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15B-038 (5) ' 1 01111111111111111111111111111.1 BP-2008-0684 GIS#: COMMONWEALTH OF MASSACHUSETTS 15B-038 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2008-0684 Project# JS-2008-001058 Est. Cost: $15000.00 Fee: $75.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: CHRISTOPHER LESIEUR 078200 Lot Size(sq. ft.): 119790.00 Owner: RAFHUMATHAN KARTHIK Zoning:URA Applicant: CHRISTOPHER LESIEUR AT: 2 SHEPARDS HOLLOW - 228 CHESTERFIELD RD Applicant Address: Phone: Insurance: 198 BRAINERD ST (413) 374-4737 O SOUTH HADLEYMA01075 ISSUED ON:2/8/2008 0:00:00 TO PERFORM THE FOLLOWING WORK:CONSTRUCT NEW 2ND FLR BATH 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 2/8/2008 0:00:00 $75.001236 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo File#BP-2008-0684 APPLICANT/CONTACT PERSON CHRISTOPHER LESIEUR ADDRESS/PHONE 198 BRAINERD ST SOUTH HADLEY (413)374-4737() PROPERTY LOCATION 2 SHEPARDS HOLLOW-228 CHESTERFIELD RD MAP 15B PARCEL 038 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ram Fee Paid ig436 f ?V Typeof Construction: CONSTRUCT NEW 2ND FLR BATH New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 078200 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IMI464ATION 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 -"LA" 0 efo Signature of Buil m Official Date 1 g g 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. e , ' Department use only _ _-E' _of Northampton Status of Permit: C Q _ __ V C BO ing Department Curb Cut/Driveway Permit ..7—.) ,jp --9 1 Main Street Sewer/Septic Availability i 1 tT oom 100 Water/Weil Availability ' FEB — 5 2OOJortttaa�'Ipton, MA 01060 Two Sets of Structural Plans phone 413-T7-1 40 Fax 413-587-1272 Plot/Site Plans Other SpecifyI APP 4lO"td t pC ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: (� #-o� S474-40.f DS X Lid /•/ Map 1 6'5 Lot ibp Unit 4 4i 727,9, Zone Overlay District a g A.0 Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �,� <l/,t 4'I iAC ,4a419 y4.t/ G2w���E4a el2 c /L ice" Name(Print) ,'� Curr tM in d ss: ' 1►'ttCC,.. a ephone Signature 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 /G, ,e p (a)Building Permit Fee 2. Electrical jr6 O (b) Estimated Total Cost of 00 Construction from (6) 3. Plumbing $ v�p o Building Permit Fee r 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number / 34p oir-x-___. This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector ofBuTdings Date 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 I Side L: R: _. L: .,....„...:,._ R: Rear -- Building Height _._.„..,„. Bldg. Square Footage 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 0 DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 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 0 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 n Addition ❑ Replacement Windows Alteration(s)ep<r Roofing 71 Or Doors [l Accessory Bldg. ❑ Demolition ❑ New Signs [GI] Decks [E] Siding [O] Other[O] Brief Description of Proposed D Work: 4/i/�c.! r�.,i ' '4ii, g,97".' Alteration of existing bedroom // Yes No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes /< No Plans Attached Roll -Sheet 6a. If New house and or addition t istinq 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 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,_A A, f 411i444 l',49-A/ as Owner of the subject property hereby authorize 1FSiE1.,,C. ,QSS, to act on behalf, in all matters relative to work authorized by this building permit application. ignature of Owner Date f I, vni Z,1 �! X/Ev2 , as Owner/Authorized Age t ereby declare that th statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed n er the pains and penaltie of perju ,p--- r%4i 2 Print Nam / Signature of 0 r/Age ate SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction /Supervisor: Not Applicable 0 Name of License Holder: [ h'vS7 7 �� ‘4J/44,1V. � � Q/U�� License Number a /7 7,�, ,� �y rr� CS 0)8 ©0 Address Expiration Date Signs ure Telephone /6A 0 9.Registered Home Improvement Contractor Nut Applicable 0 C he/Eve X / 6-SC2 /+,SG0D Company Name nn Registration Number AZ78 461e/*mic"a✓ (r. t;4,4 )n•9, a/o9z-- S � . 01 ddress Expir ion e Telephone 7/3 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 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 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. 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. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature - , _ _ vepartment of inaustriat Acciaents `- x,--- =' Office of Investigations 600 Washington Street rX` '� Boston, MA 02111 � 4 ...r www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ( ' cjezz 7 4, _ /� Address: /YY �/-/j).N.cdt- d c.Jjn -. City/State/Zip: °XS—Phone ft: y/3� 25 7 Are you an employer?.Check the appropriate box: Type of project(required): 1.❑ I am a em to er with 4. ❑ I am a general contractor and I p y employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.� listed on the attached sheet. 7. Remodeling I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition working. for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing.all work officers have exercised their 11.0 Plumbing repairs or additions [Nocomp.myself workers' right of exemption per MGL y c. 152, 14 , and we have no 12.❑.Roof repairs insurance required.] t § ( ) 13.❑ Other 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. "Ho meowners 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 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance overage verification. I do hereby certify- er-t • alties-f-perju-ry-that-the information provided above is true and correct Signature: /I� _ Date J- ..16 i5.4g y� Phone#: S. �5� - S/J 3 7 _ __:..--OfficiaL use.zeanLy_ D_o ol_write.nshis area to beLcompleted by city-or town ficial City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector 6. Other , Contact Person: Phone#: .r.,,, ,i, DEP.'??TME.NT Or EUTLDL'\G L'SPEC:TiONS _____i_( I N E P CTO 212 Main Sues. • itif u:zic ipal E aiiC lng `s,� �%' 1\iorlaampr.on,MA 01060 HOME OWNER EXEMTTJON ACKNOWLEDGEMENT I The State of Massachusetts allows the homeowner the right under 780CINIR 103.3.4 to act az rislher construction sup':: 'sor. 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 atwefli g atached or detached structures accessory to such use and/or Sara structures. A personc�-ho constructs more than one home in a two-year period shall not be considered a home owner." The bu di -4epar lent for the City of North mpton wants any per sons)who seek to use the note 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 bac ll). . sonotube boles (before Hour). a rough building inspection(before work is • concealed.insulation inspection (ifrecuired) anda finn1 built i, .inspection. The building deparpnent requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until- Work -be-insof.,-tom _ - 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 proper until such time as the proper permits and inspections are made 1, ________ understand the above. (some owner Lresident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me_ y 2 Date " Addr-ess_of work _.— -- location _ _ __- 1 1 } - } r 1 A t } ' _ - f r t } ' - 1 I f r } $ - } 1 r - 1 1 1 _ � - -f f I 1 - 1 1 1 - r + 1 A } 1 1 1 ,// I r r - - 1 - , } r f A 4 c............._, . , 1 1 .....,,,,, 1 . ..r. . 4 o H i J , _ . . _ . . _ . r . 1 � _ , • J I -Y