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37-065 (11) 125 BLACK BIRCH TRAIL BP-2016-1280 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 37-065 CITY OF NORTHAMPTON Lot: -000 Permit: Building Cate,orv: renovation BUILDING PERMIT Permit# BP-2016-1280 Project# JS-2016-002203 Est.Cost: $16000.00 Fee: $104.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MATTHEW KOZUCH 106644 Lot Size(sq.RJ: Owner: RATTNER BAMBE Zoning: Applicant: MATTHEW KOZUCH AT: 125 BLACK BIRCH TRAIL Applicant Address: Phone: Insurance: 6 HIGH ST (413) 570-3279 0 FLORENCEMA01062 ISSUED ON:6/28/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:REMODEL BASEMENT KITCHEN ADD FULL BATH, BEDROOM & CLOSET 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 6/28/2016 0:00:00 $104.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck-Building Commissioner FilesBP-2016 280 tyy/� OZuctiegttaa, Cayl APPLICANT/CONTACT PERSON MATTHEW KOZUCH ADDRESS/PHONE 6 HIGH ST FLORENCE0I062(413)570.3279 0 PROPERTY LOCATION 125 BLACK BIRCH TRAIL MAP 37 PARCEL 065 000 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid l 9!l/t] *91 Building Permit Filled out Fee Paid Tvpeof Construction: REMODEL BASEM, LT KITCHBN ADD FULL BATH B ,DRtO & 'LOSET New Construction No Structu al ter r re o Cons Addition to Ex'stinc _ Accessory Sticture Building Plans Included: Owner'Statement or License 106644 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON MIN ORMATION PRESENTED: proved,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 I-• • e la . 7 f Signature of Bn di ;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, r Department use only :: F :'�ED City of Northampton Status of Permit Budding Department Curb Cut/Onveway Permit MAY - 4 2018 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans Dat'r aulminoIhsaecuwo ictont _ rvca�sina,au,iapuli0ne 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 125 lel NCO° fpP^ES^ � ECAl Map 7 Lot (p -) Unit 1" t0(py\ Q tMI\ OtoG2- Zone Overlay District Elm St.District ''CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Ntti\b, Q %a1 tQr \25- eLcjc6iecnL Tre., Name(Print) Current Mailing Address Telephone Signature 2.2 Authorized Agent: IMAA-A" \FI (p OP' c \ - flofeAce MA 0,062_ Name(Print) Current Mailing Address: Signature ),`n"14 -5-70 -3 2-71 Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant I. Building 7 I�I/ (a)Building Permit Fee 2. Electrical ^ j, (b)Estimated Total Cost of 1.... h Construction from(6) 3. Plumbing I/ Building Permit Fee 4. Mechanical(HVAC) f l 5. Fire Protection /)/, 6. Total=(1 +2+3+4+5) I (p ,Check Number iTc2, This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date t • Section 4. ZONING Alt Information must Be Campieted. Retort Can Se Domed Due To incomplete Information _ Existing Proposed Required by Zoning ( { IDe� ls<otulo be filledFr.by wl�l/W OA�Ij (\o cAsole. Building Dep,mmem Lot Size _. ._.._ _ Y . _-. _. Frontage ---- -- - --- Setbacks Front --` —� Side ._ ._ Rear Building Height Bldg.Square Footage -fine 4e� __. 55 .. Open Space Footage __, % - - -- eat areamiow bldg&paved 0 c O parhinc F ofParkine Soaces S 1 - --- —. (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? N0 Q DONT KNOW er YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW Q YES Q IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO V DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO er IF YES, describe size, type and location D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading, excav ton,or filling)over l acre or is it pan of a common pian that will disturb over 1 acre', YES Q NO IF YES,then a Northampton Storm Water Management Fermi:from the DPW is required_ SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House D Addition T1 Replacement Windows Alteration(s) Roofing n 0 Or Doors O Accessary Bldg. Demolition ! 1 New Signs [c] Dec s Cf Siding jD) Other[DI Brief Des tionafPro used f.3�i� Mala. Work: ( eModelpexls}in5 baseu o,A AtAtok tiv� lASII'S AICUR (e-1-1 al _ ux.!ietodc�Dse�. Alteration of existing bedroom J Yes -,_No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes y No Plans Attached Roil -Sheet Ga. 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 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ,as Owner of the subject property ALAI-11 ``// hereby authorize AL 4 14 or r to act on my behalf, in all matters relative to workiN thorized by this building permit application. C73 x eT+-N-ke akiwv.o. S 131[Ltd Ha signature oof ofOwner `/%. 2slDate 1"\ 0. 1 Ot' k. ,as avner,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. iV & Y GWcJ\ Print Name �/ -- er nttir j1 S� Signature of Owner/Aden Da • SECTION 8-CONSTRUCTION SERVICES 8.I Licensed Construction Supervisor Not Applicable E 1t�t� If ,,, (� /l,,L{r NAme o4 License lsoltler' �'V\(L�k IWr-l/C \ CS I �+�'r' L //�' { t^^ Licensee Number 1p *l `�` c�1-- 1- • AC = Akk Address § Expiration Date il► _ _ `(t3) Signature d Telephone S.Registered Home Improvem nt Contractor _.. . Not Applicable E ah z e- "tt2um Companyyamtio x Registr on Number �c Address - p on to 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 appfration. