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27 Dunphy shed app 2019File# BP-2019-1240 APPLICANT/CONTACT PERSON VAN CAMP CHRISTOPHER ADDRESS/PHONE 27 DUNPHY DR FLORENCE PROPERTY LOCATION 27 DUNPHY DR MAP 43 PARCEL 084 00 I ZONE THIS SECTION FOR OFFICIAL USE ONLY: }?ERMIT APfLICA TION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin Permit Filled out Fee Paid T eofConstruction: 20xl6 rebuildt shed New Construction Non Structural interior renovations Addition to Existing Accessory Structure Buildino Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION :i,RESENTED: __ Approved _ii'_ A 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 Pennit ____ -·---· Variance* ___ Received & Recorded at Registry of Deeds Proof Enclosed. ____ _ ___ Other Permits Required: ___ Curb Cut from DPW Water Availabilitv --~~ . Sewer Availability -~-__ Well Water Potability Board of Health ,..=. __ Pennit from Conservation Commission __ ._]ennit from CB Architecture Committee ___ Pennit from Elm Street Commission ___ Demolition Delay ___ Permit DPW Storm Water Management Sign~ture of Building Officiil . . . . . , . .. . . Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to corn ply 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 infonnation. City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT, SECTION 1 • SITE INFORMATION 1.1 Property Address: section to be completed by office J. 7 Pun f h I Pr. D8EP~T~.O~F~B~U;ll~D;1~~JG~INNiiit~;...-ll.~3~~t afi NORTHAMPTON. MA 01060 Unit __ _ Fl or €.'1 c.e...> /VIA-()JO~ 2.. ne ______ Overlay District. ____ _ 1-----------------------El......,m St. District'-------CB District. ____ _ SECTION 2 • PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Recort= ch r j ~ -fof Q.,~ Z7 DuAphy t>,. Florence, /YI/I 0/06.. Current Mailing' Adcfress: ,1; G Name~ ~ Sig~*1 <../13-'f::l. 7-S'""YL6 Telephone 2.2 Authorized Agent: Name {Print) Current Mailing Address: Signature Telephone SECTION 3 · ESTIMATED CONSTRUCTION COSTS Item Official Use Only 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 + 2 + 3 + 4 + 5) ~,ooo -o- (a) Building Permit Fee (b) Estimated Total Cost of Construction from 6 Building Permit Fee / 0 / 0 O Check Number This Section For Offlclal Use Onl Date Building Permit Number: ___________ _ Issued: ________________ _ Signature: ----------------- 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 , .. "" -· --·-·---' [___ ···-· . "~ -, ,,. _ _._ ----. "" '' "'" •·«"·---t .. Frontage , .. ' ....... ,-.,,.._ ... _ ._, ,.,,,. ........ -. " ~,, . •... Setbacks Front ; ; ., Side L:_' _. _.· R:_'. -···-·-· L:~• -~-R:_' -· _, Rear Building Height Bldg. Square Footage % ,. Open Space Footage % (Lot area minus bldg & paved parking) # of Parking Spaces •• ••••nw., .. --,. Fill: ; I ;, (volume & Location) "' • • · --· ,ode•,-, -~ •• •• . . .--,L . .... . ... . ·~·"· ., " «;~ . "' """'" ••• .. . ... •' A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW O YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW Q YES 0. IF YES: enter Book, Page and/or Document#. B. Does the site contain a brook, body of water ~r wetlands? NO O DONT KNOW O YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained C. Do any signs exist on the property? YES IF YES, describe size, type and location: 0 0 , Date Issued: NO © D. Are there any proposed changes to or additions of signs intended for the property? YES Q IF YES, describe size, type and location: NO/!;) 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 (8) IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK {check all appJlcable) New House D Addition D D Replacement Windows Alteratlon(s> D OrDoors D Roofing D Accessory Bldg. riJ Demolltlon New Signs [CJ] Decks [CJ Siding [CJ] Other [Cl) ~~~~escriptionofProposed R(e. bv; /t S~e)..._ k,'fl~ Je./iVQ.f fA"'llJ J,e,f uA [,1M.ale.. bf.,(_is. ;-~ ( (t, ... :l-,,/e,tlvr\ Alteration of existing bedroom __ Yes _l_ No Adding new bedroom ___ Yes ~ No o vf,f f-h / I '1" Attached Narrative Renovating unfinished basement Yes },. No c ~1 , ·d 1 'I) Plans Attached Roll -Sheet 07(..!. &a. If New house and or addition to existiJll bouafnQ...COfJ'JPllte b tonowtna: 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, property , as Owner of the subject hereby authorize ---------------------------------------to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, ---~..;;___:_...:_.;__.;__-'----=-------=---1---------------· as Owner/Authorized Agent hereby declare that the tatements and information on the regoing application are true and accurate, to the best of my knowledge and belief. SECTION 8 -CONSTRUCTION SERVICES I 8.1 Licensed Construction Supervisor: Not Applicable')!. Ngm~ Qf bl!.!:DH Hgld~r : License Number Address Expiration Date Signature Telephone 1. 8!glatered Home lmorovement Contractor: Not Applicable)(... CQ!!!e!nx Name Registration Number Address Expiration Date Telephone - SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) I 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 ....... D No ...... D City of Northampton Massachusetts m:PARDJENT OF BUILDING INSPECTIONS 212 Main Street• Municipal Building Northampton, MIi. 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, 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 UC, that entity must be registered. Type ofWork:_~8~, ~/}_,·~s_A~J~--s~h~e-~'-~''tt.