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12C-001 84 NORTH FARMS RD BP- 2011 -0870 GIS #: COMMONWEALTH OF MASSACHUSETTS Map.-Bloc 12C - 001 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: roofing BUILDING PERMIT Permit# BP- 2011 -0870 Project # JS- 2011- 001428 Est. Cost: $2600.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CYRUS NEWMAN 064690 Lot Size(sq. ft.): 43560.00 Owner: WARBURTON LINDA LEE & BARBARA WARBURTON Zoning: SR(100)//WP/WSP Applicant: CYRUS NEWMAN AT. 84 NORTH FARMS RD Applicant Address: Phone: Insurance: 697 Brid Road (413) 586 -1093 Workers Compensation NORTHAMPTONMA01060 ISSUED ON :412912011 0:00.00 TO PERFORM THE FOLLOWING WORK: STRI P & SHINGLE ROOF 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 4/29/20110:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner City Of Northampton�� Building Department nail p Z5 Go 212 Main Streete LC Room 100 90 orthampton, MA 01060 hone 413- 587 -1240 Fax 413- 587 -1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address Map Lot Unit Zone" Overlay "District Elm St :District CB District SECTION '2 - PROPERTY' OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record Name (Print) Current Mailing Address: Telephone Signature 2.2 Authorized A ent: Name (P nt) _ _ Current Mailing Address: 0 7 Sign tur Telephone SECTI ESTIMATED CONSTRUCTION. COSTS It Estimated Cost (Dollars) to be Official Use Only F=ih completed by ermit applicant 1. Building ®p (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit. Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 +2+3+4+ Check .Ni This Section Fort fficial Use Onl Date Building Permit Number: Issued: Signature: Buildng Commissioner /Inspector of Buildings Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomptet[amation Existing Proposed Required by onin$ This column to 4 filled in by f'S 2QA, 1 11 - I Building Depa ent Lot Size Frontage Setbacks Front Side L: L--. = R:--,- LL—L R:�Z Rear Building Height Bldg. Square Footage % r 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? Y–A NO 0 DON7 KNOW 11Q YES IF YES, date issued:1 IF YES: Was the permit recorded at the Registry of Deeds? NO _0 DON7 KNOW YES .......... IF YES: enter Book 1 Page', and/or Document B. Does the site contain a brook, body of water or wetlands? NO 0 DON7 KNOW / Q YES 0 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 NO IF YES, describe size, type and location: T D_ =e any proposedcanges to o of signs intended - fog the property ? YES 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 I acre? YES No IF YES, then a Northampton Storm Water Management Permit from the DPW is required. r 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 [M Siding [O] Other (0) Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa: 1f. New. house .and- 'or..addrhon ° to °ezisfil rci iousln6, Coi4 k6thefoltouuinQ: 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 P -ERMiT 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 vi M O as Owner /Authorized Agent hereby oeclareThat the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the ai s and penalties of perjury. Print e Signature of Owner g nt J Date s SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder : License Number 1 is Y3 Csc wt ) P Address Expirati n Dat � 6 g Telephone 9. ,;Re' r'steredrliame Irn" rri" enerttCoritracf�~ ;'- Not Applicable ❑ Combany Na Registration Number Address �` C z ' z Expirati n D e Telephone �(� " °� ®�� SE CTION 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....... No...... ❑ Lhe_cuuent_exemption for `.`homeoYv_ners" was e xtended 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 Employccs 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 nrt amptan r tnanGes, e . tts General-La- wsAnnotated. Homeowner Signature The Commonwealth of Massachusetts Department oflndustrial Accidents Office of In vestigations 600 Washington Street Boston, MA 02111 www.mass.gov1i a Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Le6ibly Name ( Business /Organization/Individual): Ll'C� j�✓! ,� ' Address: n, " �c5to6CZ City/State/Zip: Phone . #: 516 -'lCJ!9 a Are you an employer? Check the appropriate bog: Type of project (required):, 1. I am a employer with 4.. 0 I am a general contractor and I employees (full and/or part- time).* have hued the sub - contractors 6. New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet 7. Remodeling ship and have. no en-up loyees These sub - contractors have .8. Demolition to - ees working for me in any capacity. y andhave workers' # . 9. 0 Budding addition [No workers' comp. insurance comp. insurance.. _ required:] 5. We are a corporation and its 10.0 Electrical repairs or additions 3 _.__ - -_ o �ficers a vexxercise d �iL_ - -�1 g epairs or additions . Q am emeswaer demg�li ork - - aRlumbin r myself [No workers' comp. right of exemption per MGL 12 Roof repairs insuran required:] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insuran 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 them hire outside contractors must submit a new affidavit indicating such. IContractors 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' coral. policy number. lam an employer that isproviding Workers' compensation insurance for my employees. Below is the policy and job site f Insurance Company Name: JL Policy # or Self-ins. Lic. #: 1 Expiration Date: f '7 J ob Site Address: — 4 1 - a City /State /Zip: t� t (A6 Attach a copy of the workers' compensation policy declaration page (showing the policy number and irati date). on - -- - Failure to secure coverage: as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a fine lip to $1,500.00 and/or one. =year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a , re of up to $250.00 a day against the violator. 15e advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insuran coveraze verification Ido hereby _certify under thepains andpenalt es ofp. erjury that the infornw onprovided -above rs-true-atrdcorrect___ _.._ Signature: g' Da Phone #: Official use only. Do not write tt i1ii area, to be completed y city or town official City or Town- Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical I nspector 5. 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 persons) 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 x P�nlatinnc Th_. e ;r�sn�ction n �Q Eess mires that the building department be call to inspect work at various stages, which include foundation /footings (before backfdl), sonotube holes (before hour), 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 ..insuections_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 -- - - - - -- - permi in-conjunctionrto_ the_ building_permitissued,.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. mat Address of work location NEWMAN'S CONSTRUCTION 697 Bridge Road NORTHAMPTON, MA 01060 (413) 586 -1093 " C} PHONE DATE TO : JOB n / -� NAME / LOCATION J s y v✓L�IC� IkIA 6z JOB NUMBER JOB PHONE We herel�y submit specifications and estimates for: e- F �i�•�T>r l SrZs O ( 'ec0 (j _1___ L Le1e? DYi �✓[ T.:�� �( �c %(,1 ��L�'`� � � r �� � v� �✓� �� �� 2 Ud I= ,�2fr� 12 clelfr-L 15 T /�> p � f J✓L-' S �G Y'r` (J �O�'� W P R0 POS E hereby to furnish material and labor — complete in accordance with the above specifications, for the sum of: G C+ G -- dollars ($ Cni� ). Payment to be made as f lows: All material is guaranteed to be as specified. All work to b completed in a professional -� manner according to standard practices. Any alteration or deviation from above specifications Authorized involving extra costs will be executed only upon written orders, and will become an extra Signature charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry tire, tornado, and other necessary insurance. Our Note: This propo ay be � workers are fully covered by workers Compensation insurance. withdrawn by us if not ac p d within / days. A CCEPTANCE OF PR OPOSAL —The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Pa;menl will be made as outlined above. Signatu Date of Acceptance: Signature PRODUCT 131 2PT FOLD AT (,)Torn COMPANION - M DV -O -VUE ENVELOPE. PRINTED IN U.S.A. B