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11C-067 87 FLORENCE ST BP-2018-1074 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 1 IC-067 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Categorv:Bath reno BUILDING PERMIT Permit BP-2018-1074 Project# JS-2018-001937 Est.Cost: $15000.00 Fee: $90.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License. Use Group: Homeowner as Contractor_ Lot Size(sp.ft): 20908.80 Owner: PALMER DONALD R&BONNIE C zoning:URA(100)/ Applicant. PALMER DONALD R & BONNIE C AT: 87 FLORENCE ST Applicant Address: Phone: Insurance: LEEDSMA01053 ISSUED ON:411912018 0:00.00 TO PERFORM THE FOLLOWING WORK.1 ST FLOOR BATH RENO - NEW SHOWER AND FLOORING 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: OII: 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 4/19/2018 0:00:00 $90.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2018-1074 � l it r 'I a�'"• '�� APPLICANT/CONTACT PERSON PALMER DONALD R&BONNIE Cy ADDRESS/PHONE LEEDS 1 PROPERTY LOCATION 87 FLORENCE ST MAP I IC PARCEL 067 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ^ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid n n Building Permit Filled out Fee Paid Tvmeof Construction' IST FLOOR BATH RENO-NEW SHOWER AND FLOORING 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 emolition Delay y lax, -Sigria-tt of Building OfficiaV 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. City of Northampton tatusof Permit. ` N ,6 l Building Department 212 Main StreetcA " Room 100 Water T3` Availsbif "r- 6-Ir Northampton, MA 01060 `SetsOf �.A phone 413-587-1240 Fax 413-587-1272 ,F APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property AddressThis section to be completed by office � LDIPCNLt � 57- Map IC-Lot 0 C ) Unit L 5- 3 zone Overlay District Elm St.DistriIX CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: Doi✓AiD r iaNiv)I= /jgt,MEk $? F[o�H CF' ST LE£O% CJlOS3 NanSe1prin[) // Current Mailing Address�Si '.Y/ ,nature 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 .I b0U (a)Building Permit Fee 2. Electrical `7 (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 1��664nn 6. Total=(1 +2+3+4+5) f3-Q OO Check Number JN� This Section For Official Use Only Building Permit Number: Date Issued: Signature: ��j 5'4 Building Co issionedlnspeotor of Buildings Data 0 EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Complete J. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column m be filled in by Building Depanmeut Lot Size Frontage Setbacks Front Side L R L' - .. R. Rear Building Height Bldg. Square Footage Open Space Footage % J,et area minus bldg&paved polemic #ofParking Spaces Fill: (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:. IF YES: Was the permit recorded at the Ron;istrI of Deeds? NO O DONT KNOW O YES O IF YES: enter Book '. Page and/or Document#I B. Does the site contain a brook, body of water or wetlands? NO © DON'T KNOW Q YES 0 IF YES, has a permit been or need to be obta tied from the Conservation Commission? Needs to be obtained © Obtained ® , Date Issued C. Do any signs exist on the property? YES 0 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 © 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 partof a common plan that will disturb over 1 acre? YES © NO IF YES,then a Northampton Storm Water Managame nt Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows AReration(s) © Roofing or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs 10] Decks [p Siding[01 Other[p] Brief Description gq � roposed j //11 Work: Pia Th lGno ✓cl1rOn �St��AOt tled ' SItO U'C.f -J 1'�00f Alteration of existing bedroom_Yes 1/No Adding new bedroom Yes Vl� No Attached Narrative Renovating unfinished basement Yes V/ No Plans Attached Roll -Sheet Ga. N New house and or addition to existina housing, complete the followinw 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? T 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• fJO,�N1 X17 � ���� , asOwner/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. GL�✓✓ficb � �/3Crr� Pnnt Name $/9n ture of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9.Registered Nome lmuravement Contractor: Not Applicable ❑ Company Name Registration Number Address Expiration Date Telmph,me SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit must be completed and si bmitted 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...... ❑ City of Northampton Massachusetts z DEPABTIIDYT OF BUILDING INSPECTIONS 212 Main Street • Muni<ipal avileing Ztr %b Northampton, Mx 01060 a�A AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation ("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes, a contractor must be registered as a Home Irnprovement Contractor("HIC"). M.G.L. Chapter 142A requires that the "reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered. Type of Work: Est. Cost: Address of Work: Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): _Sob under$1,000.00 _Owner obtaining own permit(explain): _Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBH.ITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties ofpedury: I hereby apply for a building permit as the agent of the owner: Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: pp / Date Owner Name and Signature City of Northampton IQdS .dCYll5Etf4 � c s DEPARTMENT OF EU.WING INSPECTIONS -� 212 Main Ser t • Nvnieipal Building N th ptm., M 01060 Massachusetts Residential Building Code Section I IO-R5.1.2 Homeowner: Person (s) who own a parcel of lard 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 strictures. A person who constructs more than one home in a two-year period shall not be eonsidercd a homeowner. Section 110.R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR I 1 O.R5, pi ovided that if a homeowner engages a person(s) for hire to do such work, then such homeowrer shall act as supervisor. 