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23D-049 (8) 101 RIVERSIDE DR BP-2008-0748 GIS#: COMMONWEALTH. OF MASSACHUSETTS Map:Block: 23D-049 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED C3NTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2008-0748 Proiect n JS-2008-001163 Est. Cost: $45000.00 Fee: $225.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: STEPHEN DROSS 079160 Lot Size(sq. ft.): 14157.00 Owner: GOLDSTONE DOROTHY Zoning: LR.B Applicant: STEPHEN D ROSS AT: 101 RIVERSIDE DR Applicant Address: Phone: Insurance: 36 SERVICE CENTER RD _ -. (413) 584-1224 O R WC NORTHAMPTONMA01060 ISSUED ON:3/18/2008 0:00:00 TO PERFORM THE FOLLOW 1NG WORK:CONVERT BREEZEWAY INTO MUDROOM & STUD OUT BASEMENT POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough:5/2/001A House# Foundation: Drivewy Final: Final:), API 7-dg a k:1 Final: V349 1 �!! � Rough Frame: o rG 4:3 'c1 o 2' o$ L0u j S CO verz) Gas: Fire Department Fireplace/Chimney: Loll/< &MENr 0l< o4046 Rough: Oil: Insulation: �� F'uial°—7�g �, Smoke: Final: (9i<' 7-8-Q g -- 4-1 THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGUL IONS f? Certificate of Occupanc �i Signature: ���'i���4�' FeeTvpe: Date Paid: Amount: Building 31 18/2008 0:00:00 $225.00273 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 7/3/)e s File#BP-2008-0748 ' APPLICANT/CONTACT PERSON STEPHEN D ROSS ADDRESS/PHONE 36 SERVICE CENTER RD NORTHAMPTON (413)584-1224() PROPERTY LOCATION 101 RIVERSIDE DR MAP 23D PARCEL 049 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out an3 Fee Paid / r Typeof Construction: CONVERT BREEZEWAY INTO MUDROOM&STUD OUT BASEMENT New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 079160 3 sets of Plans/Plot Plan frlieV( 4/ 11244( C THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: pproved 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 _,J7al� Signature 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. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/VVell 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 Map Lot p, zoos Unit Zone Overlay District Elm St. District CB"bistrict SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Wt. -a//5 v�0 �� e s-to a /Dg--/ p7 4- Name ' nt) Current Mailing Address: / //q Telephone Signature 2.2 Authorized Agent: /� 7 ` ' - i �`��` 1 —cr. J t(�U �✓4.�7`'� le f�H l3n�Q 7-cr�i Name( int) Current Mailing Address: igna a Te ephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building GG 'Al (a) Building Permit Fee 2. Electrical �/ G� (b) Estimated Total Cost of ea, Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 6 /OO&. iv 5. Fire Protection 1 6. Total =(1 +2+ 3+4+5) y Udo, Check Number 2 T'aas 75 ' - This Section For Official Use Only Date Building Permit Number: Issued Signature: Building Commissioner/Inspector of Buildings Date pira)212-+ 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 14136 square feet 14136 square feet Frontage 152'/186' 152'/186' Setbacks Front 11' 11' Zoe.) Side L:,40' R: 11' L:40' R: 11 1 Rear 40' 40' ZO Building Height 25 25 Bldg.Square Footage 2585 18 % 2825 20% Open Space Footage �,(��i-1 (Lot area minus bldg&paved 104E i 74 102E 72% ww parking) /Dy7( /V 2?Ce #of Parking Spaces 2 2 Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW Q YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW O YES IF YES: enter Book [ Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW O YES 0 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 Q 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 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 Q 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) Roofing i l Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [EJ Siding [D] Other[D] Brief Desc i tion of Propose / / Work: 24 5=•-, K �S'71U d 644 tt , ✓Gt Or-c w41k Alteration of existing bedroom Yes No Adding new bedroom Yes G' No Attached Narrative Renovating unfinished basement J Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following: 1, 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, 30r0 _ (9OZ>s/ ?Y)1_ , as Owner of the subject property here authorize 5V-'C kve- i> 01 act? my behalf, i II matters lative to work authorized by this building permit application. l(na of v�itt" Date I, S14G /•ct--, - "S' , as Owner/Authorized Agent hereby' eclare 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. tZof 5 Print Nan>z_e_e_ -7/2_17;ie Signalgre of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ID Name of License Holder: c� 4.64 - P. f et 5- C 74 ( Q License Number 3 4 S-��v;c ��H �.