~.5_W ___ Est. Cost:_f_O--#-,_o_0 _0 __ Ovttfht D,. Eloce.J1C€. mA-01062- Date of Permit Application: ____ 5°"_1#--/_J_/~z~o~/..__.°f~--------------- Address of Work: 27 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 permit (explain): _________________ _ __ Building not owner-occupied _Other(specify): _______________________ _ OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WIIB UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HA VE 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: Notwithslanding the above notice, I hereby apply fo, a building permit as the owne,-of cl:''°pe'l -D-a~+l--3+/-v_o_l ..... ? ___ S-~-r-e:-~-!:-lll--~-d<w'_Si-gn-atur .... tlt_t-"----c_h_~-r,_ _______ ...... ±)-,,.... __ v~ 0, City of Northampton Massachusetts DEPARDa:NT OF BUILDING INSPECTIONS 212 Main Street• Municipal Building Northampton, MA 01060 Massachusetts Residential Building Code Section 11 O.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. Sec ti on 110 .R5 .1.3 .I 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 IIICPAR'IMENT OF BUILDING INSPECTIONS 212 Main str-t • Municipal Building Northampton, Ml!. 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: )7 Putith t l)r. . (Please print house mb rand street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) -Si-g~n~~tu_r_e_m_P_:_rm-~-it~p~~-li-ca_n_t_o~-O-~-n-e_r_Da-0-e~~--~~$~/ 3/-z..~7 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 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia • Department of Industrial Accidents Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUfHORITY. A licant Information Pl ase Print Le ibl Address: __ 2._7 __ v_v_11__,f_h~f--D_r_. ------------- Pf o ( t-r'\ c.e_ MA-0 I{), 2. Phone#: '-/ / J-'-/ 2 7 -~ 8 'f 8 City/State/Zip: Are you an employer? Check the appropriate box: t.O I am a employer with ___ employees (full and/or part-time).* 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.o I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. l,'gl 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 proprietors with no employees. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers' comp. insurance.I 6.0we are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. 5"New construction 8. D Remodeling 9. D Demolition 10 0 Building addition 11.0 Electrical repairs or additions 12. D Plumbing repairs or additions 13.0Roofrepairs 14.00ther ______ _ • Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy infonnation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractms 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: _____ /1/--i/'.'--)t'-------------------------- Policy # or Self-ins. Lie. #: A/ '4 Expiration Date: ________ _ Job Site Address: "i-7 ])v" f "-t Dr · r ~ ~ City/State/Zip: f/ :;..r t,'1\ c-' 1 vV' A-o Io 6 2- 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 ofa STOP WORK ORDER and a fine ofup to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office oflnvestigations of the DIA for insurance coverage verification. I do hereby certify der !he P. ·ns fnd penalties of perj:r{ that the information provided above is true and correct. ~ if Q'W\ Vi Date: 5 1 2-0 I Phone#: 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): I. Board of Health 2. Building Department 3. City/fown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other ___________ _ Contact Person: __________________ Phone#: ______________ _ Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as " ... every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the aerropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office oflnvestigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in ___ (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: Revised 02-23-15 The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA02114-2017 Tel.# 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 www.mass.gov/dia -NOTE-THIS PLAT IS COMPILED FROM DEEDS, PLANS AND OTHER SOURCES AND IS NOT TO BE CONSTRUED AS AN ACCURATE SURVEY AND IS NOT TO BE RECORDED. BUILDING LOCATION ACCURACY IS NOT GUARANTEED CT TO AND TOGETHER WITH 1ENTS AND RIGHTS OF WAYS :CORD. \..___ __ -I._ I I ~"v:'Cb~ ./ 1 c§-& ~ "v;-C5 / f:-~ <::)<::)· ~ "'' ~ O)' " ~ "~ ~.9-~\ I\ / ~~ ~ 0 ov /. e.i"T" ~(> -~ "v:'~ ( -~ ~ e.i ~ <c / /1 o;& f,..,, ~ / (w(J ~ 9J'S q_'v 05 «:t· q) · A PORTION OF BOOK 3580, P AG PLAN BK. 135, P LOT #1 r AMERICAN TITLE INSURANCE COMPANY ~ST OF MY INFORMATION, KNOWLEDGE ANO BELIEF REPORT THAT I HA VE EXAMINED THE PREMISES AND BASED ON EXISTING ' rATION ALL VISIBLE EASEMENTS, ENCROACHMENTS ANO BUILDINGS ARE LOCATED ON ND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY WITHIN THE LOT LINES, S NOTED. I FURTHER REPORT THAT THE PROPERTY IS NOT LOCATED WITHIN PRONE AREA AS SHOWN ON FEDERAL FLOOD INSURANCE MAPS FOR Y #250167 ~Will ~--:r~.-~ ~ SEE: DRIVEWAY EASEMENT ...-AGREEMENT BOOK 12467, PAGE 173 169.55' lg: Paved , o drive ').<;,. oO~ -C?. ~9" -~y,.'< OR I Ve ~~ <) -NOTE-THIS PLAT FOR MORTGAGE LC AND DOES NOT CONSTITUTE . -MORTGAGE LOAN INSF NORTHAMPTON, MA PREPARED LORI A. SCHWARTZ & CHRI: SCALE: 1"=80' HAROLD L. EATON AND REGISTERED PROFESSIONAL 235 RUSSELL STREET -HADL 5/9/2019 OLIVER maps.massgis.state.ma.us/map_ol/oliver.php 1/1 OLIVER: MassGIS's Online Mapping Tool OLIVER Updates 27 Dunphy Drive 01062 Zoom to a town 0 m