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37-065 (62) • 100 BLACK BIRCH [RAIL BP-2007-0696 CBs #: COMMONWEALTH OF MASSACHUSETTS Map:Block:37-065 CITY OF NORTHAMPTON Lot:-00I PERSONS CONTRACTING WITH UNREGISTERED CONTRACT ORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MOL c.142A) Catenery: BUILDING PERMIT Permit# BP-2007-0696 Project# JS-2007-001047 Est. Cost:$2500.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Coast.Class: Contractor: License: Use Grouo: Homeowner as Contractor_ Lot Size(sq. ft): 371 566,80 Owner: ROCKY BILL COHOUSING LLC Zoning: SR Applicant: ROCKY HILL COHOUSING LLC AT: 100 BLACK BIRCH TRAIL Applicant Address: Phone: Insurance: CIO THOMAS P HARTLEY FLORENCEMA01062 ISSUED ON:11512007 0:00:00 TO PERFORM THE FOLLOWING WORK:ERECT 12 X 16 SHED 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 1/5/2007 0:00:00 $25.00417 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo File#BP-2007-0696 APPLICANT/CONTACT PERSON ROCKY HILL COHOUSING LLC ADDRESS/PHONE C/O THOMAS P HARTLEY FLORENCE PROPERTY LOCATION 100 BLACK BIRCH TRAIL MAP 37 PARCEL 065 001 ZONE SR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Bui S ne Permit Filled out Fee Paid 4/ �y `'J�— �)ljQ c -- TvaeofConstruction: ERECT 12 X 16 SHED New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owned Statement or License 3 sets of Plans/Plot Plan THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN ATION PRESENTED; Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Regisny of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street -. fission Signature of Building Official T Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A, Contact Office of Planning&Development for more information. 1 Oeyanmentus. y tCityof Northampton isoEF�$uiiding Department a u , enn 212 Main Street trtfs11 u Room 100 mol ` rit "- acJorthampton, MA 01060rtra r `3 +a .p"t ex phone 413-5871-1240 Fax 413-587-1272 `i$K '' APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION i.t Property Address: � ,�/�. i. TJdssechto b one completed byoffice . WO F7�A-C I< (/i . C0- 1/}+"'• -t 'Wh=; € . .... . Unit . rtir 1.1 (t"b'/ 0/ G/o Z Vona Ure layDistnM + kn St;-D)sfi7cY -` ,.CB.DisMcr -. SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: FLOCK--Y ItI t-(.- tilfaKei V-6,1944 r C047,fit?V(r t_LGco slack_ 13:76r0C‘ rya ( Name I) l�.q �- cumentfiln Ad,.�d A7 -- /r i / � 51 %c-i.l Telephone Signature 2.2 Authorized Agent Name(Print) Current Mailing Address' Signature Telephone SECTION -ESTIMATED.CONSTRUCTIO,N COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by Permit applicant 1. Building y 2/ cy pe, (a)Bui/ding.Perme Fee 2. Electrical (b)Estimated Total Cost of Constriction-from.(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection '!, 1.t c 6. Total-n(1 +2+3+445) Check Number Xl , 'rn ayr This Section For Official Use Only !!! I' Building Permit Number. - Date Issued: Signature: Building Commissioner/Inspector of Buildings Date Section A. ZONING An 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 Denotement Lot Size _—.._..— _ _ -- Frontage — -- Setbacks Front _1 Side I.—.- R:— L. R'._ _—/e) /6 Rear ' 35 - /D Building Height -- ,____, —in 1 Bldg.Square Footage _ — /o ,.. Open Space Footager % (Lin mm minas bldg&paved parking/ #of Parking Spaces .- Fill: — _. (volume&Location) A. Has a Sp cial Permit/Variance/Findin ^��g ever been issued for/on the site? NO DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW O YES 0 IF YES: enter Book Page' and/or Document S'. B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW © YES W IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained V Obtained © , Date Issued: C. Do any signs exist on the property? YES © NO Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO V IF YES, describe size, type and location: J E. Will the construction activity disturb(Gearing,grading,ex ation,or filling)over 1 acre or is ft part of a common plan that will disturb over 1 acre? YES O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition D Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessary Bldg. ❑ Demolition ❑ New Signs (Ci] Decks ID Siding[p] Other[r Brief Description of Proposed ? Work: ill 7fY�� - APfWVT- /1 J27y I LX (b rlig E-+ Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roil -Sheet calf`Net hlfgae'ailia a d t' o`m#' ezts' inf, tisinq amp" e e t atito to lw ne 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 A 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. I. Septic Tank City Sewer Private well City water Supply SECTION la-OWNER AUTHORIZATION-TOME COMPLETED WHEN OWNERS AGEN DR-CONTRACTOR APPLIES FOR BUILDING PERMIT I. _,,, 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 I. D/Mani- (041J ,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 oer)ury. panvto (pAdl Pd/nt Name ;` � 2 `�2/{, ✓Signature of Owner/Agent Date t/ SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9'.xt"u&s't`siutilar elttAF Inc it COrttmaek4r r, an Not Applicable 0 Company Name ,V Registration Number Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(S)) 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 0 No 0 e I El uot P ',EI t R !S The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 ns supervisor.CMR 780. Sixth Editing Section 108,35,1. 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-war period shall pot be considered a homeowner. Such'Tomeowner'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 Wider the buildiot Pernik 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,von may be liable for persons) 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. V Homeowner Signature _ The Commonwealth ofMassachusetts Department of Industrial Accidents _, Office of Investigations • ]f1= ') 600 Washington Street � • Boston, MA 02111 wwrumass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Orgaaizaiioriltndividual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 4. 0 I am a general contractor and I 6. 0 New construction employees(full andlorpart-time).: have hired the sub-contactors 2. I am a sole proprietor or partner- listed on the attached sheet 7. 0Remodeling ship and have no employees These sub-contractors love 8_ 0 Demolition working for me in any capacity, employees and have workers' 9 0 Building addition [No workers'comp.insurance coni.insurance.t 9��] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0j 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 employees.[No workers' 13.0 Other comp.insurance required.] "Any applicant that checks box%I must also fill out the section below showing their workers'comprnwnon policy intim-Elution. t Homwwners who submit this affidavit indicating they arc doing all work and then hire outside contactors must submit anew affidavit indicating such. kContactors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employ=s,they must provide their workui coag.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.Lk.#:� 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 requited 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 ill 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 jpvestigation.4 of the DIA for insurance coverage verification. I do hereby cent nder the pains and penalties of peduryi that the information provided above is true and correct Sygp : meq. ((2 "'7 _... Date: 1 � 7/. / Phone it: P: 7 b -�- ( 0el 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#: O.�ttti4PTO = y ^- c 4ks (rifp of azf( svtttarr � Vii. was Q.. dO4t[h119tft! ! 1 \ DEPARTMENT OF BUILDING INSPECTIONS \�`\tit-lar-Er7-t r= INSPECTOR 212 Main Street • Municipal Building Northampton,MA 0I060 . r HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 784CMR 108.3.4 to act as his/her construction supe: . sor. The stale 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 ,, 21,4 _ ____<�O 1I AA 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 1 / "/ Q2 Address of work location proposed shed oc. - 100 Black Birch Trail -4----- = — — — — — r r y , - V `%+ 0 I c ; ° i _ Rocky Hill CoHousing Northampton, Massachusetts 11 q o\ December, 2003 h vv �` s u )b s o —meq