Loading...
17A-051 BP-2010-0554 GIS COMMONWEALTH OF MASSACHUSETTS - W-rii = 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 -0554 Project # JS- 2010 - 000781 Est. Cost: $3000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: C onst. Class: Contractor: License: Use Group: ROGER B GUNN 033055 Lot Size(sa. ft.): 10018.80 Owner: - ANDREW SCOTT J zoning: URB000) Applicant: ROGER B GUNN AT: 123 BRIDGE RD Applicant Address: Phone: Insurance: BOX 12 (413) 207 -4790 WC CUMMINGTONMA01026 ISSUED ON :1112012009 0:00:00 TO PERFORM THE FOLLOWING WORK. REPAIR GARAGE 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 11/20/2009 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo i 1 4 r City of Northampton ooh Building Department��� 212 Main Streete a �� Room 100 Northampton, MA 01060'A� phone 413 - 587 -1240 Fax 413 - 587 -1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be completed by office 1.1 Proi)ertv Addm ss /a Map Lot Unit ±Overlay District Etm °St District CB Distric SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT' 2.1 Owner of Record: Awl Name nt Cu ent ailin A s 1 Telephone Signature 2.2 Authorized Agent: Name (Print) Current ailing Add ess: C! O ,, 11207- yr79y Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building boa (a) 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 O#flcial Use Onl Date Building Permit Number. Issued: Signature: 1 / 0 9 Building Commissioner/Inspector of Buildings Date a 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 A Side L: R L R.! Rear _.. _.. Building Height Bldg. Square Footage % { °' Open Space Footage % _ (Lot area minus bldg & paved p arking) # of Parking Spaces " -° If A Fill: (volume &Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Regis" of Deeds? NO DONT KNOW YES 0 IF YES: enter Book I 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 0 NO IF YES, describe size, type and location: ............ . ... .._ - b`: re t ere any propose c anges to or a rtlons o signs intendfor the property ? YES NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, ex ation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 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 Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C7 Siding [0] Other V 47 Brief Description of Proposed Work: OC . V 47 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa. lf_New tiotise n, or a +cC> i a �c sfiE�i " ©assn coin ' ` ate fo l i a. Use of building :One Family Tw amity +� Other b. Number of rooms in each family u Number of Bathrooms c. Is there a garage attached? �p _ d. Proposed Square footage of new constructs 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 wetla ? Yes N Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floo elow finished grade k. Will building conform to th uilding and Zoning regulations? es No. I. Septic Tank ity Sewer Private well City water ply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT dR CONTRACTOR APPLIEShFOR U.ILDIND PERMIT A w bRX , 1 as Owner of the subject property hereby authorize to a my behalf, ' all matt s relative to work authorized by this building permit appli tion. ignature of OwnerDate T Z4 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. Signe der the pains and nalties of perjury. 5 Print e Signature of Owner /Agent Date •af SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder License Number r 07323 a�5 Address Expiration Date Signature Telephone oo --' d F el ��,� y13 -907- 9 79D 9...Re4is#ered Hdme.Impro4err►enf Gantracto% ,. ._ Not Applicable ❑ Company Name Registration Number 3 & I Address M � � Expiration Date L WAUYiww.,en7 Telephone �—� S ECTION 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...... ❑ 1 ..� ,: -The-current-exemption for "homeowners" wa e xtended to include Owner - occupied Dwellin -s 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. CAM 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, ut is intended to lie, a one or two family dwelling, attaohed or detached structures accessory to such nse and/ or farm structures. A person who constructs more than one home in a two -vear 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 al :Laws- Annotated. o ampton " r - tn nces;' a zr Homeowner Signature + a y _ ' KI ne Commonwealth of Massachusetts Department of Industrial,4 ccidents Office of In vestigations 600 Washin Street Boston, M4 02111 www.mass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumb.ers Applicant Information Please Print Legibly Name (Business/organization/Individual): Address: N-2 " IQ Z! x tmZZ 7-V,2 J O I&Q l // City /State /Zip: 1 )" Phone. #: l,� 3 - cj9n Are you an employer? Check the appropriate box: Type of project (required): / 1. I am a employer with 4.. E] I am a general contractor and I * have hired the sub- contractors 6. ❑New construction employees (full and/or part-time). 2. ❑ I am a sole proprietor or partner- listed on the attached sheet 7. Remodeling ship and have no eznployees These sub - contractors have S. ❑ Demolition wor king an for me in capacity. employees and have workers' Y aP ty 9. Q Building addition [No workers' comp. insurance _ comp-ins required:] 5. We area corporation and its 10.0 Electrical repairs or additions cers�ia exercised the 3.0 I- am- werk- - - -- - -- -- - - — -- 1 - 1 -0 -glumhing ;e'Paus or additions myself. [No workers' comp. right of exemption per MGL 12. Q Roof repairs insurance 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 fin out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing an 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. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site formation. Insurance Company Name: A dds.11�.MAI I A ^4"_&-A = �1..�� .�dtrQJt O 3 g o.0 Policy # or Self-ins. Lic. C 3 `l 1 /221 of q Expiration Date: Job Site Address: City /Sta d I �p Attach a copy of the workers' comrensation policy declaration page (showing the policy number and expiration date). Failure tcr secure coverage as required under Section of MGL c. 152 can lead to the imposition of crimm4l penalties of a fine lip to $1 and/or one -year imprison as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.44 a day against the violator. to advised that a copy of this statement may be forwarded to the nffi'i P of Investigations of the DIA for insurance coverage verification I do hereby_certify under the pains and penalties ofperjury that the information provided_above rslrue�nd correct_ __ _ -._ Signature: (� �►.�.o Date Phone r Q - Official use only. Do not write in thisarea, to - be completed by cityy or town officr'aL City or Town: Permit/License # Issuing Authority (circle one): I� Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Ins ector - -- _ 6.Other Contact Person: Phone #: • 1 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 r ation s The inspection m ess requires 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 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 its.- in- cenju. action -to_thebudding4xrmitissued, 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