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13-031 436 RTP UNG s BP- 2010 -0673 G1S #: COMMONWEALTH OF MASSACHUSETTS M #U: B1oC #c , - , 03 1:' CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category BUILDING PERMIT Permit # BP- 2010 -0673 Project t# JS- 2010 - 000986 Est. Cost: $10200.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin: DANIEL DROLLETTE 072267 Lot Size(sq. ft.): 58806.00 Owner: OWEN NANCY & MATT Z,onin�: SR(100)/,/Rl Applicant: DANIEL DROLLETTE AT. 436 NORTH KING ST Applicant Address: Phone: Insurance: BOX 137 (413) 665 -4818 WHATELYMA01093 ISSUED ON. 1/27/2010 0:00:00 TO PERFORM THE FOLLOWING WORK. REMODEL KITCHEN (CABINETS,COUNTERTOPS & FLOOR 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 Si FeeType: Date Paid: Amount: Building 1/27/2010 0:00:00 $60.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo File # BP- 2010 -0673 APPLICANT /CONTACT PERSON DANIEL DROLLETTE ADDRESS /PHONE BOX 137 WHATELY (413) 665 -4818 PROPERTY LOCATION 436 NORTH KING ST MAP 13 PARCEL 031 001 ZONE SRO 00) //RI THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid pw Typeof Construction: REMODEL KITCHEN (CABINETS,COUNTERTOPS & FLOOR New Construction Non Structural interior renovations Addition to Existin Accessory Structure Building Plans Included: Owner/ Statement or License 072267 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: pproved 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 1 2- el6? 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 CiIa ewa�� x' v 212 Main Street Room 100 aab�lrt� �u Northampton, MA 01060 � ^` L $hone 4,13 -5$ -1240 Fax 413 - 587 -1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTIONA -SITE INFORMATION This section to be completed by office 1.1 ProDertv Address Map Lot Unit Overlay District I��n •� G �� a ., W/4 O t oCe5 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 Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED! CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applic ant 1. Building to (a) Building Permit Fee CG NCO 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) t0 ZaD Ghe * Number L This Section F&bfftE1ifUii6Wr Date Building Permit Number. Issued: Signature: Building Commissionertlnspector.of Buiidings 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 Side L: R. 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? dvs NO D ONT KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO l DONT KNOW 0 YES 0 IF YES: enter Book Pagel and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 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 NO IF YES, describe size, type and location c ,,x �2 N kill& nW'` i'lAL. 001\oC s`l)re�t ere'anR ro osedchan es o or a rtlons of si ns intened the` ro "ert YES NO P P y• 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 F Addition F Replacement Windows Alteration(s) 0 Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding [0] Other [0] Brief Description of Proposed �+ f Work: ��. �( �CVr`tl \i /NEw �rp �S C L rt d✓ �� We L' Y °s nt' Alteration of existing bedroom Yes X No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa. If Ne hAUSe °and or addtttbri - -`to eXistmciy #ollowing: 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 as Owner of the subject property hereby authorize to act on my be alf, i� all ryatter 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. Print Name - - -- Signature of Owner/ gent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder : - �✓` L e j _ i(e t t L S - 7 -� q 67 License Number � r? ( ( r, L4 C1 V�lCi6'�A1 S b✓� C Wn a t :� W, k 1u 1 7 - Address Expiration Date Signature Telephone 9 :. Re4 lstered , Homerlmproueitent.Conlractar Not Applicable ❑ Th vae�wc�� Company Name Registration Number q 1 .�K ( i Address Expiration Date W �G'CN 1� ►�I 1a C� I O �j 3 Telephone + z 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_w -ners" 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 ort ampton r tnances,' a e - s- 0eneral-faws- Annotated. Homeowner Signature The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investig, ations ' 600 Washington Street Boston, MA 02111 www.mass govA a - Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb.ers Apoiicant Information Please Print Lesibly Name ( Business /Organiiation/Individual): (e 1{ e: Address: 2A City /State /Zip: WLcAe(, WA ntco, 3 Phone.#: 4t ecS ( - 9 Are you an employer? Check the appropriate box: Type of project (required) : to 1. ❑ I am a employer with 4.. [D I am a general contractor and I employees (full and/or part- time). * have hired the sub-contractors 6. E] New constmction 2.9 I am a sole proprietor or partner- listed on the attached sheet 7. © Remodeling ship" and have. no. Vloyees These sub - contractors have. .8. E] Demolition working for me in any capacity. employees and have workers' 9. Q Building addition [No workers' comp. insurance comp. insurance. b 5. We are a corporation and its 10.❑ Electrical repairs or additions o _ "fic_ess_ haye.xescis_d .theiz am a�iomeowner Being- all�vork 1. �--P -lamb m g repairs or additions myself [No workers' comp. right of exemption per MGL 12. Q Roof repairs nsuran required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation polcy information. t 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 isproviding workers' compensation insurance for my employees Below is the policy and joh site formation. Insurance Company Name: Policy # or Self-ins. Lic. #: Expiration Date: Job Site Address: 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 criminal 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 f Of up to $250.00 a day against the violator. De advised that a copy of this statement may be forwarded to the Office of Investisations of the DIA for insurance coverage verification I iio here certi under the airs and enalties o e 'u that the inform ation rovided_above istrus and-- _ f P P fP -�Y Signature: I c U Date: Jq. Phone #: 4 t 3 G Ems' ykll!� - -- Official use only. Do not write r: this area, — to be completed by c or town official -City or Town: PermitUcense # Issuing Authority (circle one): I.- Board of Health 2. Building Department 3. City/Town- Clerk 4 Elec trical Inspector 5. Plumbing Ijor 6. Other I 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 xegniation The in oc�ion pess�e�uir�� that the building department be calle to inspect work at various stages, which include foundation /footings (before backfilI), 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 ---------- _pe=its- in- conjunctionto- the- buildin"ermit-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. Address of work location t 16 do io WO rz k v - oaf kA e ' 0 Oil d ro 0 - t,,- 4se eel r- — T4 Le t c'e (toe 4a Pr t r a L L,) 70 C, v kt, 4"1 de e- r V D D. P 7-1 TE WMT � L - � t j 01093 665-4818 16 do 10 WO k AL A N V- Pk e 1'c o ond C h a Se. c roe, I-s: Le 41C r- L ) e IZ 4, r(.- Wet f'i^ 7,A r 1.2 5; P at -t 4f'� D D. 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