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17A-086 (4) 9 MOUNTAIN ST BP-2016-1260 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-086 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-2016-1260 Project# JS-2016-002169 Est. Cost: $8000.00 Fee: $140.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 13895.64 Owner: TAUSCHER NATASHE Zoninb: RI(100)/URA(100)/WSP(100) Applicant: TAUSCHER NATASHE AT. 9 MOUNTAIN ST Applicant Address: Phone: Insurance: 9 MOUNTAIN ST (413) 559-1761 (� FLORENCE ,MA01062 ISSUED ON:4/29/2016 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE SIDING, 14 REPLACEMENT WINDOWS, ROOF, SILLS & REPAIR RIM JOIST 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 4/29/2016 0:00:00 $140.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2016-1260 APPLICANT/CONTACT PERSON TAUSCHER NATASHE ADDRESS/PHONE 9 MOUNTAIN ST FLORENCE ,01062(413)559-1761 Q PROPERTY LOCATION 9 MOUNTAIN ST MAP 17A PARCEL 086 001 ZONE RI(100)/URA(100)/WSP 100 / THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid c .;T_ V Building Permit Filled out ,T Fee Paid Typeof Construction: REPLACE SIDING, 14 REPLACEMENT WINDOWS,ROOF, SILLS&REPAIR RIM JOIST New Construction Non Structural interior renovations Addition to Existine Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOR RESENTED: 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 De n Delay _ _ y�19W 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. j Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability -- Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify 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 j Map Lot Unit _ f Zone - Overlay District �`z-w r,_&r-Tc I t ` Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: f Name{Print} -, �.-•' Current Mailing Address: / Telephone Signaturc-r 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. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 1 4. Mechanical{HVAC} J 5, Fire Protection ff 6. Total=(1 +2+3+4+5) ',. Check Number , This Section For Official Use Only Building Permit Number: DateIssued: Signature: Building Commissioner/inspector of Buildings Date Section 4. ZONING AR 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 Setback.,; Front Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bIdg&paved #of Parking Spaces A. Has aSpecial Permit/Variance/Finding ever been issued for/on thesite? NO \~~��/ DONT KNOW YES �_�� / IF YES, date issued:,' | IF YES: Was the permit recorded atthe Registry ofDeeds? NO { > DONT KNOW 0 YES /FYES: enter Book | Page, and/or Document# �� D. Does the site contain n brook, body ofwater orwetlands? NO \�J DONT KNOW YES YES IF YES, has permit been or need to be obtained from the Conservation Commission? Needs to be obtained /-� Dbteined /�� Date \~~� \~/ ' � C. Dnany signs exist onthe property? YES 0 NO IF YES, describe size, type and location: \ ! �-----------------^-------_-__'___-_-___ ___J D. Are there any proposed changes to or additions of signs intended for the property? YES �-� NO IF YES, describe size, type and location: � E. Will the construction activity disturb(clearing,gradingexcavation,orfilling)over 1 acre orisitpart ofecommon plan that will disturb over 1acre? YES � \ NO �� |FYES,then aNorthampton Storm Water Management Permit from the DPW imrequired. SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9.Reaistered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Address Expiration Date '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...... ❑ 11. - Home 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- ear 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 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: 'A c tom, - R The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant C . omt Date Signature of Permit Applicant City of Northampton f f ', Massachusetts �v - '��✓ DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building �JLCb 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 I, °�G?'."�.T` Q fa V�� , -~v 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 I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibty Name (Business/Organization/Individual):_ C I I A I IS) . T7( ddress: t City/State/Zip: Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1.El I am a employer with 4. Fj I am a general contractor and 1 6. F�New construction employees (full and/or part-time),* have hired the sub-contractors 2.0 1 am a sole proprietor or partner- listed on the attached sheet. 7. F-1 Remodeling ship and have no employees These sub-contractors have 8. F�Demolition working for me in any capacity. employees and have workers' 9. F-1 Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. F-1 We are a corporation and its 10.F-1 Electrical repairs or additions I am a homeowner doing all work officers have exercised their I L F0 Plumbing repairs or additions myself No workers' comp. right of exemption per MGL 12.F-1 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. tContractors 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 certify u the pains and penalties ofperjury that the information provided above is true and correct. Si Run Date: 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#: