17c-120 (5) 34 SHEFFIELD LN BP-2017-0674
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 120 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: WATER DAMAGE BUILDING PERMIT
Permit# BP-2017-0674
Project# JS-2017-001102
Est. Cost: $18000.00
Fee: $117.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 38115.00 Owner: BENNET MARK
Zoning: URB(100)/ Applicant: BENNET MARK
AT: 34 SHEFFIELD LN
Applicant Address: Phone: Insurance:
34 SHEFFIELD LANE (413) 559-9240 O
FLORENCE ,MA01062 ISSUED ON:11/16/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIRING WATER DAMAGE, INSULATE &
FRAME BASEMENT WALLS, INSTALL DROP CEILING, INSTALL BASEBOARD HEAT
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 Occu.anc Si•nature:
FeeTvpe: Date Paid: Amount:
Building 11/16/2016 0:00:00 $117.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0674
APPLICANT/CONTACT PERSON BENNET MARK
ADDRESS/PHONE 34 SHEFFIELD LANE FLORENCE , (413)554-4240 Q
PROPERTY LOCATION 34 SHEFFIELD LN
MAP 17C PARCEL 120 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid */11 7
Building Permit Filt¢c(am ,�17T
Fee Paid
Tvpeof Construction: REPAIRING WATER I 'AGE,INSULATE&FRAME BASEMENT WALLS
INSTALL DROP CEILING, INSTALL BASEBOARD HEAT
New Constmction
Non Structural interior renovations
Addition to Existing
Ac sso Stru e
Building Plans Included:
Owner/Statement or License
3 sets of Plans/ Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFtIRMAT!ON 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 Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
D ol"
.00.1 VrVer
Signature of Building 0 Icial Date
Note: Issuance of a Zoning permit does not relieJe 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.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/SepticAvailability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 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
3LASMap Lot Unit
Plot v,, Inn-A- 0 (d b Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
Z1f Owner�^ of Record: ^',� -? c /y�
V- gx r k-- FD e✓�v.Y -J 4 ] h2..`�r}- ,�-c��(. Lr1rA(
Name(Print) Current MailingA°?d
L._ — _ TaE � 3 � Lid J
Sig - .re
2.2 Authorized Aaent:
Name(Punt) Current Mailing Address:
Signature Telephone
SECTION 8•ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed,/, by permit appNcant
1. Building IX l 5
, POC2 (a)Building Permit Fee
2. Electrical tcs_c (b)Estimated Total Cost of
l Construction from(6) _
3 Plumbing ' r rep Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection ,9 q 7 f
S. Total-ft +2+3+4+5) Ikeyea Check Number 5"tt6 r tI
This Section ForOfficialUse Only
Building Permit Number:__ Issu
Dated
Signature:
Building Commissioner/Inspector of uildings Date
NGS 14
PUT cF aclL.'%/:F
n
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to he filled in by
Building Depenmem
Lot Size
Frontage
Setbacks Front
Side I.: R: L: R:
Rear
Building Height
Bldg.Square Footage 7o
Open Space Footage
(Lot area minnn bldg&paved
parking)
H of Parking Spaces
Iill:
Homme&Loc:ahom
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW ® YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW ® YES O
IF YES: enter Book Page and/or Document
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES O NO El
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 ')
IF YES, describe size, type and location:
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? YE: O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 8*CONSTRUCTION SERVICES
8./ Licensed Construction Supervisor: Not Applicable ❑
flame or License Holder
License Number
Address Expiration Date
Signature Telephone
9.Repiatered Home Improvement Contractor: Not Applicable 0
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 0 No 0
11. - Home Owner Exemption
The current exemption for'homeowners"was extended to include Owner-occupied DweHings 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 actp
as supervisor.CMR 780, Sixth Edition Section 10835.1.
Definition of Homeowner Person(s)who own a parcel of land on which helshe resides or intends to reside,on which there
is,or is intended lo be,a one or two family dwelling,attached or detached cinctures 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 homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official.that he/she shall he
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required Dom 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 presents)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the Stale Building Code.Cit} of
Northampton Ordinances,State and Le Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature // A �(� '%'"'
SECTION S DESCRIPTION OF PROPOSER WORK(check all applicable)
New House n Addition Replaceme t indows Alteration(s) ❑� Roofing n
Or Doors I���
Accessory Bldg. ❑ Demolition 0 New Signs CD Decks C Siding CD Other(Q
Brief Description of Proposed / 1��� 1I11 I
Work'. LYN/enc.^ trG\wt ref 1,wtA.w_ "^µS1 t -5'kt it ro G4r�4 r 'P{a(1 F( 66-.r( kfR/
Alteration of existing bedroom Yes . No Adding new bedroom Yes Dc No
Attached Narrative Renovating unfinished basement '•r/ Yes No
Plans Attached Roll -Sheet
6a.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 Woodetoves 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
rFOR BUILDING PERMIT
I Co,✓ Cur - ry 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.
Signatureof Owner�pDate
it
v, u.r IZ_ 4 2y1,rwC.cr ,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 a'n'd//penalties of perjury. yy--
Mott 14 t✓1.„ve l '
Pant Name //{,
111111111,
Signatu -of• rP.f/Pgent Dale l I' l l
The Commonwealth of Massachusetts
Department of Industrial Accidents
)*ri y�� Office of Investigations
lam�g+, I Congress Street,Suite 100
"..."‘41
Boston,MA 02114-2017
• www.rnass.govldia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information �—}�
Please Print Legibly
Name[Business/Organization/Individual): UN/Ice-Li ?gin r/A—E / _
Address: -344- lrvt e ( eF ( o w qtr-r—e yn-ef_
p: fl c� InnAolo o ` _ g /0
CiTy/State/Zt one#: V( (� �S Z
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1
employees(full and/or part-time).'
have hired the sub-contractors 6. CI New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. Zda Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity, employees and have workers'
9. ❑ Building addition
[No workers comp.insurance comp.insurance?
required.] 5. CI We are a corporation and its 10.0 Electrical repairs or additions
1 am a homeowner doing all work officers have exercised their
11.0 Plumbing repairs or additions
vself. [No workers comp. right of exemption per MCL 12 ❑Root repairs
insurance required.]` c. 152.4114)-and ire have no
employees. [No xsorkcrs' 13.0 Other
comp. insurance required.]
'My applicant that checks box#1 must also fill out the section below showingtheir workers compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractorsmust submita new affidavit indicating such.
:Contractors 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 employees,they must provide their workers'comppolicy 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 1:or Sell-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 MG!.c. 152 can lead to the imposition of criminal penalties ofa
fine up to$1.500.00 and/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a line
of up to$250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify oder pains and penalties of perjuiyThr : the information provided above is true and correct.
St nature: -r- — Date: ] ( ( 11 ( (4
Phone 's: L'h ? 575. C— 91-46
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/l.icense#
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 M:
City of Northampton
41,
ae :o
Massachusetts s+ t,• '
A c �r yj DEPARTMENT OF BUILDING INSPECTIONS
P"im1N'-1' irg212 Main Street • Municipal Building • ,
Northampton, MA 01060 v tfr arS0
-NS PE^^OR
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/footi gs(before backfill). sonotube holes(before Dour), a rough building inspection
(before work is concealed) insulation ins tion (if rep it d 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 DFLAY the project until such time as the proper permits
and inspections are made yJ�
I, t fi.i� �th✓`'C I t 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 ( 1 4
Address of work location //,
c .jp ,_cL Lov_v`
rt LAN-Pt-
b ( BG2
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: 3 ''( cLtt-pc;t(o` \ c „ c flirt d rt . t C 7/14.cA G l 0 6
The debris will be transported by:
ItM r ,-k_ &' cv.,n.[ t T
The debris will be received by: U4ltit CZ-CC c l;
Building permit number:
Name of Permit Applicant v v"�
i
Date Signature of Permit Applicant
Insulate exterior walls w/ rigid foam
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