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12C-072 (3) 12 MARY JANE LN BP-2019-1184 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 12C-072 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categorv:Door Replacement BUILDING PERMIT permit ft BP-2019-1184 Proiect# JS-2019-001922 Est.Cost:$1000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group Homeowner as Contractor_ Lot Size(sa R.): 10715.76 Owner., DIAS JESSICA zonitur Rl(I00)1URA(I00)/WSP(I00N Applicant., DIAS JESSICA AT: 12 MARY JANE LN Applicant Address, Phone: Insurance: 12 MARY JANE LANE FLORENCEMA01062 ISSUED ON:4/24/2019 0.00:00 TO PERFORM THE FOLLOWING WORKINSTALL SLIDING GLASS DOOR IN KITCHEN AND ROOF REPAIRS 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: QW 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 Occuoancv Sienature: FeeTYDe: Date Paid: Amount: Building 4124/20190:00:00 $65.00 212 Main Street,Phone(413)587-1240,Pax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2019-1184 APPLICANT/CONTACT PERSON DIAS JESSICA ADDRESS/PHONE 12 MARY JANE LANE FLORENCE PROPERTY LOCATION 12 MARY JANE LN MAP 12C PARCEL 072 001 ZONE RI(100)/URA(100)/WSP(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST �NCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid l Building Permit Filled out Fee Paid Type fConstruction: INSTALL SLIDING GLASS DOOR IN KITCHEN AND ROOF REPAIRS New Construction Non Structural mteriorrenovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 Demolition Delay 4-Z+Zai9 Sigr,Vwe 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 MGL 40A.Contact Office of Planning&Development for more information. hXY pp City of No hampimECEIVE "� MF«� z * a'a �'�",�� "'� a�usnrh'�' Building D Part a ant 212 Mai Str at T �" Room 100 APA 2 4 2019 Northampton MA 01060 phone 413-587-1240 Fan `QI. SPECT ,.. ' nonTHAWTnv IAAotes APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Property Address: This ssRio—nli be comWetsd i yj ce 12. Ma1j lww. Lin Map lotC Lot 0173 UnIt F--bQvtcr MA p10b2— zone Overlay District Mee SSL DistricL, CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED ilGENT 2.1 Owner of Record: r y L�Gs£-t Cc D40�s 1Z GL LJ f f!NC'o r1 ,, MA c)io(, Name(Print) GeentwmgVres ,,, Signature 2.2 Authorized Anent: Name(PdnQ Cuvenl Mellkg Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only comoleted by permit applicant 1. BuildingIl O O0 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. PlumbiN Building Permit Fes 4. Mechanical(HVAC) LV) 5. Fire Protection a lJ 6. Total=(1 +2+3+4+5) .p1000� Check Number This Section For Olflclal Use Only Building Pennit Number: Date Issued: p Signature: Building CommissbneAnspector of Buildings Date (esSjICl. dUhA @ W,04 . (,OM EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incompte Information le Existing Proposed Required by Zoning This column to be filbd in by Bou Unix nepemncnt Lot Size Frontage --- --- Setbacks Front Side L w R:l— .i' L:If_ R Rear __.. L_ Building Height "' -- -- Bldg. Square Footage �- % Open Space Footage ._, % (Lot area minus bldg&paved '.... -- kin N of Parkin Spaces '- --' Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW W YES O IF YES, date issued:', IF YES: Was the permit recorded at the Re istry 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 O 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 O , Date Issued: C. Do any signs exist on the property? YES O NO 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 B`C IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,gradingwvation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ( NO IF YES,than a Northampton Storm Water Management Permit from the DPW is required. SECTION S-DESCRIEM OF PROPOSED WORK lchaek all applicable) ,mow New House ❑ Addition ❑ Replacemen(�V Intlows Alterations) O Roofing 1 x 1 Or Doors �lJ �"C Accessory Bldg. ❑ Demolition ❑ New Signs [D] Docks fq Siding t[3] Other[I7] Brief Description of Proposed Work: " n VV3 9. Alteration of existing bedroom es_No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet eii#I-AA, :, R `'. ...., VbUY)MI.: 1�tl'Nli0lbwltlO: a. Use of building :One Family Two Family\ Other b. Number of rooms in each family unit: b (Intl wl#L Lumber of Bathrooms c. Is there a garage attached? V/ / d. Proposed Square footage of new construction. 010._ Dimensions e. Number of stories? t Method of heating? 54L.5 Fireplaces or Woodstoves "10, Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of constructionm- ICl'L.. L 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 M'OPTI hn82MPn k. Will building conform to the Building and Zoning regulations? ✓ Yes No. I. Septic Tank_ City Sewer ✓ Private well_ City water Supply I/ SECTION 70.