�✓ I �l/�e y/z /' Address Expir ion Date V/ 3 5'—gtf-- / ZZy Signal Telephone 9.Registered Home Improvement Contractor: Not Applicable�j 0 cif 9 Corn bl nv Name Registration Number e ,/70,1910 rt. Address Expir4tion Date Telephone /z 'T 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 buildi g permit. Signed Affidavit Attached Yes 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 ' , �� D K��� '. ~~. - _ .., : 4401nio , - '........ 4..... , _ , , .""*".6.4....................-.....--,... .... 4410: 7 'AP At ' 44re 4. 74.,, _ "It.Apir - - 4 ,,0 AP .., - , .. - * - . 11 64_ 5,' a • • . r,e. '' 4 - t , .- o - : .. ''' 1161.-67•Ii• • 'ff• ',,- 1•• '• •2.4 ' 4. 0 '' b' . A' . 111.,1 P.40' 'A, II',,-...II k,„.,,t . "-' • . 4 •' ... ,,,. 0,•.,‘ 467 Ali ... '. 4. A. 41Ak.4" qr i '4' lir ir w 4,*me t• # # 4' ' ”i, • -') .:* 4% ' 4,.46-4'4."4'.4" .104.440. ta.•4 • 446. 416. R III I.I.A 13 Ifr ..' 11.,,,, -'• .,, ,4 i, 4 . • • ' ' 'P 4P • ' 10 410'.44'. II _ , 4, 1 412.-41i4; 2 1 _ .„.• * • ;.,; 4„, -6--40'4b744...-AA'r 1‘-•".'4 ,...4,,:is rill!..... v.' ,• • • • * • !!! _ ,,,,.__. . ,•4,1: ' 4 . --4., 44, 44, my Nor 44. 414. .1- 4 4b 4b 4 4b A A - I , - -'-'.01•Mr. ei 1 " 4A, --3 r ' . A A ' / _ is , ... .0 , __ -—--- .... ,... __- . .,. - _. 4 —--- ___••••__.4ur4_4,44444A_._r _ ----....---- .....7 , 1 _ , _ , _ ,, . , .— ,, , ie isi _ .._ _ __. . — _____ _. , , _ _ _ _ .. ,,.., ......_ , __ NM+,'iii - , ------ r- • . - , I '' i ' 1•1 0 1../.'ir,Crl 19 ht k.1,-co\) --a ...,..._ ,,.. „,.....„ ,... ,„ irr 0.10. ' v., . r ,,„4- , s . ' t , } , „,h.: _,,,,,.......__,..r. - 14',-.4 ,,,,.; ir • f ..:11;0. ‘ 4(2i- —e7' q il I — crgnovi 3< 3 oi... .),--y/Y\ '. ' -.. A • . mgt. to%,.., .... . . 4..,, t___: _ 41.e. •,-.1, . , -------, - - - - . . . _ _ . _ _al• -....., :,•.... . • , • , ..-.4...••„,,. -- , .. , iplit;4i 4 4 a t• .1 A2 iv ./.;001,1A1Witt;-•A'..- ,%. ' A: i; / .eif,,„„ge - ' ' i . „oildriP1 't ' \ , ; asif A l d 0, - .. 1 iit• -,..-::::- g-e(DF OvEZ 1Z,2EEZ,Ew, Y AV Dv Li) UkL� �ot� .. ,drr► �C 15 T I N T I,U C.4T 1 0 t..1 f0.,„..,,,L' - _ -,7 f tr _, ::: _ 440,...41111 rr _._ _ 4 • `l '',0 r " t kw 4 '} • 4,•i-Ir _-� i `� w .- 4 .<" — � • c ;,�t�lw r,,,,, -" air wT,,c , • o- a•,�,lge",+-r t. 'y i M` ,,. ti s 4, t 3 .....wv. .v.c I nrvI rdyc. I UI I /YYYY ACORD. CERTIFICATE OF LIABILITY INSURANCE CSR SF ) CO NSA SD D DATE(MM/DD)MMIDD 7/02 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION IRM Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Barry M. Stephens, CPCU HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 75 North Main St.-P 0 Box 564 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. East Longmeadow MA 01028 Phone:413-759-0010 Fax:413-759-0017 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Central InStlrlltlCe Companies INSURER B: OneBeacon Insurance Construct Associates, Inc. )NsuRERc 36 Service Center Road INSURERD Northampton MA 01060 INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IDISR Auu L POLICY NUMBER POLICY EFFtL LIVE POLICY EXPIRA PION LIMITS LTR NERD TYPE OF INSURANCE DATE(MM/DDM/) DATE(MMIDD/W) GENERAL LIABILITY EACH OCCURRENCE $500000 A X COMMERCIAL GENERAL LIABILITY CLP7834317 07/01/07 07/01/08 PRAE ISES(Ee ccuence) $100000 CLAIMS MADE X 1 OCCUR MED EXP(My one person) $5000 PERSONAL&ADV INJURY $500000 GENERAL AGGREGATE $1000000 GEM.AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $10 00 0 0 0 il POLICY n,PET n LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ^ANYAUTO 1E54491 07/01/07 07/01/08 (Ea accident) $1000000 B ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ H ANY AUTO OTHER THAN EA ACC $ AUTO ONLY. AGG $ EXCESSAIMBRELLA LIABILITY EACH OCCURRENCE $1000000 A X `OCCUR 1CLAIMSMADE CXS7834319 07/01/07 07/01/08 AGGREGATE $1000000 $ DEDUCTIBLE $ X RETENTION $0 $ • WORKERS COMPENSATION AND X TORY LIMITS ER A EMPLOYERS'LIABILITY WC783431817 07/01/07 07/01/08 E L.EACH ACCIDENT $500000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED9 E.I.DISEASE-EA EMPLOYEE $500000 If yes,describe under — SPECIAL PROVISIONS below E.L.DIGFASE-POLICY LIMIT $500000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION CONS 0 01 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Construct Associates, Inc. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENT'S OR 36 Service Center Road Northampton MA 01060 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE IRM Insurance Agency Inc. ACORD 25(2001/08) ©ACORD CORPORATION 1988 0,0,0 skic,„,..3,,7' S1 I ,;] yi Lcj, To: Northampton building dept. Fax: 587-1272 Fes: Stephen Ross Date: 3/14/08 Re. Goldstone covenant :4 Attn: Tony Patiiio • Urgent Er For ReviLow 0 Meese Comment RI Please Reply 0 Please Recycle they sent me let me know if this will meetthe needs or if they need to make any Stephenrose 36 SERVICE CENTER ROAD NORTHAMPTON,MA 01060 413 554 1224/FAX 413 584 7504 090TO 1.j ti01% ,'J 940±1;11194l cr.) i.'�,�,::i J0 idl0 802 ti L 0NW 11 F A II • NJ � RESTRICTIVE COVENANT TO THE BUILDING DEPARTMENT OF THE CITY OF NORTHAMPTON 1. Whereas., David Goldstone and Dorothy Goldstone on March 14,2008 have requested a permit to finish the basement; reconstruct the stairs to and finish the room over the garage; (the work); at 101 Riverside Drive, Florence/Northampton,Hampshire County, MA; and 2. Whereas, the Building Department seeks to ensure that the work is not being added as additional living or habitable space within this single family residence which would constitute a violation of the Zoning Ordinance of the City of Northampton. Now therefore said David Goldstone and Dorothy Goldstone, grant the following rest tiw zzwenaant 10 the City of Nor-A znpton_ 3. David Goldstone and Dorothy Goldstone specifically state that the finished basement and room over the garage shall be used for the purpose of storage,etc., and shall not be used as living or habitable space as presently defined in the State Building Code except as may be provided by the Northampton Zoning Board of Appeal, or by a change in law allowing same; at which time this restrictive covenant shall be null and void. 4. The inspector of building and his agents,on reasonable notice, are authorized to enter the premises at: 101 Riverside Drive,Northampton, MA for the purposes of ensuring compliance with this restrictive covenant. 5. This restrictive covenant shall run with the land and inure to the benefit of the inhabitants of the City of Northampton and shall apply to all successors,heirs and assigns to title. 6. The restrictive covenant applies to the premises identified as 101 Riverside Drive, Northampton,MA granted to David Goldstone and Dorothyldstone by Harold F. UUCL H\W • Duffy,Jr. and Kim A. Duffy,by a deed dated October 29,2007,and recorded at the Hampshire Registry of Deeds, book 9307,page 131. —___._ I C'r ! may rr� 800Z 1 l 8 bW 11 IN WrI NESS WHEREOF,the said David Goldstone and Dorothy Goldst ne heifeur to seta their hands and seals this day of March,2008. DAVID GOLDSTONE DOROTHY GOLDSTONE Commonwealth of Massachusetts Hampshire ss. Then personally appeared the above-named David Goldstone and Dorothy Goldstone,and acknowledged the foregoing instrument to be their free act and deed. Before me ,my Commission Expires: t � File#BP-2008-0748 APPLICANT/CONTACT PERSON STEPHEN D ROSS ADDRESS/PHONE 36 SERVICE CENTER RD NORTHAMPTON (413)584-1224 O PROPERT LOCA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid of Construction: CONVERT BREEZEWAY INTO MUDROOM&STUD OUT BASEMEN111111.11, ew ons Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 079160 3 sets of Plans/Plot Plan THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: pproved 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 Signature of Building Offi al 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 �(J ` tv of Northampton Status of Permit: (tom 8uillding Department Curb Cut/Drveway.Permit 212 Main Street Sewer/Septic Availability �1A 2QQ8 Room 100 Water/Well Availability MiNt Northam ten, MA 01060 Two Sets of Structural Plans '�.. phone41 r1587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify ACTION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE_INFORMATION � '"v 1.1 Property Address: This section to be completed by office - Map Lot Unit /d/ Zone Overlay District ElniSt.