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 present. 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 injim s not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable or person(s) you hire to perform work for you under this permit. 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: Z`1 F)4 (-ence s� The debris will be transported by: Roi e— Clark The debris will be received by: Building permit number: Name of Permit Applicant A-01d % PO44 )r- - )r- �` Date Signature of Permit Applicant The Commonwealth of Massachusetts Department oflndustrialAccidents 1 1 Congress Street,Suite 100 Boston,MA 02114-1017 www.mass.gov/dia 11 orkers'Compensation Insurance Affidavit:Budders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lealibly Name(Business/Organization/Individual): }')ey3 -a Address 8 7 j4a eez✓,'t 5� City,'SEIC/Zip: -/il otos e3 Phone _;7 e-,1 Are you an employer?Check the appropriate boz: Type of project(required): 1.❑I am a employ, on creloyees(full-do,p.hose)" 7. ❑New constmetl0n 2.�Iamasolepmpn'e[or or partnership mdhave no employees woddvg fmmew $. E]Remodeling they capaaty.[No workers'comp_Wturance required] 3❑I a homeowner doing all work myself[No workcm'comp.Imurmce required.]N 9. ❑Demolition 4homeowner and will be biring contractors to conduct all work on my property. I will 10❑Building addition camme Nat an vemota tior conmer bove wkscompensation ieane,or are sok 11.❑Electrical repairs or additions pmpnetors with no employees. 12. Plumbing repairs or additions 5❑tame general coatlacha and t have hued the have women'co listed a the attached ghee[ 13.❑Roof repairs These mb-wnhacmrs have employee and beveworkers comp.insurmce_ fi.❑We sm,u uslomdon and its officers have c—rhuseldcurphe of exemption p,MGL c 14.❑Other 152,§1(4),and we have no employees [No workers'wmp,crooner required `Any In.that checks box#1 must also fill out the section below show.,Weir workerscompensation policy information. r Hom who submit this affidavit indicating the,are doing all work and Wen the o elide crourcrtors must submit a new affidavit concerns,such. tContractove that check this box must attached an additional these sheaving the time of the sub-convectors and state whether or not those entities have e nployees. Ifthe subcontractors have employees,they must provide thea workers comp.poley vumbn. I am an employer that is provi&ng workers'compeasadon insurance far my employees, Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins-Lic. #: 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 MGL e. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify Um ler thepains andpenalties ofperjury that the information provided above is true and correct Slenamre: Date' Phone 8-2-f 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 empicyers to provide workerscompensation 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,associaion n other legal entity,employing employees. However the owner of a dwelling house having not more than three spar[nems and who resides therein,or the occupant of the dwelling house of another who employs persons to do main mance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not I ecause of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every start 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"Ilelther thi commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work rotil 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 co rpled ily,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)namely,address(es)an I phone numbers)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limi_ed liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' con pensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this af.idar it may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application ford c permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarc ing the law or if you are required to obtain a workers' compensation policy,please call the Department at the turn>or 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 legi>ly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Iavestigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which wi I 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 named 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 yen,Where a home owner or citizen is obtaining a lice ise a permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.) said person s NOT required to complete this affidavit. The Department's address,telephone and fax number: The Con monwea:th of Massachusetts Department of H_dustrial Accidents I Congress S xeet, Suite 100 Boston, Mt,02114-2017 Tel. #617-727-4900 axt. 7406 or 1-877-MASSAFE Fax# 61 -727-7749 Revised 02-23-15 www.mx ss.gov/dia