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....._ E No £ 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Owellinos of one(t) 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 censtrgcts 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 res•onsihic for all Itch work •crf rmed under the buadina •ermil. ' 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 The Commonwealth of Massachusetts fit - Department ofIndustrial Accidents .�. . • a_�—,�, Office of Investigations 1 E' lsa `1 600 Washington Street .4, Boston,MA 02111 www.mass.gov/dia Workers' Cmmnpemsatiou Insurance Affidavit: Batilders/Coate ctors/Electriciaa/IPlosrbers Attelicamt Information Please Print LeEibiv Name (Business/Organization,/Individual): ts, -{ 1'yc'Z t/ Address: A City/State/Zip:. t AL Dice- Phone f: `Ii . Are you an employer? Check the appropriate box: Type of project(required): 1.E I am a employer with 4. ❑ I am a general contractor and I s have hired the sub-contractors 6. ❑New construction __,„employees (full and/or part-time).* �,/' 2.er7 t am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9addition [No workers' comp. insurance comp. insurance.t E Building required.] 5. 9 We are a corporation and its - 10.0 Elech'ical repairs or additions 3.T I am a homeowner doing all work officers have exercised their I1.❑ 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 employees. [No workers' 13.11 Other comp. insurance required.] *Any applicant that checks box Fl must also fill out the section below showing their workers'compensation policy information. trio 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 thesub-contactors have employes,they must provith their workers'comp.policy number. Iain 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.Lie. #: 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 t i 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 5250.00 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 of perjury that the information provided above is true and correct. Sienatttre:��11 - Date: �' tt -'l Phone#: -1jJ' m� I0-3 • Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License g_.... 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#: City of Northampton . s, Massachusetts z DELPART[SET O? BUILD:TWO IDIS?ECTIOE5 a ) ff 3: 212 Hula Strait HunicCpal Building y9 Northampton, MA 01060 \sn ,vjt INSPECTOR Louis Hasbrouck Chuck Miner 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 try 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/footinas (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 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 City of Northampton 212 Math 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: A25 (3\o_t_06(4. -4,, 1- 1otence I The debris will be transported by: i\�ti i i,z✓c The debris will be received by: \)aA\ Rec./ Building permit number: Name of Permit Applicant % ciA- V.,, S/3/ 114 Date Signature of Permit Applicant L"]o.1v34,\ ala tlesr' j5 S��UCf(/�t? c g ON � �� ‘2-S- aLCIL atetn Tfa,� r (JSP 'QS q WWa \c.�y ore/i / ( 4✓"/ eue 2S �,4GIME Sl Noy-ea_ -- a f— C ' ----1 /- � Existin5 S„,k City of Northampton Building Department I . — �e 212 Main l'iStreet 9 a a�(! © Northampton, MA 01060 d � \l IF i IZiia ' �t Illi N6Zrelt el O . . ....\ E� 2i �- A 1tri p ka. 1 ____, :__., ii ,,,,,,_ --,-, il Au ee e y est -Q.. _. EMetger(e,(/ �/J /p/ Egitrc�/L, I ESC9UU�e '! /✓l 2446ke awl C6 O e Q45 MpC5F l(� �eq�,i4,1 ie I,ea24r 7 Yo ce,ee coif G /t Nclaile✓tet. 3 1A 20 r pie e'era sP,Pc#C77R- Il II I ' IIIIIVIII!IIIPIIJ � II!i L34: 11)3f.4F1 11/ ('aye.. I of 1 Restrictive Covenant Reeomed. 0=ro;i?u r, o4 41, • rd Bambi Rattner, owner of the real estate at 125 Black Birch Trail, Florence, more particularly shown as Doc.# 15086, Rec Date 6/09/2006 10:37am, Book/Page 08746/102, hereby Covenant and Agree that "the structure at 125 Black Birch Trail, Florence, MA will be occupied as a two-family dwelling unit by persons living as a two family dwelling without first obtaining a building permit and meeting all the requirements of the City of Northampton Zoning Ordinance and the Massachussetts State Building Code for a newly created three family dwelling or an accessory apartment. " Executed as a sealed insturment this May 4t4q, 2016. t JJa.-.D . (MTh-r »-a � ,sr, o BAr1B \ ma )' RPTTti t (Z Owner's Name and Signature Hampshire, ss COMMONWEALTH OF MASSACHUSETTS On this 5th day of May, 2016, before me, the undersigned notary public, personally appeared BAMBI RATTNER, proved to me through satisfactory evidence of identification, which was a valid Massachusetts driver's license, to be the person whose name is signed of the above Restrictive Covenant, and acknowledged to me that she signed it voluntarily for its stated pyrose. AsOf ( 1 Notary Publid / MICHAEL J. CAREY Y • ^'_!Punt Oflomosith d Ilassacbusrs My Commission Emir Oamber 21,2022 es