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37-065 (63) 109 BLACK BIRCH TRAIL-44 BLACK BIRCH TRAIL BP-2007-0697 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 37-065 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-2007-0697 Project# JS-2007-001048 Est. Cost: $1500.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const Class: Contractor: License: use Group: Homeowner as Contractor Lot Size(so.ft.): 371566.80 Owner: COHN DONNA Zoning: SR Applicant: COHN DONNA AT: 109 BLACK BIRCH TRAIL - 44 BLACK BIRCH TRAIL Applicant Address: Phone: Insurance: 109 BLACK BIRCH TRAIL (413) 586-2904 0 F L O R E N C E M A 010 6 2 ISSUED ON:1/5/2007 0:00:00 TO PERFORM THE FOLLOWING WORK:ERECT 8 X 10 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 $25.00416 212 Math Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo File#BP-2007-0697 APPLICANT/CONTACT PERSON COHN DONNA ADDRESS/PHONE 109 BLACK BIRCH TRAIL FLORENCE (413)586-2904 0 PROPERTY LOCATION 109 BLACK BIRCH TRAIL-44 BLACK BIRCH TRAIL MAP 37 PARCEL 065 001 ZONE SR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Pemrii Filled out ))��//,, �q� Fee Paid *yN10 VA(73' Tvpeof Construction: ERECT$X 10 SHED New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF( NATION 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 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 Conunittee Permit from Elm S et Commission • 1/17(an-2 Signature of Building Official Dat 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. x; DeparMentueeoniy City of Northampton S1asoEP mfg = .�> r " Building Department , • 212 Main Street -+""=+3.. 'r•* . n , , `°'*' Room 100 "' - Z ,TT Northampton, MA 01060 i e e' ' ' phone 413-587-1240 Fax 413-587-1272 ` ";a APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION secti-otnoQ#c,y-ebdeaely OmtsPfrtoeotdy ofFcUe 1.1 Property Address: ? ,-dJ iryL cW" tem-b / 9lIOC) n ft i imflt D(sCjcU' CB>astrict' SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2A Owner of Record: C oW) t CWW,! foci A-Cle-.1 Offeal 1 t2-tLL Name(Prinif'1 Current Mailing Address: qI. t & �-4 U'f yY '� Telephone V Signature 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 'r 5a(J (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 hh _ B. Total=(t +2+3+4+5) Check Number[ Tins Section For Official Use Only Date Building Permit Number._. .Issued: Signature: Building Commissioner/Inspector of Buildings Date Section A. ZONING Ali Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This colwm to be filled in by Building Department Frontage —.. Setbacks Front : -Jr Side L: R:-- L: ,_Rn -----4 Rear Rear 2.6".: - • Building Height / . Bldg,Square Footage % is/ Open Space Footage °!o Swaim minus bids&rimed __ parting) It of Parking Spaces -- Fill: r (volume&Location) A. Has a Sp ial Permit/Variance/Finding 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 0 YES O IF YES: enter Book ': Page ' and/or Document# B. Does the site contain a brook, body of water or wetlands? NO el DONT KNOW 0 YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained V , Date Issued: C. Do any signs exist on the property? YES © NO © ' 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 0/ IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,pradinsgvation,or Ming)over t acre or is it part of a common pian 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 ❑ Replacement Windows Alteration(s) n Roofing n Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [C] Decks [l] Siding[o] Other[El rief Description of Proposed Wod: 141.42 A 5(ft-10 -No ;UVN�,� nov nt (0 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet da tr 4 ho'u`sz:-8nd or-adt tio't r ez s tiir" +us ni q cot'p l lflii 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 stones? 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 7a-OWNER AUTHORIZATION TO BE COMPLETED WHEN'. OWNERS AGENT OR 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 l• ,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. Prim ame /IAA_ ll/6// 17;/V Signature of Owner/Agent Date LLL SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of tLcense border: _ License Number Address Expiration Date Signature Telephone B:-Ramal ier�dnTeltfi d'YenieMCHnrctic' „'yaui" crex^r n Not Applicable ❑ — Company Name Registration Number ____ Address Expiration Date Telephone_„_,_.,—.Y SECTION 10-WORKERS'COMPENSATION INSURANCEAFFIDAVR(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 sx:.��0 No C 1_` c iflli `'am' is• lti I €flll The current exemption for"homeowners"was extended to include Owner-occupied Dwelfinrs 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 as supervisor.CMR no. Sixth Edition Section 708.3.5.1. 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 shalt 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 h@ responsible for all such work performed under the bnildiae permit As acting Construction Supervisor your presence on thejob 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 aqd Locals and State of Massachusetts General Laws Annotated. fomeowner Signature 1tJOr.-'tP Y , The Commonwealth of Massachusetts Department of Industrial Accidents t=•� Office of Investigations • @i -I= " E: 600 Washington Street A— C Boston,M4 02111 www.inass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 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. Q I am a general contactor and I employees(full and/or part-time).* have hired the sub-contractors 6. [1]New construction listed on the attached sheet 7. Q Remodeling 2.0i am a sole proprietor or partner- ship and have no eailoycu These sub-contractors have &. Q Demolition working for me in any capacity, employees and have workers' 9. addition (No workers'cornp.insurance eon.insurance.: 0 Building Squired.] 5. Q We are a corporation end its 10.0 Electrical repairs or additions 3. 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 MOL 12.0 Roof repairs insurance required.]t c, 152, §1(4),and we have no employees.[No workers' 130 Other comp.insurance required.] 'Any applicant that checks box#1 mus:also fill out the section below showing their workers'campmsatiw policy info:nmdon. I Homeowners who submit this affidavit indicating they are doing oU 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 subcontractors and state whether or not those einem 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 Naas: Policy#or Self-ins. Lic.it 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 fee up to 31,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fie 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. Ida hereby re under the pains and penalties of perjury that the information provided above is true and correct ,aS,tanaturc �. ?/f/l Date: / / ''�/o 7 _ Phone#: 7 t tS O 4�.1 _. 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person:_, Phone#: �2-°,'. Pfe (Clip iii Narthampton .* R�, DEPARTMENT OF EUILDING INSPECTIONS �: _=/� INSPECTOR 212 Main Street • Municipal Building Northampton,MA 0I060 .117' Northampton, e HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supe: ;isor. 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 he 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, aniviz o c____ _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 I �1 ]- Address of work location . 7 G ,. ti. . ' r . i { wills" 1 �y • A. � ; 109 Black Birch Trail 110. / 1�, 4 f � 1 � zA . Ci e I f Rocky Hill CoHousing o - II u Northampton, Massachusetts \\ o \\ \` December, 2003 _ u \\ o m