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15B-021 (3)
PLP Vi cc 2� � BP- 2010 -0562 GIs #: COMMONWEALTH OF MASSACHUSETTS f ass . az 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- 2010 -0562 Project # JS- 2010 - 000788 Est. Cost: $20000.00 Fee: $120.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SACKREY CONSTRUCTION 040714 Lot Size(sq. ft.): 32365.08 Owner: HOUCK GEORGE F & HEATHER G Zoning: URA(100)/ Applicant SACKREY CONSTRUCTION AT. 101 CHESTERFIELD RD Applicant Address: Phone: Insurance: 83 SOUTH MAIN ST (413) 665 -9995 () Workers Compensation SUNDERLANDMA01375 ISSUED ON. 1112512009 0:00:00 TO PERFORM THE FOLLOWING WORK.-FINISH TV ROOM & HOME OFFICE IN BASEMENT 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 11/25/2009 0:00:00 $120.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo File # BP- 2010 -0562 APPLICANT /CONTACT PERSON SACKREY CONSTRUCTION ADDRESS /PHONE 83 SOUTH MAIN ST SUNDERLAND (413) 665 -9995 Q PROPERTY LOCATION 101 CHESTERFIELD RD MAP 15B PA 021 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out -04 24 2 e4 Fee Paid Typeof Construction: FINISH TV ROOM & HOME OFFICE IN BASEMENT New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 040714 3 sets of Plans / Plot Plan THE FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN 'O IATION 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 L 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 Status of 0 rhn -- Building Department e ft" ri�lt 212 Main Street Setiver�S'q W&A�at1 GOB Room 100 a Northampton, MA 01060 T, S- 5871240 Fax 413 - 587 - 1272`2 - ------- ----- 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 i (� , gL Qwt � y a✓p '`�� Map Lot Unit L-v -levS v V%&A Zot e' Overlay District ElniSt District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record Name (Pr Current Mailing Address: 77 / � 1 Telephone Signature 2.2 Authorized Agent: Name (P ' t) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMA D- CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Gastef 2 1 s Construction from 6 3. Plumbing L Btfi ing:Permit Fee i 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Z-- U 6I6 Check Number l2 ... This Section Fnr f ffiriel Us P ( nl ' Building Permit Number: Date Issued: Signature: - Building Commissionerllnspector: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 m T Side L: R. L R. "........_M Rear Building Height Bldg. Square Footage % Open Space Footage _ _ ". , % — " —. (Lot area minus bldg & paved p arkin g ) # of Parking Spaces -. -._. Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 07 YES 0 IF YES, date issued:, IF YES: Was the permit recorded at the Regis ry of Deeds? NO 0 DONT KNOW YES IF YES: enter Book Page' and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 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: propo set changes to or additions of signs nfen for - the property ? YES � NO 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 U NO 0 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) Q Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C] Siding [O] Other [O] Brief Description of Proposed Work: Pt V D `T, y , (; cl�ilr. t� .(7 V ' O ffl U 1,-S '16 AS k w. -64,k -� Alteration of existing bedroom Yes Vie/ No Adding new bedroom Yes 1/ No Attached Narrative Renovating unfinished basement ✓ Yes No Plans Attached Roll - Sheet sa_ if, Nev+r.house and ©r:addition to existin I a. 6,6 te.thii6fidwinA: 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 st ories? 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, 40NC \ as Owner of the subject property hereby authorize to act o y behalf, in all m tter relative to work authorized by this building permit application. Si o Owner Date as Owner /Authorized Agent hereby declare that the statements and info on on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed u r the and penalties of perjury. Print Name :3 L15�- Signature of Owner /Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder L' C5 -79 j � -f License Number `vy,�.r Addres Expiration bate SignatireV Telephone 9- Reg- i "stered klorne ,lrnproverxtent;Gonfractar: 4 Not Applicable ❑ Company Name Registration Number Address L Expi ation ate 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...... ❑ The-current-exemption for "homeo_wners " was ext ended to include Owner -occupied Dwellings of one (Z) 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 pen is issued. A,lco be adviegd that isith rPferrnreftn Chartrr 157 (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) y oufiiire to perfoim work for yo�aZtnderthis perrttit - - - - -- _------ - - - -__ __ - - -- The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of - Noirtfamp on - r inances, - a e Lamt Z, al- Laws- Annotated. Homeowner Signature a The Commonwealth of Massachusetts Department oflndustrial Accidents Office of In vestigations 600 Washington Street Boston, MA 02111 www.massg ovlifiQ -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print LeDffiIv Name ( Business /Orgam zation/Individual): Address: �5 6 City /State /Zip: °J�Ur��6rt v-� Phone.#: `i have r1. 2. re you an employer? Check the appropriate box: Type of project (required): D'i ,, I am a general contractor and I am a employer with 1 4.. f 6. F1 New construction employees (full and/or part time). * have hired the sub- contractors 0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling sub - contractors , ship and have. no. employees These 8. � Demo working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance.1 required:] 5. We are a corporation and its 10.0 Electrical repairs or additions ___2 cers vexercised tiaeir -- Plumbing repairs or additions 3. [Q I am- a�omeou�ner- denwork - —1-1 r myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required] t c. 152, § 1(4), and we have no - employees. [No workers' 13.0 Other comp. insurance required]. "Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information- Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors 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. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and joh site _ tnformatwn. Iusu ance Company Name: I • . Policy # or Self -ins. Lic. #: Expiration Date- Z to Job S ite Addre 01 C t t`L�sG t `� c 1- z. �-PS City /Sta&Zip Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of cr iminal penalties of a 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. 1�e advised that a copy of this statement may be forwarded to the Office of Investisiations of the DIA for insurance coverase verification - - 1 do_hereby cent(y u er and penalties of perjury that the information provided above is Si tore: ate Z3 _ Phone #: `f l 3 j ° 10' e - 7 j, C Official rose only Do not write in flit areiz, fo be- co�eied by city or town official City or Town: Permit/License # Issuing Authority (circle one): - g I Board of Health 2. Building Department 3. City/Town Clerk 4. Eiectrical I nspector 5. Plumbing Inspecto -- - -- __ 6. Other Contact Person• Phone #• r A HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CNM 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 xeg»lations The insnecti °n requires that the building department be call to inspect work at various stages, which include foundation /footings (before backrdI), 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 — -- - - - - -- - - - - - -- pits- in,conjunction._to_tbebu _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