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone 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 3(:)/ )69°- (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fir=Protection ,le) 6. Total= (1 +2+3+4+5) :› [�'' Check Number U 79 I /�� eSection For Official Use Only Date Building Permit Number Issued: Signature: [3wlding.Commissioner/Inspector_dt iduilomgs Date * Section 4. ZONING I 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 r.._._--_ r-.-..._....w_........_.,-.__.__....._._. Lot Size .* w,,. ____ , - _ Frontage _.___._. ,. __ .. _.____ .._ _ Setbacks Front Side L:` R: ...._._.__ L: R:. Rear _ Building Height ___... _., Bldg. Square Footage _._...._. % ___ _:.._... Open Space Footage I % _._ (Lot area minus bldg&paved „, li _,. —`-'""" narking) #of Parking Spaces w "—_ 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 Q 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 Q 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 Q 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 coin on plan that will disturb over 1 acre? YES 0 NO 0 IF YES,then-a-Northampton Storm Water Manageme t-Peimitfrom the DPW is required. 4 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aoolicable) New House I j Addition ❑ Replacement Windows Aiteration(s) Roofing n Or Doors 0 Accessory Bldg. ❑ I Demolition ❑ New Signs [El] Decks [L^L Siding [C; Other[MI Brief Description of Proposeddd . /� � lam` Work: i / I � Alteration of existing bedroom Yes No Adding new bedroom Yes Nc Attached Narrative Renovating unfinished basement Yes Nc Plans Attached Roil -Sheet ba. If New house and or addition to existing housino. complete the followinc . 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. cf 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 Ne. I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHOP.IZ&TION-TO BE COMPLETED WHEN OWNERS-AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 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 , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best cf my knowledge and belief. Signed under the pains and penalties of perjury. Print Name Signature of Owner/A ragent mace IF SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Super/visor: Not Applicable ❑ Name of License Holder: License Number .ddress Expiration Date Signature Telepncne t_'Registered Home Improvement Contractor: Not Applicable 0 ;omnanv Name Registration Number ddress Expiration Date Telephone ECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§;25C(6)) 'orkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result the denial of the issuance of the building permit.• gned Affidavit Attached Yes 0 No 0 11.Y 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 ander 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 allIP II • . The Commonwealth of Massachusetts Department of Industrial Accidents = Office of Investigations 600 Washington Street Boston, MA 02111 �- , www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers ADplicant Information Please Print Legibly Na;ne (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑Newconstruction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9 ❑Builrli addition [No workers' comp. insurance comp. insurance.x required.] �• 0 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.❑Plumbing repairs or additions myself. [_'v o workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no 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. 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 nanr of the subcontractors and state whether or not those entities have employees. If the sub-contactors have employer,they must provide their workers'comp.policy number. lam 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 S250.00 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 coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: iOfficial 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. CityiTown CIerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: 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 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 I, 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 Address of work location