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23D-079 (6) B 83 WARNER ST P-2005-0538 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23D-079 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2005-0538 Project# JS-2005-0706 Est. Cost: $4000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Andrew Church 104480 Lot Size(sq, ft.): 60984.00 Owner: LAPLANT NICOLE Zoning:URB Applicant: Andrew Church AT: 83 WARNER ST Applicant Address: Phone: Insurance: 184 Spring St (413) 586-0918 FLORENCEMA01062 ISSUED ON:11/2/04 0:00:00 TO PERFORM THE FOLLOWING WORK:REBUILD CHIMNEY & LINE SUPAFLU LINER 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: Fi ai:Smoke: 24,4 Final: © `/(�0s' THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATI N OF ANY OF ITS RULES AND REGULATIONS. �� '------ delVrere Certificate of Occupancy Si nature: FeeType: Receipt No: Date Paid: Check No: Amount: Building 11/2/04 0:00:00 2408 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo r ` Department use only �.�. _.-- City of Northampton Status of Permit 1�+ Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability NQv - 200 Room 100 Water/Well Availability �; Northampton, MA 01060 Two Sets of Structural Plans 413-587-1240 Fax 413-587-1272 Plot/Site Plans C3f 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 Unit a',3 2126 revue s TT District `i/� �� 7 Zone Overlay District ??di-Th o/P W Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: X N1Cole Lc;l avNi- A83 ac Sf floreice /`1 VtOD Name(Print) r Current Mailing Addr ss: G, X 444 TelephoneH1 - Signature 2.2 Authorized Accent: Name(Print) Currbnt Mailing Add ess: /e /97424.0ca..44;6 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection �y- 6. Total =(1 +2+3+4+ 5) �`jiG�v�'— Check Number ,[]j pl5--- This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date Section 4. ZONING All Informatibhh 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 1 Frontage E E Setbacks Front L—I Side L: R:r-----IL:' R: • Rear • Building Height 1 . Bldg. Square Footage 1 I i % r—� r-- i Open Space Footage (Lot area minus bldg&paved . • i j 1 i parking) #of Parking Spaces I Fill: , I' (volume,&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW it YES 0 " IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW * YES 0 1 IF YES: enter Book Page; 1 and/or Document# B. Does the site contain a brook, body of water or wetlands? NO EY DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 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 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,a vation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 ,- NO i 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 r7 Replacement Windows Alteration(s) n Roofing n Or Doors ED Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [D Siding[0] Other[El] Brief Descri io of Pr p sed // / / Work: /21 /� �J>? "� r6ri2- 5�`�i°�q�/ - /i!U c Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa:It<N eW,hOUS d or additIOf-xa_ez�stlnQ:�houstng:corimplete the::followin : 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, )( `v\Coe L.ck c.vt+ ,as Owner of the subject property /0 heerebyyauthorize )KI deirek to act on my behalf, in all afters relative to work authorized by this building permit application. g VIZ VA Ib 271 opt Signature of Owner Date - ------ - ----- C4I, j o"r Gt2 C! ,as Owner/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. c14nt> CAI r Print Name 1,51)PndtZ4A -C-2 Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES I 8.1 Licensed Construction/Suupery Supervisor: . �Y� w Not Applicable 0 Name of License Holder: F 1-724 1 4.' CA u r see ® 6 License Number _5"/° / 415 s we c /®,-five, Address �. ��/� Expiration Date dL z'ne'Lt) / / Signature Telephone e•ls re• orrre,m o. eme� attic ar ' <` �� ..�. x Not Applicable J (// ibey .S#Ue` . /c'9 O Company ame 1! Registratio Nu ber ,17/ ,j 57— /, 6- Address Expir ion 16 e rhi'edir--e' j /9" Telephone e'9' 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 J1 ' No 0 1 T , m ?Qx erE, emotion 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 su_pervisor.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 r 1 • „�,�c``:�4.„ �•.1�E (ri[i of �arf12Unlpfo11 — 1-_`i� ' E �Zcaa�ccllnsclle'vat'. , — -p- DEPARTMENT OP nUILDINc INSPPCr10NS 212 Main Street ' Municipal Building Nt Northampton, Mass. 01060 r` WORCER'S COM:PENSA`IION MSURANC.L AFFIDAVIT I, ___ �777,U'o7c'r,4-> ae-i r-C_---0C • (l i ccnscxd permi t i cc) \vlth a principal place of business/residence at: — --- t r-- o /or e,zcc (phone ) 7� rI none `.S�"� o (surf/city/st2icJ p) do hereby certify, under the palm and penalties of perjury, that ( ) I am an employer providing the following worker's compensation coverage for my employees wor dng on this job: • (Lasu-mc Comp:Lay) (Pelic:Nu- r) (Expiration Date) ( ) I am a sole proprietor, general contractor or homeowner(circle one) and have hired the conmactors listed below who have the following worker's compen_tadon policies: (Nome of Corr tcior) (Insuranc; Coinoall}'fPoUci Nu171liC:) (E\piranon Date) (Name of Coon-actor) (Insw-anc;- Compan -Po!ic-v Ntmc-r) (1-pinion Date) • (Name of Conuaeto;) ( asuranc: Company/Polio- Number) (Expirtion Date) (Name of Contractor)) (Insurance Company/Policy Nttmb:.r) (Expiration Daft) . (oa th oc d eCQtf acOaa:Y t O,OJu c tIIfOrt oo pC7asnSac to a.1.1 0oo7-_CArl) • - 1,. ....Lm a a sole proprietor and have no one woridng for me. ( ) I am-a home owner performing all the work myself. NOTE:plesc be cw re the'A a bccocoveoc.3 wbo employ pe-roat to do r-, •.-v, c—.r,.o -rr.ta.•uric oa a d..c11_C of one mote th_a t oe=is in u'ich the bocnoowoc rid or on the grou.otS xppurtco them e_i on(C ----IIy coed-ed to be citployc-3 arch_the wceir.er's m.•-7e_-lion Act(GUI 52-=1(5)).:pplinboa by a bomo o fare b '- or permit tr_y cs-id the togal ctanu of as erployec under tbo Worir-oh Com:p.m.-ioa Act - I uodczs�d that a copy of this mt.amrm m.y b.focwnvd.ed to tbo D p.rtmrat of 1 :rsic!Accietora'OIL..of Imuc.aoe roc tb. cov r.ge rcircnsioa and that C_ilttre to saauc tovcrase unrtr-soctioa 25A of MOL 152 tun led to the impuitieo of ciminal peasttia Cia:-ice of.fine of up to St3oo.00 andfor imrprisoazo=of up to one yt.r and civil pm.tuo in ex Cost of Stop Work Or and. rim o(S 100.00 a thy Lc:inu ax. For dew^-.—.t u.c only - Pc-rsait Number Si of Licut_scc/PcrmiLE= -- - 1 i. ..lit'fp2.. moo " " , Oat a Northampton L_ =* _ 1 ke DEPARTMENT OF BUILDING INSPECTIONS '44 _ /_ INSPECTOR 212 Main Street • Municipal Building Northampton, MA 01060 s`, e HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction sups.: •' 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 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)z 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 r I