35-037 (12) 198 WEST FARMS RD BP-2016-1077
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 -037 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-2016-1077
Project# JS-2016-001838
Est. Cost: $15000.00
Fee: $98.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CHAD ALEXANDER 108150
Lot Size(sq. ft.): 118918.80 Owner: WERNIK JOSEPH M&SUSAN
zoning: Applicant: CHAD ALEXANDER
AT. 198 WEST FARMS RD
Applicant Address: Phone: Insurance:
4 FOX RUN (413) 210-3038
EASTHAMPTON MA01 027 ISSUED ON:3/8/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.CONVERT 3 SEASON RM TO LIVING SPACE
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:
FeeTvpe: Date Paid: Amount:
Building 3/8/2016 0:00:00 $98.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
V -r, ,w-f Xs"T&.t--46a��
17epartment use only � �i
City of NorthamptonusPerm J� y
�
Building Department cr -:
MR '
212 Main Street _ -r Sep leA aila6l(rty i
Room 100 el Ava la6il(ty
Northampton, MA 010 0Twgseta >s#r ctural Pians
phone 413-587-1240 Fax 413 7- ns y "
— - - - --
F
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE,INFORMATION.
_ _..-_. yff
1.1 Property Address: ice
_ -
/ t Map Lot Unit
_Zone Overlay D�sfncf
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT: .
2.1 Owner of Record:
Na int) Current Mails Address:
TelephoneC
Siga2fure
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building1� t C�C)
(a).Building Permit Fee
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) t Y,60CL00 Check Number
This Section For Official Use'Only
Date
Building Permit Number: Issued:
Signature:
Build' 0 sio- r/In.spector.'of Buildings: 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
Setbacks Front
Rear
Building Hei�ht
Bldg.Square Footage
Open Space Footage %
#of Parking Spaces
(volume&Location
A. Has a Vcciat Permit/Yaria nce/Friding ever been issued for/on the site?
~��
NO �� DONT KNOW �~� v��Y�� \��
IF YES, date issued:!
IF YES: Was the permit recorded atthe Registry ofDeeds? �
NO � YY
� � DONT KNOW /ES '
�
IF YES: enter Book Pag /or �� ��Document#
61�B. Does the siteLe contain a brook, bodyofwaterorwetiands? NO DON7 KNOW �_� Y�� \_� �
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tubeobtained Obtained
D t Issued:
0 �
C. Doany signs exist onthe pm ��property? YES �^� NO
IF YES, describe size, type and location:
D. Are there any proposed changes to oradditions of signs intended for the property7 YES 0 NO (2�
IF YES, describe size' type and location:
E Will the construction activity disturb hng.gradingUon. orfilling)over 1acre or|o/tpart orocommon plan
tho�wi/|dis�urbover1uce ��? YES [ ] NO da
IF YES,then a Northampton Storm Water Management Permit from the DPW is required. �
�
i
' | �
/ �
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Vidows Alteration(s) Roofing F7
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [ZI] Decks [M Siding[0] Other[0]
Brief Description of P[oposed
Work: C 1 tAa y IACr �0'.N.J P-..0 D M
Alteration of existing bedroom Yes No Adding new bedroom Yes 11_�No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Sheet
sa. If. New house and_oraddttio'n to exlstinhousin co leve fhe followrn
a. Use of building :One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms Z–
c. Is there a garage attached? YZ t—
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? CL�G'fRi c. _9A.':i7 br>A-&A Fireplaces or Woodstoves 4/0 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
I,
tic)Sep k Sa n Vl ei� X1 as Owner of the subject
property
hereby authorize OA&rtA60XC.r JaJ
to act on my behalf, in all matters rela ive to work authorized by this b ing permit applicatio .
Signa a of OvIner Date
I, G� A 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
3 >
Signature of Owner/Agent Date
- I
SECTION 87 CONSTRUCTION SERVICES
8.1 Licensed ConstructionSupervisor: ( Not
'Applicable £
Name of License Holder: (i Y► �/�I P)CrAM o h s o
License Number
Fa)� _Rv„ L cs+", Q 4o,� , /` otoQ 7 I�f I C 7
Address Expiration Date
&t3) glo , wig
Signature Telephone
--
tra' Not Applicable £
9�'Re isfered-Home lm covement:Conctor '-
�� cam' 175(, S9 75(, S9
Company Name Registration Tmber
L P'D QRSI DOI
Address Ex�o Date T
C S G(►�Q A_6iUk"7 Telephone&1.3 3.10--Xg
SECTION 10-WORKERS!COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c..1 52,§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 theIding permit.
Signed Affidavit Attache es....... No...... £
11 Home Qwner Lgeffiption
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 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 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,
i
R The Commonwealth of4lassachusetts
Department of Industrial Accidents
Office of1nvestigations
x 600 Washington Street
17jr Boston,M4 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Colr>praetors/Eleetrgcia ns/Plumbers
Applicant Iflnformation Please Print Lezibly
Name (Business/Organization/Individual): LA /4 i,,.�,
Address: PLA-1
City/State/Zip: L- Phone#: !' a 'U '3032
Are you an employer? Check the appropriate box: Type of project(required):
1.71 a employer with 4. ❑ I am a general contractor and I
ploy
(full and/or part-time).
* have hired the sub-contractors 6. ❑ construction
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 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 10.7 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.❑ Other
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.
lam an employer that is providing workers'compensation insurance far 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 declarations 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 pains and penalties ofperjury that the information provided above is true and correct.
Simature Date: .341A
Phone#: ( 1 02
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 Z. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS ✓= -x,'
- J h
t: a i 212 Main Street • Municipal Building rJ'•. =be'
`fir^ Northampton, MA 01060 ass', Lit'
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
Faccessory
f Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
n supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which
des or intends to be, a one or two family dwelling, attached or detached structures
o such use and/or farm structures. A person who constructs more than one home in a two-
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/footinqs (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 i
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
understand the above.
(Home owner/resident's signature requesting exemption)
will call to schedule all required building inspections necessary for the building permit issued to me.
)ate
address of work location
i
M
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: jq9,
The debris will be transported by: op'�'
The debris will be received by:
Building permit number:
Name of Permit Applicant
r6 .�
Date Signature of Permit Applicant
FT �UR 231 Main Street ORDER: 24135
�,/ 1 Easthampton, MA 01027-2024 ORDER DATE: 2/26/2016
PH:(413)527-2693
L U M B E R FX: (413)527-9110 ORDER CONTACT:
www.fleurylumber.com
QUOTE
INVOICE INFORMATION SHIPPING INFORMATION
GENERIC WINDOW QUOTE GENERIC WINDOW QUOTE
SHIP VIA:
CUSTOMERREF
24135 ( 2/26/2016 DON ALEXANDER
1 AURORA NC C2 4 48 W X 42 H $471.08 $1,884.321- x`
ROUGH OPENING $0.00 $0.00
LINEN $0.00 $0.00!( I
OVERLAP FULL SCREEN $0.00 $0.00` ---
LEFT/RIGHT OUTSIDE $0.00 $0.00
STANDARD HINGE $0.00 $0.00
FIBERGLASS $0.00 $0.00
DUAL GLAZED $0.00 $0.00
GLASS TYPE DG(LOW-E S1370) $40.86 $163.44
PERFORMANCE RATINGS: U:0.3 I SHGC:0.28 VT:0.47 AIR:50.3
ITEM SUBTOTAL: $511.94 $2,047.76
TOTALS: 4 SUBTOTAL: $2,047.76
TAX 1 6.25%: $127.99
TOTAL: $2,175.75
COMMENT:
2/26/2016 11:41:11 AM 1 of 1
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