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16B-013 71 BRIDGE RD n BP- 2010 -021 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Bloc 16B - 013 CITY OF 14ORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category_ BUILDING PERMIT Permit # F3 P- 2010 -0216 Project #:: IS -2010- 000270 Est. Cost: $5400. F ee: $35.00 PERMISSION IS Hr- RE-13 GRANTED TO: Const. Clas Contractor: Liccnase: Use Grou THOMAS J BOYLE JR0 40979 L ot Size(sq. it.): 1001 8.80 _Owner LL_QW1CZ_'.K THO MAS & SI IARON Zoning: URB(1 Applicant: T S J BOYL E JFt Applicant Addr a Phone_ Insu rencte: P O B OX 15 — _ -C413) 296 - 544 " CHESTERFIELDMA01012 I&VUT'_D ON.8 2ti%JUO9 0 :00 : 00 TO PERFORM THE FOLLOWING WORK .- REPLACE PORCH CEILING,GARAGE DOORIWINDOWS & CLAPBOARDS POST THIS CARD SO IT IS VIS FRO M�THE ST REET Inspector of P umbing Inspector of Wiring; D.P.W. Bu;ldiag Inspector Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: DrivovKy hindl: Final: Final: Rou(Th Frame: Gas: Fire Departme Fireplace /Chim -ney: Rough: Oil Insulation: Final: S Final: OK 61) 110 L4(4( , s THIS PERMIT MAY BE REVOKED I3Y T1 IE CITY OF NORTHAMPTON UPON VIOLATION OF' ANY OF ITS RULES AND REGULATIONS ' p C ertificate of Oc cuu ancv 6 / /a _ signature: _ Fee .a_ Da Paid: A Building 8/26 /2009 0:00:00 4 5.00 212 Main. Street, Phcne 413 587 -1240 Fax: 413 58 ( ) ( ) - 71272 Building C�mmissiomor - Anthony Patillo i J R BP- 2010 -0216 GIs #: COMMONWEALTH OF MASSACHUSETTS '�. 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 -0216 Project # JS- 2010- 000270 Est. Cost: $5400.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THOMAS J BOYLE JR 040979 Lot Size(sq. ft.): 10018.80_ Owner: LUDWICZAK THOMAS & SHARON Zoning: URB(100)/ Applicant: THOMAS J BOYLE JR AT. 71 BRIDGE RD Applicant Address: Phone: Insurance: P O BOX15 (413) 296 -4544 CHESTERFIELDMA01012 ISSUED ON. 812612009 0:00:00 TO PERFORM THE FOLLOWING WORK .- REPLACE PORCH CEILING,GARAGE DOOR/WINDOWS & CLAPBOARDS 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 8/26/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo � A � v �F7e aa�eltse�Orlly a City of Northampton Spa `et Building Department 212 Main Street Sestu Sep�cFII Xx Room 100 Aorthampton, MA 01060 � e� �� � � � X, t:U\J Ohone 413 -5q7 -1240 Fax 413 - 587 -1272 PI Site s� � 5 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 Zone OyerlayDistrict ' EIm St `District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) Current M,*Iinq A dress: C 1 r Telep one Signature ` 7 2.2 Authorized A en 1-1-7 r PQ Aw. Name (Pri v Current Mailing Address: y13 S ature Telephone SECTION l3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only competed by ermit applicant 1. Building ('a) Building Permit Fee 'y 100 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 Jl This Section For Official Use Oral Date Building Permit Number. Issued: Signature: Building Corrmmissionerllnspector:of Buildings-!- - Date � w Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomptete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage�� Setbacks Front Side L: –_. — R ,. ". "_ L :—,-- R Rear Building Height p...... _ Bldg. Square Footage % i Open Space Footage "_. "__. _ % _. (Lot area minus bldg & paved m i -kin # 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 IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES 0 _ IF YES: enter Book 's Page and /or Document #` B. Does the site contain a brook, body of water or wetlands? NO Do 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 re t>iiere'any proposec anges o or adait�o� ns o'stgns intended - for tTie property ? YES NO IF YES, describe size, type and location: E. Will the construction activity disturb {clearing, grading, ex vation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YEsn 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 E] Or Doors i Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding Other [o] Brief D scn ion of Pr d LD�L��. Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet Ga if,:New.house and or..a itil sort °.to: ez sttnq fiousil q ,rco r►plete th f6[l6wh : 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 FOK BUILDING !PERMIT as Owner of the subject property A hereby authorize ( l to act on my behalf, in II m rs relative to work authorized by this buildingnrn a — pepplication. � O© gndrur& of Owner Datc as Owner /Authorized Agent hereby declare that the statements and inf orm ati on on t e foreV ppli tion re true and acc rte, to the best of my knowledge and belief. ' Signed undcr the Paine and penalties of perjury. P J� J' ezq v� F 2 F rE ignature er /A Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder : 1-1-7 V {3d yd E r y® q , f License Number y 1 b2 -0 ���v}Z �' �'�7" 1� �l r ono/ 6 ao-� �o1I A Expiration Date Telephone 9 :Regis #ereit Hrimp:ltxtztviriefmct4r ;,. Not Applicable ❑ ompanv Iffame _ Registration Number Expiration Date Telephone — -2!R,4 L15�/�► _SECT 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...... it T_he_currennt_exemption,for,' homeo�a%ners" was exte-ndPrl to inclnde, er- occupie 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'perfori . work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of orthiff pton r finances;° a e and o s General barus- Annotated. Homeowner Signature The Commonwealth of Massachusetts Department of IndustrialA ccidents Office of Investigations 600 Washington Street Boston, MA 021II www.massgov /dia - Workers' Compensation Insurance Affidavit: Builders/ Contractors /Etectricians/PIumb.ers A t)licant Information Please Print Legibly Name ( Business /Organiaation/Individual): Address y City /State /Zip 4 , tD . Phone. #: Are you an employer? Ch the appropriate box: Type of project (required): 4.. I am a general contractor and I 1.0 I am a employer with 6. 0 New construction employees (full and/or part - time).* have hired the sub- contractors 2. X_ I am a sole proprietor or partner- listed on the attached sheet: 7. Remodeling ship and have no loyees These sub - contractors have 8. � Demolition wor for me in an capacity. employees and have workers' Yap tY• .. 9. Q Building addition [No workers' comp. insurance cos *_ms , mancp required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a o ce -baiv e i���heiz_ -Q Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required] t c. 152, §1(4), and we have no . 13. [� Other employees. [No workers' comp. insurance requited}. 'Any applicant that checks box #I mim also fin out the section below showing their workers' compensation policy information. t Homeowners who submit this afdavit.indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. ZContractors 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. rf the sub - contractors have employees, they must.provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site in Insurance Company Name: Policy # or Self-ins. Lic. #: Expiration Date: Job Site Address: city/State/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 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. De advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hgreb y� cent under the pains and penalties ofperjury that the information provided- above_is-true andcorrect-- _ Signature ate: - Phone #: - Official use only I)o not write vi this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): - - I: Board of Health 2. Building Department 3. City/Town 4. Electrical_ #or S. Plumbing Inspect — - -- 6. Other i Contact Person: Phone #: y J 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 regulation The inspection n that the building department be calle 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.r_esult 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 ------- - - - --p it- s -i-n -- 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 me. 4 _ Date _ Address of work location