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 T I, �PSS-/.� dT1 as OwnerlAuthonzed 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. J Csst c-a- D'II ce C Print Name 64 23 � Signature of Ovmerl ant Date SECTION 8.CONSTRUCTION SERVICES 81 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expimlion Data Signature Telephone IL C Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10.11YORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,$25C(8)) 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...... ❑ City of Northampton Massachusetts -s- ti � DEPARTt4;NT OF BUILDING INSPECTIONS 212 Gain Street • I icipal Building Worths ton, IM 01060 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 Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovabon, 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: 1 hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): _Job ander$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 NOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.C.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: 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 hereb apply for a building permit as the owner of the above property: 11/2-qll 9 A Date O n Name and Signature The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Suite 100 Boston, MA 02114-2017 www.mass.gov/dia WWorkers'Compensation Insurance Affidavit;Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly i Name(Raineex/orgaAni�,ar�nr"✓I'n'ai.ianaq: Address: 2 rvft.-laK-�f _r.IQ City/State/Zip: C LM 0104-Phone ft: 41 218 (063 2- Are you av employer?Check the approprute box: Type of project(required): I.[]I am a employer with employeas(full and/or past-time).' 7. ❑New construction 2❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling �..r(any capacity.No worked comp.insurance required.] I.IX l i am a homeowner doingall workm IE No workers'mm m Imd. 9. El Demolition �[ myself,[ p.insurance qu ]' ❑I start homeowner and will bo hirin unetem to conduct all work onmy rt I will 10 E]Building addition 4. g con y prop¢ y en etre that an conuaaorsdmer have workers compensation ireurance or ere sole 11.❑Electrical repairs or additions propdet—with no employees. 12.❑Plumbing repairs or additions 5 I am a general cono-dor and l have heredthe aWrommemas listed on the atmehed sheet, 13.�RooC repairs These sub-cormenrots have employees and have workers'rump.insuranee.t 6.❑We are aam matmeaad es arrears have exenkad their rightef,oma im per Min,a, 14.[]Other 152,§1(4),and we have no employes.(No workers'comp.iammnce required.I `Any aPPlicant Nat checks box pl mus[also fill out Ne sation below sM1owing Ncir workcrf compensation policy irm min[inn. Homeowners who submit this atHdave indicating they ere doing all work and than him onside wat.,t.m ares,submit a new aRrdi vil indicating such lCradractors that check Nis box most attached as additional had showing the name of the sub-conuacmrs and state whether or not those entities have employees. If the subconwcess 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 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 a 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 under the �pains andpenafties ofperjury that the information provided above is true and correct t//1F—H.(N Simamm Date' T�2N�Iq phone 4: N 278 • 6fo3'2- official use only. Do not write in this area,to be completed by city or town of iciaL 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#: City of Northampton Massachusetts :` 4s DEPART OF BOLLDLMG TXSPSCTLONS �p 212 Main Street a Municipal Building H IC Morthv ton, N 01060 Massachusetts Residential Building Code Section I IO R5.1.2 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 shall not be considered a homeowner. Section I IO.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 110.R5, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner 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 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 Annotated, you may be liable for person(s) you hire to perform work for you under this permit. City of Northampton Massachusetts (i) (0 DEPARTMENT OF BUILDING INSPECTIONS 212 Rain Street •Municipal Building Northampton, MA 01060 Debris 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. The debris from construction work being performed at: IZ Ma." TA,lae, 1j, R AA oloto2 (Please pri t h use number and street name) Is to be disposed of at: (Please print name and locatiorlpt facility) (3q),c%�p,p, „q/N\A 0100a- Or will be disposed of in a dum aster onsite rented or leased from: (Company Name and Address) Signatu a of Permit Applicant or Owner Date If,for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed.