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43-044 41 AUTUMN DR BP- 2010 -1028 GIs #: COMMONWEALTH OF MASSACHUSETTS Map :Bloc 43 - 044 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 -1028 Proiect # JS- 2010 - 001519 Est. Cost: $3000.00 Fee: $1.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor. License: Use Group: Homeowner as Contractor Lot Size(sa. ft.): 12109.68 Owner: LADOUCEUR FRANCIS J JR & MARGA Zoning: Sg R(100) //WSP II Applicant. FRANCIS J JR & MARGA _ A?: 41 AUTUMN r;t? Applicant Address: Phone: Insurance: 41 AUTUMN DR (413) 586 -2956 O FLORENCEMA01062 ISSUED ON :512112010 0 :00 :00 TO PERFORM THE FOLLOWING WORK.- REPLACE 8 X 10 SHED W/8 X 14 - MUST ESTABLISH SIDE SETBACK PRIOR TO INSPECTION 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: ©j THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occu anc y signature: FeeType• bate Paid: Amount: Building 5/21/2010 0:00:00 $1.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo File # BP- 2010 -1028 APPLICANT /CONTACT PERSON LADOUCEUR FRANCIS J JR & MARGA ADDRESS/PHONE 41 AUTUMN DR FLORENCE (413) 586 -2956 Q PROPERTY LOCATION 41 AUTUMN DR MAP 43 PARCEL 044 001 ZONE SR(l00 )//WSP II THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out i Fee Paid Typeof Construction: REPLACE 8 X 10 SHED W/8 X 14 New Construction Non Structural interior renovations Addition to Existin Accesso1y Structure Building Plans Included: Owner / Statement or License Maw ESTANi5if 5i D6 S ETBA(A P RAd 10 1 SV('C ld � 3 sets of Plans / Plot Plan ' THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN 6RMATION 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 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. w ' City of Northampton Building Department e . 212 Main Street Room 100 ✓ Northampton, MA 01060 phone 413' - 587 Fax 413- 587 -1272 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 L 4 1 CA�V m f Map Lot Uait rr Zone, 4z '" verlay Distnct c E64t' bistric! CB,District SECTION'2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record j - LAhQL6UK, 'I/ A (, v\ K Or rLorfit'(J� Name (Print) / Current Mailing Address: Telephone z Signature / v v ��O� 2.2 Authorize 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 applicant 1. Building �� / (6) 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 Date Building' Permit Number: Issued: Signature: Building Commissioner /Inspector:of Buildings Date 1 L 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 I Setbacks Front r --- -- ; Side L: R: i i L: R: ..,..._ Rear � 7 Building Height ---- Bldg. Square Footage % r--- Open Space Footage (Lot area minus bldg & paved par # of Parking Spaces Fill: volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO DONT KNOW 0 YES Q IF YES, date issued: { E IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page ! 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: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q 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 n 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 El Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding [0] Other [a Brief Description of Proposed C�� �� /Q Work: d Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 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 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 pedury. EA9CI y ►4 �lc1 �C -+� (� Print Name S-/ Signature of r gent Date r y SECTION 8 - CONSTRUCTION 'SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone °mw v,.a .w Not A pplicable ❑ Oak "iff 0-mm rMH.. PP Company Name Registration Number Address Expiration Date Telephone SECTION 40- 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 ho meowner. 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 Zonin La and State of Massachusetts General Laws Annotated. Homeowner Signature T The Commonwealth ofllfassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass govli a -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print LejibIy Name ( Business /Orgmizatiomandividuai): . Address: City /StateMp: Phone. #: Are you an employer?. Check the appropriate box: Type of project (required) :. 1. El am a employer with 4.. E] I am a general contractor and I employees (fall and/or part-time).* have hired the sub- contractors 6. ❑ New construction 2.. 0 I am a sole proprietor or partner- listed on the attached. sheet. 7. Remodeling ship ;n• have no. employees These sub - contractors have. .8. ❑ Demolition working for me in any capacity. �Io_yees_and have worhers' 9 : _ - -- -� -- addition t# DF'OTkCPS' cO=P` fi.wurance -. coIDp, mctmanrr #... ._ � _ _ :.. required:] 5. � We are a corporation and its 10.0 Electrical repairs or additions I am a homeowner doing all work Officers havexeroised thee 1 L❑ Plbing repairs or additions ` myself (No workers' comp. of exemption per MGL 12. hoof ins c. 152 § insurance required) t 1(4), and we have no exnnloyees: [No workers' 13.E Other comp. insurance required }. `Any applicant That checks box #1 must.also fill out the section belowshowing theirworkas'- comp ensation poficy uifflrmpdowL t Homeowners who submit this affidavit.indic Ling they are doing all work and then hire outside contractors rmtst submit a mw affidavit indicating such =Cofactors that check this box must.attached an additional sheet showing the name of the sub-Contractors and state whetherornot those entities have employ —..lf the sub- sontraciors have employees, they mnstrrvide their workers' comp..policyntanber. I am an employer that u providing workers compensation insurance for my employees Belo_ w is the policy and job site information. Insurance Company Name Policy # or Self-ins. Lic. A Expiration Date: Job Site Address: Cimstate/Zap: Attach a copy of the workers'' compensation policy declaration page'(showing the � P oIi number and itatton date . : Failure . to secure coverage_ as required undes.Seation 25k of1VIGI:'c.15Z can lead "to the imposition of pcnalhes of a fine up to $1,500.00 and/or one- year t, 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 maybe forwarded to the Office of . ,. InvestiQahons of the bIA foinsurance` covera:ae verification. , - I Hereby ov gertify under the pains d ofPedwy thafthe in ornurdan rovidedlrb� r�ue_aadrvrr f P Ap _ at �are: ate 5 V. Phone #: y - Offrcial use only. Do not write in this area, to be completed by city or town official 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 your), 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 permits 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, I— understand the above. .(Home er /resident's A re requesting exemption) I will call t schedule all require building inspections necessary for the building permit issued to Date Address of work location L// /ac n Ai (' r. 9 I ` a� ��i � �— ' �a ' jai n �, � i ���� � I I II I, - I 1 I I 1 I I I 1 O I I O 11 I ■� C O I I I Alt CA) C:) oil I 1 I I N I ,I I I I I ® I I, I •� I O � tip /r �I i i xr I x I #d? , N I A , Nth, x .