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11A-023 32 UPLAND RD BP-2021-0026 GIs#: COMMONWEALTH OF MASSACHUSETTS Maj.-Block: l 1A-023 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buifding DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:ADDITION BUILDING PERMIT Permit# BP-2021-0026 Project# JS-2020-002129 Est.Cost: $73000.00 Fee: $474.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HorneoWner as Contractor Lot Size(sq.ft.): 14853.96 Owner: RONDINA DAVID C Zoning:URA(100)/ Applicant: RONDINA DAVID C AT:- 32 UPLAND RD Applicant Address: Phone: Insurance: 32 UPLAND RD LEEDSMA01053 ISSUED ON.711012020 0:00:00 TO PERFORM THE FOLLOWING WORK ADDING 2ND FLOOR 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 7/10/2020 0:00:00 $474.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-11272 Louis Hasbrouck—Building Commissioner Z V K File#BP-2021-0026 APPLICANT/CONTACT PERSON RONDINA DAVID C&TRINE F ADDRESS/PHONE 32 UPLAND RD LEEDS PROPERTY LOCATION 32 UPLAND RD MAP I IA PARCEL 023 001 ZONE URA000)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED RED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: ADDING 2ND FLOOR 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 IN ORMATION 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 SewerAvailability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street CommissionPermit DPW Storm Water Management Demolition Delay � `710 as Si nature,of Building Oficial JU 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. Department use only City of Northampt K �ta US,of Pert„it Building Depart. entEll CutlDrivewayP�xmtf�r � x � 212 Main Street W�epllcAvatlabliRoom100 ' el'Av tlabilttyy F T - Northampton, MA 0 ans u a phone 413-587-1240 Fax 413- rr„ , Plot/S e Plan Teti��S.O Qt r Spe � '"' E�"�r� �� i '• ^. �m�; APPLICATION TO CONSTRUCT,ALTER, REPAIR, REiN OTMOL H A ONE OR TWO FAMILY DWELLING , SECTION 1 -SITE INFORMATION 1.1 Property Address: 2 ;L up� A,� This section to'be completed by.office L e e J'3 /�� Map /� Lot [/ Unit Zone Overtay'District' Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: no I�` D/szi D1 Ul IPP 4ih 4 3a vpte , Aga I CCJs QleJ17 Name(Print) Current Maili g Address: Telephone Signature 2.2 Authorized Agent: / .S �+►e Name(Print) Current Mailing Address: Signature Telephone SECTION 3=ESTIMATED ONSTRUCTION COSTS Item�/ Estimated Cost(Dollars)to be Official Use Only completed by permit applicant /1 Building l S,.57` ©Otq (a)Building Permit Fee ij 2. Electrical J �''`QED (b)Estimated Total Cost of d ) Construction from 6 3. Plumbing 3 vee Building Permit Fee 4. Mechanical (HVAC) ��` Q I F7 IV L/7V 5. Fire Protection % /1 ,9,09 6. Total=(1 +2+3+4+5)-/ QQQ Check Number / This Section For Official Use Only / h p, t Date Building-Permit.Nurnber: r� Z G Issued: Signature: TjArvu l� Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 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 _ Frontage Setbacks Front Side L: ' R: L:P� .�., R: 3 Rear Building Height " Bldg. Square Footage "'"" "' 0/0 Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location 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 0 DON'T KNOW 0 YES 0 IF YES: enter Book r Page and/or Document# �_..�.,,..__.._.._.. _� B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 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? YES 0 NO 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) Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[0] Other[p) Brief Description of Proposed ^ o _ r, Work: /'1 fi�� �(' !' 0,7 Siff /y �o L9'e !n.ri 3�LC�1 C-1 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet a&nq, sa.IfNew..ho sexand or' additon foexisting:housing,:<'corriplete.ttie#olloiiving:. a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms V c. Is there a garage attached? y t'r d. Proposed Square footage of new construction. l®®� Dimensions e. Number of stories? J � f f. Method of heating? 3 /Q � To�� 0 r c d a; /�'I-ireplaces; or Woodstoves Number of each g. Energy Conservation Compliance. a 1' Masscheck Energy Compliance form attached? YI O h. Type of construction tIJoO Con u e al i oa e i. Is construction within 100 ft.of wetlands? Yes _Y No. Is construction within 100 yr. floodplain Yes k 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, y / D / rP 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, Q v cC C /01 D N ^ C' Jas Own /Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to es f my knowledge and belief. Signed under the pains and penalties of perjury. Print Nr_a n / C�C Signature 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 e r9;I ectisfere Home: mpro�remenf`66Mractbr._..... _._. _ _.�. . k .< ._._. 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...... ❑ City of Northampton Massachusetts "O DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building �Ja ebb, " Northampton, MA 01060 rs •• �10�` 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, 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: P.,4 6)L9 r $i I TT c, QG�Gti 7io�Est. Cost: Q Address of Work: q-.7 C Rd L ee ds A14 Q Date of Permit Application: S DJ 0 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): Job under$1,000.00 Owner obtaining own (explain):LtA 11 dd 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 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 hereby apply for a building permit as the owner of the above property: dodL2 P C1 d C/ ate Owner Name and Signature I City of Northampton z Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building yJyb �� 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 1111, S 150A. The debris from construction work being performed at: (Please print h use number and street name) Is to be disposed of at: iA c 1�P iF �D "UtzA 1��, (Ple se print nam and locati n offacility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) C` Ay� 7/-j1 Signature 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. The Commonwealth of Massachusetts Department of Industrial Accidents a I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia «Yorkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. ApRlicant Information Q� m Please Print Le 'bl Name (Business/Organization/Individual): Q L i J C d t D I'� Address: a ®( rq City/State/Zip: s Phone#: /�� S�� 6 Are you an employer?Check the appropriate box: Type of project(required): 1.[—]I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'col insurance required.] 9. El Demolition 301 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10A,-#Building addition 4.F1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ p Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors 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. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name: Policy#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 MGL c. 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 and penalties of perjury that the information provided above is true and correct. Signature: c 1, !� Date: 7�T(2 Phone#: V/3 - ),rD t ` .9.) 6 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#: City of Northampton Massachusetts ' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building vy ti ria Northampton, MA 01060 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 s I, Ci 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 ' 0 d D Address of work location -�a t l p Z,rX 9 d