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10-005 311 KENNEDY RD BP- 2011 -0190 GIs #: COMMONWEALTH OF MASSACHUSETTS , Map :Bloc 10 - 005 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- 2011 -0190 Project # JS- 2011- 000323 Est. Cost: $15000.00 Fee: $90.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SACKREY CONSTRUCTION 040714 Lot Size(sq. ft.): Owner: GORDON JEFFREY D & DIANA M Zoning: Applicant. SACKREY CONSTRUCTION AT. 311 KENNEDY RD Applicant Address: Phone: Insurance: 83 SOUTH MAIN ST (413) 665 -9995 0 Workers Compensation SUNDERLANDMA01375 ISSUED ON: 91212010 0:00:00 TO PERFORM THE FOLLOWING WORK.- ENCLOSE W /SCREENS EXISTING COVERED PORCH 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 9/2/2010 0:00:00 $90.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner File # BP- 2011 -0190 t ' APPLICANT /CONTACT PERSON SACKREY CONSTRUCTION ADDRESS/PHONE 83 SOUTH MAIN ST SUNDERLAND (413) 665 -9995 Q PROPERTY LOCATION 311 KENNEDY RD MAP 10 PARCEL 005 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid _ 1? AP 7V Typeof Construction: ENCLOSE W /SCREENS EXISTING COVERED PORCH New Construction Non Structural interior renovations Addition to Existin Accessory Structure Building Plans Included: Owner/ Statement or License 040714 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: Approved 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 Y I 0 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. City of Northampton., Building Department 212 Main Street Room 100 Northampton, MA 01060 phone 413- 587 -1240 Fax 413- 587 -1272 x- 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 Overlay District ,L Elm St` Dlstrict CB "District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record J) d u d r\ i a ►ma �� t' c r 3 I I �Ce ►� e� �� . e S. G 10 S Name (P Current Mailing Address: / Telephone Signature 2.2 Authorized Agent: (�' Z , /� v v J S � L+X Name (Print) Current Mailing Address: C� Signature Telephone SECTION 3 - STIMATED CONS RUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building I �, q (a) Building Permit Fee 2. Electrical U v (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 p This Section For Official Use Onl Date Building' Permit Number: Issued: Signature: Building Commissioner /inspector 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 Department Lot Size Frontage Setbacks Front Rear Building Height Bldg. Square Footage 0110, Open Space Footage % (Lot area minus bldg & paved 7 F # of Parking Spaces (volume & Location) A. Has a Special Permit/Variance/ Finding ever been issued for/on thesite? �� �� NO «�� DONTKNOW vLj YES v� �� � |F YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds »~� NO x�� mun/ xnv,v 0 YES IF YES: enter Book Page and/or Ducument# M B. Does the � �� site a brook, body NO �_� DDNT KNOW YES IF YES, has permit been or need to be obtained from the Conservation Commission? Needs tohembtained »�� �b��ned »r� Qate<ssued'| � v�� �_� ' ' C. Dn any signs exist on the property? YES 0 NO |F YES, describe size, �peand �cation: | _ D �~� x~� Are YES NO D. �~� |F YES, describe size, type and location: E Will the construction activity disturb (clearing, gradingexcavation, nr filling) over 1 acre nrisd part ofo common plan that will disturb over 1acre? YES K @ NO K�� �� 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 [0] Decks [0 Siding [0] Other [O] �rrp� Sc�tLd [� r « Brief Description of Proposed Work: w5 fi {C S (I ! � /'S 6 9 'P OKA A IC- Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes �K No Plans Attached Roll - Sheet s a, tf�leut� hatrse a »c��r'ad�ti�iol�k+� ex���n+e �„# ��s�11cf� ©f��e��� ; #�tllc��ttrr�ct• 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 Gl VN Q 1/ fi Lc r a C Y-) as Owner of the subject property _ hereby authorize r S &'&krej to act o in tte elative to work authorized by t s building permit application. Signature of Owner Date J ( j'�►y p —�-c as Owner /Authorized Agent hereby declare that the statements and information o the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of rjury. Print Name n o I J (� Signature o er/ a r Date SECTIONS -CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder b yk-t4 kk Ac C `7 ` 9 3 5 License Number Address Expiration Signature elephone 8. Reaiteck :omlttftat`i�fireltciridctory o �,� °_ ,,,.R. a Not Applicable ❑ Company Name Registration Number � s " (" III i� Address Expirat� Date g Ul — �,{1� "1�1i(L� �tv- -� V `� ` Telepho e 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....... 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 buildine 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 The Commonwealth of Massachusetts Department of Industrial Accidents - Office of Invest4gations 600 Washington Street Boston, MA 02111 a www.mass gov1&a -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Le�ibIV Name ( Business /Orgmiiatiowiadividuat): Pt Address: c S 3 S - iNL+4- City /Stat u t-wD CA.." 'D Phone. #: y ( J " f " 1 c l 1 � Are an ., 4._ ❑ I am a employer ?.Check the appropriate box: Type f project (requir 1. m a employer with •'� general contractor and I 6.0 New construction employees (full and/or part-time). * have hired the sub- contractors 2.0 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 wor ' ' for -mein an emPloyees_and have worb=e y capacity. 9 � ' -= addition [No workers' comp. innnance _ comp. insurance #_. ❑_ _ required:] 5. ❑ We are a corporation and its 10 ❑ Electrical repairs or additions 3.0 I am a homeowner do' all work officers havehercised their 11. mg ❑ Plumbin g repairs or additions myself [No workers' comp. right of exemption per MGL i2:0.Roof repairs insurance required] t c. 15 § 1(4), and we have no employees. [No workers' 13.0 Other wasp_ insurance required]. 'Any applicant that checla box #1 mist also fin out the section Belo* showing theirworke:s' mw=..d- policy information. t Homeowners who submit this affidavit.indicating they we doing all work and thew hire outside conttwtois must submit anew affidavit indicating such_ :Contactors that check this box m st.attached an additional sheet showing the name of the sub=contractors and stater whether-or not thoseetrtities have employees. if the subcontractors have employees, they must provide their workers' comp. policy number. J am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information / Insurance Company Name: W V lJ� U0 Lk4!,� Policy # or Self ins. Lic. #: Expiration Date: Job Site Address: iw City/StafelZip: C� 3 Attach a copy of the workers' compensation policy declaration page (showing the p9ticy number and expiration date). �P Penalties of a Failure to secure coverage.as required tinder Section 25A ofMGL c. 152 can lead to 13ie' osition of " 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Off 'ce of InvestrQations'o 'MA f insurance`coveraee verification._ I do_hereb _Y ce der tj pair an exalties ofperftay that Me information rovuled.abovr islrue_andcorred -- Si D ate, 4 Phone #: f' Official use only. Do not write in this areq to be completed by city or town 'offu ie City or Town- PermitUcense # Issuing Authority (circle one): .1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 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 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. (Home 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 � ` `-_ / / / r �no Jo '