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17C-253 (3) May 29 2012 I request you grant a modification to waive the requirement for control construction for the project at 29 North Main St, Florence, Ma because the work is of minor nature, will not effect health, accessibility, life and fire safety , or structural requirements and is impractical in that the cost of control construction is considerable when compared to the cost of the proposed work. Thank You for your consideration. Respectfully, Larry Jubb Jubb Construction Co. P.O. Box 429 Greenfield, Ma 01301 t t ' • • . AFFIDAVIT . . . t• • As a result of the provisions of MGL c 40, 554, I acknowledge that as a condition of Building Permit •• • Number • all debris resulting from the construction activity governed by this . • Building Permit shell be disposed of in a properly licensed solid waste disposal facility, as defined by MOT. • ', c111,S150A_ t • I certify that t will notify the Building Official by • . (l'vo months maximum) of the location of the solid waste disposal facility where_th'e debris , resulting from ' • thr, said construction activity shall be disposed of, and I shalt submit the.appropriate: fowl for attachment • to th e Building Permit. . ' .. • . . • Date �� Signature of Pernalt Applicant • • ' ; • • • (Print or type the following information) ' • . • . .4 � 0 j ,. ' Name of Permit Applicant • ( O /2 C T ; . Firm Name,. if any • • • „ • , • • .. Address • • .. . ... _..:. ...1.. _ •;Th d bri ..11 := disposed`:.o f . : ..;; ; :. :; ..• ,.:.: • „ .... : Y..: .: : •, : :;•-•; • . ( J :. V Locata on of Facility) • • • • _* Department of Industrial. Accidents =�?�1. = Office of Investigations � =-- � 600 Washington: Street _...rte — :: c Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): ® I ,AI A 4 R Address: po.�1� (DQ 1 City /State /Zip: 1._!= Phone #: (a ) r7 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6 ❑ New construction employees (full and /or part- time).* have hired the sub- contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. $ 7 ❑ Remodeling ship and have no employees These sub- contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL i LE Plumbing repairs or additions myself [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13. El Other comp. insurance required.] "Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. , Insurance Company Name: `�C U o �� c )nairPAnCo Policy # or Self-ins. Lic. #: (/ " g0 6"i r " 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 ,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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify undfr the pa penalty ofprjury that the information provided above is true and correct F � Signature: n, �` r- �,���• Date: Phone #: �� - !aD Official use only Do not write in this area, to be completed by c or town offic City or Town: Permit/License # 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 #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: ,{ ,, ���J p ,r^ Not Applicable ❑ ____ p,()-(0,s- Name of License Holder : L a u , y � 3C Q , � `( 1 , r ( N., i q •-•-i License Number „..., --,,_ .. ),/,.0)(./ ., Addre s Expiration Date y? =ture Telephone • 9. Registered Home 1 provement ontractor. Not Applicable ❑ ,. 1 di di e / J CompanyN e i Registration umb 'O it_))( ( IP - 7 / 6,0 il Ck,61 r '- . Address �� �, ��� Expiration ate Telephone //"%(.r 6 �/- - SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(8)) 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 ❑ 11. - Home Owner Exemption 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 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 Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WQRK (check all applicable) New House Q Addition ❑ Replacement ndows Alteration(s) ❑ Roofing n Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [ ] Decks [[] Siding [0] Other [CI] Brief Description of Proposed (4 PPOk Ab p' ` \ 3 Work: V Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa. If New house and or addition to existing housing, complete the following: 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 I, % A4 f ..J le i , as Owner /Authorized Agent hereby declare that the statemen 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 an"- f Signature :f Owner /Agent 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: L: R: Rear Building Height Bldg. Square Footage Open Space Footage % (Lot area minus bldg & paved , parking) # of Parking Spaces ' Fill: (volume & Location) , A. Has a Special Permit /Variance /Finding ver been issued for /on the site? NO 0 DONT KNOW YES IF YES, date issued:' IF YES: Was the permit recorded at the Re stry of Deeds? NO © DONT KNOW YES IF YES: enter Book ' Page 1 and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ' DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the C nse anon Commission? Needs to be obtained O Obtained ® , Date Issued: I C. Do any signs exist on the property? YES ® NO IF YES, describe size, type and location: 1 D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, 'ty ( ' g, g ding, ex ., vation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO ip IF YES, then a Northampton Storm Water Manageme ,. P .4 it from the DPW is required. Department use only RED City of Northampton Status of Permit Building Department Curb Cut/Driveway Permit J - 6 26t2 ! 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability �tcl orthampton, MA 01060 Two Sets of Structural Plans °EPT of su '�.- N ORTHAM '" • ne 413- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE 0 TWO FAM Y DWELUNG SECTION 1 - SITE INFORMATION '3 1 1.1 Property Address: This section to be completed by office C\)? ���� Map Lot Unit FI oK PIA Zone Overlay District / ✓ 7`t Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: C htlICK /// /eC1-0(J Pe; Name (Print) Current Mailing Address??? ) 7- Telephone Address??? Signature 2.2 Authorized 'went: -7 ; i�'p 762_ 77}- 630 , 0 9' Name (Print) Current Mailing Address: j (%j ,7 . «GlTVa C� Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (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) < i / — T7 (0 Check Number i s g s �Q This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /inspector of Buildings Date File # BP- 2012 -1077 APPLICANT /CONTACT PERSON THE JUBB CO INC ADDRESS/PHONE P 0 Box 429 GREENFIELD (413) 772 -6217 PROPERTY LOCATION 29 NORTH MAIN ST MAP 17C PARCEL 253 001 ZONE GB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 7 ( 53 1-9 Fee Paid /(.JQ Typeof Construction: INSTALL REPLACEMENT WINDOWS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 55333 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: proved 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 dory- ∎'•.+ ; 'onDel.y :nature of Bui ding Of al 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. 29 NORTH MAIN ST BP- 2012 -1077 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C - 253 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: window replaced BUILDING PERMIT Permit # BP- 2012 -1077 Project # JS- 2012 - 001859 Est. Cost: $26779.00 Fee: $70.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THE JUBB CO INC 55333 Lot Size(sq. ft.): 18948.60 Owner: CLINICAL & SUPPORT OPTIONS INC C/O PATRICK LEVELE Zoning: GB(100)/ Applicant: THE JUBB CO INC AT: 29 NORTH MAIN ST Applicant Address: Phone: Insurance: P 0 Box 429 (413) 772 -6217 Workers Compensation GREENFI ELDMA01302 ISSUED ON:6/7/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS 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 6/7/2012 0:00:00 $70.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner