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1095 WESTHAMPTON RD BP-2017-0627 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:41 -022 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: REPLACEMENT WINDOWS/DOORS BUILDING PERMIT Permit# BP-2017-0627 Project JS-2017-001013 Est.Cost:$3000.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor_ Lot Size(sct. ft.): 77275.44 Owner: MEYER CHRISTOPHER Zoning: Applicant: MEYER CHRISTOPHER AT: 1095 WESTHAMPTON RD Applicant Address: Phone: Insurance: 1095 WESTHAMPTON RD (802) 522-2813 0 NORTHAMPTONMA01060 ISSUED ON:11/3/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACING EXISTING BAY WINDOW WITH NEW BAY WINDOW & REPLACE FRONT DOOR 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 11/3/20160:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton Stafus of Permit; :, _• Frtirr _ Building Department Curb'Ouflt vewaq'Pernnt ,� ` 212 Main Street Sewar%5'edttcAvailabihty . - ,` Room 100 yyateM/el(valtabtlfly t - t Northampton, MA 01060 Two Set*ofShiictural Plans ' phone 413-587-1240 Fax 413-587-1272 Plot/Site'Pran "" "- Other Specify - APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION p !IVO?? This section to be completed by office 1.1 Property Address: 1ogS vie w1-\-rc m ptcr, t2 c\ Map Lot Unit 1Z orcrcg , A O\0b2 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: C.VI r)StOo Mc-Ne, ICES Wcs-14et.n-pt r r -A ,F 1ucrce..M4o to 1:z>2- Name 2Name(Print) Current Mailing Address'. E,02 522 .2813 C�,//�— rip Telephone Signature/ �n� � ; ctvr,cyac4cEEt . r-..1-ccm 2.2 Authorized Agent' Name(Pont) 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-y—YY3 m (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 6. Total=(1 +2+3+4+5) $ 3caC:CD. oo Check Number /?r 7/ hyo This Section For Official Use Only Building Permit NumberDate Issued: g /fes!' �_ /7 ?—Zef Signature: �ui F mis io -r/Inspector of Buildings Date L Section 4. ZONING All 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 f -_ II r _ . 1 Frontage [ .. ..__ I1 _.__ -J I __- ___I Setbacks Front I I I I I i Side LI._ . I R:I I LI --_ I R 1 -. ..I I Rear I._ I i Building Height ----, Bldg. Square Footage d. % Open Space Footage _ % _ (Lot arca minus bldg&paved f I I -I I ._I I _I I _- .I parking) #of Parking Spaces Fill: _.._ _ I (volume&Location) --- — --- - A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES, date issued:1 _ IF YES: Was the permit recorded at the Registry of Deeds? NO © DON'T KNOW O YES O IF YES: enter Book r Pagel and/or Document#1 B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: -_-._ . ....- __ _� C. Do any signs exist on the property? YES O NO O 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 O IF YES, describe size, type and location: L 1 E. Will the construction activity disturb(clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO O 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 [ 1 Addition Replacement Windows Alteration(s) U I Roofing IDOr Doors 0 Accessory Bldg. ❑ Demolition El New Signs [D] Decks [q Siding [0] Other[fl] Brief Description of Proposed Work' rep rcwr.-ct ex s*W1c cry w,ncirtW w rtsr,nCw s2.y PVP"csro-v+7, repioCi mamg Front door W.tr-+U(--KXrtcmt Erp.,t • • Y Alteration of existing bedroom Yes A No Adding new bedroom Yes A No Attached Narrative Renovating unfinished basement Yes >c No Plans Attached Roll -Sheet 6a.If New house and or addition to existind 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? ci, 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 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 Ta-OWNER AUTHORIZATION•TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT .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.N,VS \-teir L e,t( , as Owner/Authorized Agent hereby declare that the statements rind information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penaltie of perjury. eLS(--or \Air ./ PJet Pdni Name 1 OPIVI� Signature •fiwnerly_ent Date r. SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: License Number Address Expiration Date Signature Telephone G/7 Jrzr .9. Registered 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 he,a one or two family dwelling,attached or detached structures accessory to such use and/or faint structures.A person who constructs 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 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,duringand 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 perfonn work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with de State Building Code,City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature b 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: loot wesir,cr„Pl n c, Ftcncrcc- The debris will be transported by: O W h—. The debris will be received by: 'iAI k e y KCjc-Orn Building permit number: Name of Permit Applicant on nst c r r l McN4e1 200,0-1-- Date 0OCTDate Signat o ermit Applicant .\ The Commonwealth of Massachusetts �a Department of Industrial Accidents a Office of Investigations I Congress Street,Suite 10/i MIME Boston,MI 02114-2017 IL _,. www.ntass.gov/diff 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.❑ 1 am a employer with iiii_ 4. ❑ I am a general contractor and I 6. j New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g and have workers' El Demolition working for me in employeesany capacity. insurances 9. ❑ Building addition [Noworkers' camp.insurance comp. required] 5. ❑ We are a corporation and its 20-❑ 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 MGL 12 ❑ Roof repairs insurance required.] t C. 152, §1(4),and we have no employees. [No workers' l3.[] 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 arc doing all work and then hire outside contractors must submit a new affidavit indicating such. reonlractors 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. tithe sub-contractors have employees,they must provide Iheir workers'comp.policy number. /am an employer that is providing workers'compensation insurance for my employees. Be/ow is the policy and job site information. Insurance Company Name: Policy it 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 ofNMGL c. 152 can lead to the imposition ofcriminal penalties ofa 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 certft under the pains and penalties of perjury that the information provided above is true and correct Signature: Dater _.. Phone#: QCi2 -s 22- .2}a,13 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#: • Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written" An employer is defined as"an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer" MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for continuation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should he returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information (if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE Revised 7-2013 Fax # 617-727-7749 www.mass.gov/dia 3 2- City City of Northampton 4' ' Massachusetts C. 111'.: DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building J' W Northampton, MA 01060 rITV TO 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, G11 r15t-rprt0\ Meyer 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 to ze ( tb Address of work location t crt5 v.re bWWo me zn ecti Ft silence, ka 010b2