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37-065 (66) BP-2007-1165 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot *001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) categery: BUILDING PERMIT Permit BP-2007-1165 Project# JS-2007-001859 Est.Cost$2500.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Gmnv; Homeowner as Contractor Lot Size(sq.a.): 371566.80 Owner: LEAVITT MARSHA Zoning:SA Applicant: LEAVITT MARSHA AT: 104 BLACK BIRCH TRAIL - 44 BLACK BIRCH TRAIL Applicant Address: Phone: Insurance: 104 BLACK BIRCH TRAIL _ (413) 320-3646 O F L O R E N C E M A 010 62 ISSUED ON:6/I/2007 0:00:00 TO PERFORM THE FOLLOWING WORK.'ERECT 10 X 12 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: FeeType: Date Paid: Amount: Building 6/1/2007 0:00:00 $25.00530 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo File#BP-2007-I165 APPLICANT/CONTACT PERSON LEAVII 1 MARSHA ADDRESS/PHONE 104 BLACK BIRCH TRAIL FLORENCE (413)320-3646 0 PROPERTY LOCATION 104 BLACK BIRCH TRAIL-44 BLACK BIRCH TRAIL MAP 37 PARCEL 065 001 ZONE SR -HIS .ECT-}NFO' OFFCIA' USE ONLY. PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid $uil , Pe it Fi ed ou .....- pee Paid FeePaid t '• • Tvpeof Construction: ERECT 10 X 12 SHED New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Pleas Included: Owner/Statement or Licensg 3 sets of Plans/Plot Plan THE AWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN AT1ON PRESENTED: pproved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR - Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Co .ssion ., ..r ST /42 Signature of Building Official Date Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MOL 40A.Contact Office of Planning&Development for more information. • OarttXtsdonly fc7, City of Northampton Sia of2emxl+ - " ` "'""' CrTh \< " Building Department Ewb kkhrvei'�eatut > n re Oi 212"Main Street SewittitSwaxy eptic Aaeg 1 nt‘{ 'itd Room 100 WateriWeliAviiJ$drtj Northampton, MA 01060 l oS tsofSbueCusraJ vans- _ pilia '413-587:,124D' Fax 413-587-1272 Pidt/GIEe Pians om&speafy " 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 Q4 gLAC Et1RO4 TR-AtL Map Lot Unit FL0R.R—eIC . •-1A 0 I0(0Z,,,. Zane OvarlayDistnct Ern St.District es Distict- SECTION 2•PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner 0 Record: MAiRCI'A LEAVI` T- \opt b .t)( . S)Q1441 v{LA t Name(Print) • Current Mailing Address: �� 1 A, rw ukof ( z Isignature N` Telephone �t3 320 3tc t b 7.2 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 Building S. Soo (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3, Plumbing Building Permit Fee 4. Mechanical(HVAC) )53O 5, Fire Protection 5- &. Total={t -2+3+4-5) {y, sp0 Check Number lTD`�"�rl This Section For Official Use Only Issued: Building Permit Number. Date Signature: Building Commissioner/Inspector of Buildings Oate Section 4. ZONING NI Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information ®® Required by Zoning This colon m befi led in on Building Dopomnanx MINISIOMMIMMEMINEI PPIIIMNEMIEMMIMIM Setbacks Front Sipe, L_ R:Sri' —a ifi Rer —A0 alliffialleal ISIMMallIMMEMIMIIIMMIMIIII Open Space Footage IIMEIIIEIEII (Lot n®mums hoot8e paved orka _ IMIMIIIIIEIMIISIE IIIMIIIIIMIIIIIIIIIIMIIIIIIMIIIIMIMIIMIIII IIII Winill A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO © DONT KNOW 0 YES IF YES, date issued:. IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW 0 YES 0 IF YES: enter Book Pageand/or Document# B. Does the site contain a brook, body of water or wetlands? NO ?Ll DONT KNOW O YES ll IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained © . Date Issued: C. Do any signs exist on the property? YES QNO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO 0 IF YES, describe size, type and location: .., E Will the wnstruction activity disturb(nearing,grading,excavation,or filling)over t acre or is it part of a common plan that Wilt dlaturb over 1 acre"' YES 0 NO 0 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 I� Or Doors O Accessory Bldg. S21 Demolition ❑ New Signs [0] Decks [0 Siding[0] Other[ Brief Description of Proposed Work: I NST6w reC- LAILT I oK17— W°CD SH�7 Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes K No — Plans Attached Roll -Sheet 6a['If Newfiouse'andoiadditiontoexitinghouslnq completethe#o7lowinq: 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? L 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 I, ,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. AlarsL,A L141/ 11f Print Name i on4nhiz) 5 -02‘, - 07 Signature of Owner/Agent Date • SECTION 8-CONSTRUCTION SERVICES LI Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Cate Signatute Telephone --" 9:Regfstfied flome'hiffifa 'nenttonfr bieriC: _> _ _ . q .r..r Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone, SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.aL.C.152,§25C(6)} Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to pmvide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes 0 No 0 11 - FI"ome u her Eie ummi 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 78Q, Sixth Edition Section 10$.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-veer period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official.that hetshe shag 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 Ar mutated,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 tate of M. sa usetts General Laws Annotated. Homeowner Signature /2130 - _ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigaons ; 600 Washington Street 1 Boston,MA 0 211 { www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Orgznizuion/lndividual): Address: City/State/Zip: Phone it: — Are you an employer?Check the appropriate box: Type of project(required): 1.E I am a employer with 4. Q lam a general contractor and 1 6. New construction employees (full and/or part-tune).* have hired the sub-contractors listed on the attached sheet. i. ERemode2igg 2.0 I am a sole proprietor or partner- ship and have no employees These sub-contractors have g_ Q Demolition working for me in any capacity. uuhPioyees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance.] required] 5. QWe are a corporation and its 10.D Electrical repairs or additions 3 I am a homeowner doing all work ars have exercised thea ILO Plumbing repairs or additions / myself.No workers'comp. right of exemption per MGL 12.[3 Roof repairs insurance required] t c. 152, §1(4),and we have no employees.[No workers' 13.0 Other comp.insurance required] I *Pony applicant that checks box#1 must also till 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 contactors must submit a new affidavit indicating such. :Contactors that check[his box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. if the subcnntacusrs have employees,they mustprovide their workers'comp.policy numba- 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 a or Self-ins.Lic.a: 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 i.i osiaon 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 cerafy under the pains and penalties ofperjury that the information provided above is true and correct. h Smarr e: / ... , �... ' Date: -51 -26, --%J Phone S: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License a_ 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 : 4t ;r 4 trot. ? (lite of Northampton I ti +a te Alassweliusette ( _ !"1` u ,i:.) " DEPARTMENT OF fltlfIDIRIG INSPECTIONS 'r =._ INSPECTOR 212 Mann Street • Municipal Building \c{<\,94: / Northampton,MA 01060 v HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3 4 to act as his/her construction sup._ sat. 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 homeowner." 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, 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 J",,.26, —b 7 Address of work / / f location fav Bin 4 D,FcK /ey. . _.— f/alemt - 444 0/D472 • '� r h� WA. + It-40117 4-.: 4-k f % k r} `" '* � ATb¢i m'1 ��c �rT AQ Of 1 ° F.& +., 'S �f+ fit .fc. IIe �' 4a 9 as 4 y! 1----- . 3 '} men '. � j ec 1 3 a Riget, ., :41.. .. ; h4 wr+ 9tf °���� ,;� X +. .; A �S._..t _ . su