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24D-126 " BP- 2011 -0558 GIS #: COMMONWEALTH OF MASSACHUSETTS 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- 2011 -0558 Project # JS- 2010- 000039 Est. Cost: $3450.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 4094.64 Owner: SELLERS JOAN R & MARK Zoning. URC(100) Applicant: SELLERS JOAN R & MARK AT: 247 STATE ST Applicant Address: Phone: Insurance: 247 STATE ST (413) 584 -3318 () NORTHAMPTON MAO 1060 ISSUED ON :1212012010 0:00:00 TO PERFORM THE FOLLOWING WORK.- FINISH 2ND FLR (APPROX 22 X24) 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 12/20/2010 0:00:00 $60.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner City of Northampton Building Department 212 Main Street Room 100 D EC T [010 Northampton, MA 01060 phone 413 =587 -1240 Fax 413 - 587 -1272 APPLICATION T44ANSTRUCT, 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 'j SlCi y r No t//fi l�c� wip 1�i� min Map Lat knit ©! U (fl D Zane Ove�layr pisttict Errr► St nistrict , 03 a strict SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT _ 2.1 Owner of Record rky N ma a (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 e it applicant 1. Building V ri ST (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 6. Total = (1 + 2 + 3 + 4 + 5) ) Check Number This Section For Official Use Onl Building; Permit Number: Date Signature: Building Commissionerfinspector of Buildings 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 Departrnpnt Lot Size l = 1 Frontage ` 7 Setbacks Front ; i �. 5.. Side L: ___i R _._.. L: ___. = __ R• �_W____ ' I Rear Building Height S +r'r 4 Bldg. Square Footage % Open Space Footage (Lot area minus bldg & paved p arking) bt LC a # 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 IF YES, date issued: Sep' �- �7ov 1 IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q 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 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 X 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 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 ❑ Accessory Bldg. ❑ Demolition New Signs [O] Decks [❑ Siding [0] Other [a u) w 1A Brief Description of Proposed I I l Work: N'uV cC (6fG ( y� - 1" r"A V\. (j'n�y✓ ►D✓L Vi DU Alteration of existing bedroom Yes No Adding new bedroom Yes _X No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet I;a "#tii%�tctlstt tyc�ri�tc�ttsl ure S riri m bee n buy tic . j h s ilar wu t a. Use of building: One Family Two Family Other fi _� r k r) i h�� �,�6 b. Number of rooms in each family unit: ,��. dumber of Bathrooms !vii 0-Ad r L7 C. Is there a garage attached? \�� '�) 4- J,f XIS} Y abbe,,? fA 6 d. Proposed Square footage of new construction. `�o� Dimensions c X a u e. Number of stories? 1 `� � ry Ll ! U 1/� ] f. Method of heating? l"O jf— (1� Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction C. pit i. Is construction within 100 ft. of wetlands? Yes � No. Is construction within 100 yr. floodplain Yes A _No j. Depth of basement or cellar floor below finished grade 7 'J�e e t k. Willbuilding conform to the Building and Zoning regulations? _ Yes No. I. Septic Tank City Sewer Private well City water Supply _ SECTION 7a - OWNER AUTHORIZATION - MBE 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 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. JQ L Print Name Sigoture of Owner /Agent Date or SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 1 r� .,Re�rett��itntirst��trn' yet eintC `ott�a��r�t� �1�,�.,.��r��. M � �m >.�..,. �.��- Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 162, § 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...... ❑ 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. 1 Homeowner Signature e'� T The Commonwealth of Massachusetts Department of Industrial Accidents . Office of Investigations 600 Washington Street Boston, MA 02111 M www.massgov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electriciam/PIumb.ers Applicant Information Please Print L �'blv Name ( Business /Orgmiiation/Individual): z Address: z , City /Statc(Zip: Are you an employer?. Check the appropriate box: Type of project (required):. 1. ❑ Lam a- employer with 4.. ❑ I am a general contractor and I 6. [1 New constriction employees (full and /or part times).* have hired the sub- contractors 2.0 I am a sole proprietor or partner- listed on- the sheet 7. ❑ Remodeling ship and" have no employees These sib - contractors have. .8. ❑ Deaolition working for me in any capacity. enT_loyees and have workers' 9 1. t a8dtion workers Comp IICC �� incur- M f required:] 5. ❑ We are a corpoiation and its 10.❑ Elecincal repairs or additions officers havexercised their ❑ g 3. }� I am a homeowner doing all work ,;. tion p 11. Plumbing or additions r / myself [No workers' comp. right of exemper MGL 12.0.Roofrepairs c: 152, §1(4), and we have no inStr, - an d required:) t employees. [No workers' 13.❑ Other comp. insurance required.]. ;Any applicant Shat checks box #1: must also fill out the section beloashowing dicirworlmrs' compensation policy information: Homeowners who submit this affidavit,in&cating they are doing all work and the hire outside - contra=rs must submit a new affidavit indicating such. 1 Conuactors that check this box must - attached an additional sheet showing the name of the sub contractors and state whether ornovd)ose entities have employees. If the sub—traam bave employees, they must provide tk* wmi s' comp..poRcy number. I am an employer that is providing workers' compensation insurance for my employees Below is the policy gnd job site btformafion. Inset -ance Company Name: . Policy # or Self-ins. Lic. # Expiration Date: Job Sit Address: City/State/2.p. Attach a copy of the workers'' compensation policy declaraf<on page the pglicy number andezpirafion datej. Fmlure. to secure coverage_ as regmit cli ides Section 25'A ofMOL c: 15Z can lead to if le imposition of "ciim pena2ttes of a fine up to $1, 500.00 and/or one- year as well as civil penalties in the form of a STOP W(? tK GMD R and• a fine of up to S250.00 a day agamst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations "of thc'bIA for insurance covera--e verification I do hereby cent fy under the p and p s ofperjury that the information provided-abov ix.&w and correct -___ _ Si ture: ate. Phone [0ther only. Do not write in this area, to be completed by or c town offcelaL sn: Permit/License # thority (circle one): Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector son• Phone #• HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 1 08.3.4 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 �ermits 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. ome owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to Date Address of work �.. location �/ (