ I am a employer with � 6. F-1 New construction
employees (full and/or part-time).* have hired the sub-contractors
2.ELI am a sole proprietor or partner-
listed on the attached sheet. 7.0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
d have workers'an
working for me in any capacity. employees 9. F]Building addition
[No workers'comp. insurance comp. insurance.t
required.]
5 0.We are a corporation and its 10.El 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 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no 13.0 Other
employees. [No workers'
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
employee`s. 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 incur e coverage verification.
I do hereby certify un er the pans nd penalties of perjury that the information provided ab ve is tr a and correct.
Signature: Date: 3 60
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
Citv or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town CIerk 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:
License M107-2J3
r
Address Expiration Date
Signat a Telephone
9.Registered Horne.fm roverrienf Gon racfor _ s Not Applicable ❑
Company Name Registration Number
q/ rS )Lo / o
Address / - Expiration Date
rT4//e l V'i Telephohe 2`0 '.,7/0
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAV T(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit wQI result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ' No...... ❑
11., Home.Omer-Egemptian!
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 108.3.51.
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,attach4d or detached structures accessory to such use and/or farm
structures.A person who constructs more than one homelin 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(Worker'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
w `
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) 0 Roofing ❑
Or Doors C]
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [Q Siding [❑j Other[❑]
Brief Description of Proposed !2EF2AVAf bOk N 15)
Alteration of existing bedroom Yes--X1 No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -meet
sa. If New house and or addition to ersting housing, cornpiete the f ol(owing:
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.
1. 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
- a L*— L 49 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.
'Ta ��
Print Name
Signature of Owne! ent Date
y �
Section 4. ZONING ALl Information Must Be Complete J. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size - . .-.._..._ .,._._.__._.. m.......
Frontage -__. -... _A
Setbacks Front
Side L:'..-.__ R:'__._.-__ L:'�.. .-. R _.....
Rear
Building Height
Bldg.Square Footage % __....._,.
Open Space Footage _ _ % -
(Lot area minus bldg&paved
azkin
#of Parking Spaces ---- -
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on.the site?
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 YES 0
.._..... _.
IF YES: enter Book Page; and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
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 0 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 a
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,a cavation, 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 Storm Water Management Permit from the DPW is required.
s Depat,#ment use onI
W
.City of Northampton Sfatus of Peru
l,Fuilding Department .Curb C�#lE7 yeWa t'ermrf
212 Main Street 5ewer/,SepcAa�ariabiitty
Room 100 watetftdll AVdilablllty�
��ft X009 NOrampton, MA 01060 Tae#saf"StirtcturafPtars
0
phone 413,587-1240 587-1240 Fax 413-587-1272 P34tta#e Plans
Ober Sperfy
AiPQLxCATIONTO CONSTRUCT, 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
/ 5 --) g"e-- Map Lot Unit
A, s) �� � Zone Overlay District
6 /060
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Pri Current Mailing Address:
C C`fii 7 Z 7 l 0 �--
Si nature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building °7 (a) Building Permit Fee
G
2. Electrical (b)Estimated Total Cost of
Construction from 6-
3. Plumbing Building'Permit`Fee _
4. Mechanical(HVAC)
5. Fire Protection
s
6. Total=(1 +2+3+4+5) Check Number J
This Section For Official Use Only
Building Permit Number: IIsssued:
Signature:
Building Commissioner/Inspector of Buildings Date
a
File#BP-2009-0746
APPLICANT/CONTACT PERSON JOHN C LEBHAR
ADDRESS/PHONE 68 SCHOOL ST HATFIELD (413)247-5107 O
PROPERTY LOCATION 159 ELM ST
MAP 3113 PARCEL 162 001 ZONE URA(39)/URB(60)/tJRC(l)/
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: REFRAME DOORWAYS&INTERIOR TRIM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildiny,Plans Included:
Owner/Statement or License 75531
3 sets of Plans/Plot Plan
THE FOLLOWING 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
Demolition Delay
v-, f . �3 r i� 1 o
Signature of Building bfficial 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.
A
I
i
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BP-2009-0746
GIS#: COMMONWEALTH OF MASSACHUSETTS
A �_ � , 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-2009-0746
Project# JS-2009-001111
Est.Cost: $2500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN C LEBHAR 75531
Lot Size(sy. ft.): 44431.20 Owner: ROTHER BRYANT P&SUEELLEN WALSH-ROTHER
Zoning: URA(39)/TJRB(60)/URC(1)/ Applicant: JOHN C LEBHAR
AT. 159 ELM ST
Applicant Address: Phone: Insurance:
68 SCHOOL ST (413) 247-5107 0
HATFIELDMA01038 ISSUED ON:311912009 0:00:00
TO PERFORM THE FOLLOWING WORK:REFRAME DOORWAYS & INTERIOR TRIM
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 3/19/2009 0:00:00 $55.003239
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo