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28-077 Commonwealth of Massachusetts City/Town of Florence Number --^ -�---�--L Application for Disposal System Construction Permit Fee Form 1A B. Agreement The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signature _— _— Date Application Approved By: Name Date Application Disapproved for the following reasons: U Li (166 Conditions: 2).Svstem Dcsiener must m i inspect and �, That the sewage disposal system was installed I If this w In accordance with the approved plans and Title 3. 2). is a system with the S.A.S.constructed in Title S fill the System rlcsigner must conduct a bottom inspection of the excavated area prior to the ptaccmept orthe fill, 3).No changes can be made during construction by the Installer without prior approval by both the Sys a Designer and the Board OfHea(h Ageat. 4)•other conditions: t5form1a.doc•06/03 Application for Disposal System Construction Permit•Page 3 of 3 l 6 BOARD OF HEALTH City of Northampton APPLICATION FOR A WELL CONSTRUCTION PERMIT Well Permit Number (TO BE ASSIGNED BY BOARD OF HEALTH) `Fee $50.00 91 This application must be accompanied by a scaled plot plan, produced by;a civil engipeer or registered sanitarian showing the minimum distances required in Title 5 of the State Envirwmental Code. For new construction, requiring a septic system, the septic system plan submitted for the property in compliance with Title 5 requirements will be acceptable if the proposed well location is included. Application is hereby made to construct( ) or repair O a private well. n 's ame Date `` Street ress Telephone Number City, State, Zip Code Location of Proposed Well Tax Map# Parcel # (if different from address) { Well Driller(submit evidence of valid state registration) Conservation Commission Approval (SLaValley(ainorthamptonma.aov) For new construction: Septic system plan complies with Title 5: yes ( o O n/a( ) Septic system plan shows location of well: yes ( no ( ) n/a ( ) For new, repair or location to teach field, sept rcity sewer: A scaled well construction plan has been submitted:yes ( ) no ( ) n/a ( ) ALM� r\-a.v 1's Si6k&Vof Applic nt Date Please Mail Application to: Northampton Board of Health 212 Main Street Northampton, MA 01060 ------------------------------------------------------------------------------------------------------------- TO B �CO LETED BY BOARD OF HEALTH Permit expires on: (One year from date of issuance) 40M " 7 Perini issu d (date) path of least resistance and carries 99%of the moisture in a structure.This is evident every time one exposes fiberglass insulation and finds black insulation, 1102.14 2rfor a�fsealing requirementsgh the insulation. 780 CMR R601.2 for vapor retarder s and Table N 37. Unvented attic assemblies. Hot roofs are allowed,l attached, bolts or lags.780 CMR R502.2.2.1 01Noteo ThruLoks 38. Deck ledgers and post must be appropriately are engineered for post attachment supporting a railing. Lateral attachment is required for each deck per section 502.2.2.3. 39. Smoke and CO detectors as required. 780 CMR R314 and R315. a. Smokes in each bedroom, within 10' of a bedroom door, and at the bottom of a stair leading to a finished floor above. ft, code in the b. CO within 10' of bedroom doors, at each level,for every 1500 sg , (plumbing mechanical room) Except if there are no fossil burning fuels. c. Heat detector in attached garage, and other large unfinished unconditioned spaces. 40. Closets beneath stair which have doors must be drywalled with%'. 780 CMR R302.7 top 41. If there is mechanical equipment or a combustible f minimum sRO of 22acx 30n�s3r0equired to be locaasured from d in of ceiling joist to bottom of rafters an attic access an accessible place. It must be insulated,g asketed, and secured in place. Relevant items must be submitted to the building department for approvals before inspections and or Certificates of Occupancy can be issued. Feel free to call if you have any questions. My telephone for walk-ins at 12:00 noon on Wednesdays My maily through Friday, 8:30 am to 4:30 pm, excepting we close address is: cmiller(cDnorthamptonma. ov Thank you for your cooperation on these atters. uck Miller City of Northampton Assistant Commissioner and Zoning Enforcement 22. Stairs have critical standards, make sure you know the floor finishes when planning. Minimum tread 9", maximum riser 8%", maximum overall variance for the run is 3/8",4" sphere rule on risers except where the total rise is 30" or less 780 CMR R311.7.4.3 Exception,4 3/8" on balustrade, 6" in the triangle. Graspable rail 1'/0" minimum and 2 maximum rail, height minimum 34" maximum 38", required for 4 or more risers. Landing to landing constitutes a new run. Minimum 6'8" ceiling height from nosing. Rails must be continuous and returned to the wall if not to newel post.780 CMR R311.7. 23. Guards 36" minimum height above walking surface, a bench is a walking surface, required for more than 30" above floor or grade within 36",4" sphere rule.780 CMR R312.1. 24. Floor joist systems that are not equal to 1%' nominal dimension must be covered with%2" drywall or 5/8" wood structural panel or equivalent with some exceptions. 780 CMR R501.3 25. Educate the plumber and electrician about maximum notch and hole sizes, and placement. 780 CMR R502.8 and R602.6. In bearing studs holes not larger than 40%of a stud no closer than 5/8 to the edge, In interior non-bearing studs holes not larger than 60%of a stud no closer than 5/8 to the edge, or holes in joist are a maximum 1/3 the depth not closer than 2"from the top or bottom or to any other hole. Notches are different. 26. Drilling or notching of more than 50%of the wall plate width of an exterior wall or load bearing partition requires a 16 GA 1%' strap across the area and 6" beyond each side with 8- 10nd nails. 780 CMR R602.6.1 27. Dryer ducts must terminate outside of the building, have a backdraft damper, cannot include a screen, and require 3' clearance from windows. 780 CMR M1502.3 28. Dryer duct transition is limited to 8'of aluminum flex, must be exposed, and the proper UL listing.780 CMR M1502.4.3 29. Dryer duct maximum equivalent length is 25' less 5' per 901 elbow or per manufacturer's specs.780 CMR M1502.4.4.1, no screwed connections. 30. Markup air is required for any exhaust hood of 400 CFM or more. 780 CMR M1503.4 31. Fireplaces require all combustion air be provided from the exterior and below the firebox, duct work maintaining 1" clearance for 5' from the duct outlet for all fireplaces and airtight doors. 2009 IECC 402.4.3 32. Fire and draft stopping shall be completed before rough inspection.Typical locations,top (ceiling) and bottom (floor) plates, soffits, and every 10' within enclosed cavities. 780 CMR R302. 33. Ignition barriers are required over all thermal plastics and must be in place before final. 780 CMR R316. 34. Dwelling/Garage fire separation.An attached garage(within 3' of main structure) is required to have%2' drywall on the garage side of the separation wall and if there is a finished space above the garage all walls must have %"drywall and the ceiling 5/8" drywall. 780 CMR R302.6 35. Energy aspects shall comply with the stretch energy code.780 CMR Appendix 115AA or 2009 IECC. a. An initial HERS evaluation is required including insulation levels anticipated. b. A final HERS evaluation confirming code requirements have been met including duct testing. c. A signed copy of the Thermal Bypass Checklist. d. Energy information including mechanical equipment posted on the electric panel. e. Remodeling and Additions can be completed in accordance with IECC 2009 with Energy Star Windows and the Thermal Bypass Checklist. Duct blast testing when practicable. f. All band joist insulation must be enclosed within an air tight cavity,which you must create. 36. Vapor retarders.Although these are still in the code have exceptions, one must understand that there is a difference between a vapor retarder or barrier and an air barrier. An air barrier is intended to stop air flow(convection)a vapor retarder or barrier is intended to stop molecular moisture transfer(diffusion). A vapor retarder or barrier is effective even if there are some holes or gaps, however an air barrier has to be absolute and complete. If air can leak through an electrical device or through a crack it follows the 5. Through wall form ties must be removed from both faces and patched with hydraulic cement.780 CMR R406.2 of amendments. %" and be embedded a minimum of 7" into the concrete. 10" bolts! 6. Foundation anchor bolts must be 780 CMR R403.1.6 7. 780 foundations require 3/8 parging before damp proofing.780 CMR R406.1 see exceptions. 8. Emergency escape is required out of every basement whether habitable or not.780 CMR R310.1 r idea), exhausted (similar to exhaust 9. Crawl spaces can be treated in three different ways,vented (poo only systems), or treating the space with supply and return. See 780 CMR R408 10. Ceiling joist are intended to prevent spread,once raised above the wall plate they become rafters ties and may require up sizing of rafters and increased nailing for example with a 4" slope 8-16nd common are required at each connection. 780 CMR R802.3.1. When there is neither of these a structural ridge is required with a load path to the foundation. 11. Steel straps over the ridge or 1x4 minimum collar ties are required 4' OC in the upper 1/3rd 780 CMR R802.3.1 12. Ridge boards must be the full depth of the cut. 780 CMR R802.3. 13. A complete window and header schedule is required.780 CMR Table R502.5 for header sizing and number of jack studs required. 14. All framing materials which are not code prescriptive must have stamped engineering. a. LVLs b. 1-joist and or Floor Truss c. Roof truss 15. All I-Joist need to be protected from fire with%2 drywall or 5/8 wood structural panel. (R501.3) 16. A braced wall plan identifying appropriate braced wall areas where required (R301.1) and braced wall method being used.780 CMR 602.10. a. Garage corners and large corner window/door layout may require special solutions. b. All corners must be appropriately attached to the foundation. c. When using PFH (R602.10.3.3) or PFG (R602.10.3.4)the nailing requirement is 4" and 3" respectively using 8d common nails or galvanized box nails. PNEUMATIC nails must be full headed with the temper and shank sizing meeting the strict code requirement. 17. When nailing sheathing make sure your pneumatic nailers' pressure is properly set. Nails set too deep perforate the sheathing weakening it and contribute to building damage in high wind events. 18. Ceiling heights minimum 7'for habitable spaces, 6'8"for bathrooms includes tub/shower area if a shower head is used, 6'8" for basements, 6'4" at beams/ducts.780 CMR R305.1. MA amended 19. Hazardous glazing locations, within 24" of a door, or within 60" of a stair, or across from hot tubs,spas, bathtubs within 60 if not 60 above the walking surface, and other locations.780 CMR R308.4 20. Windows over 72 above grade with the opening less than 24 above the finished floor shall meet the 4" sphere rule.Order restrictors. 780 CMR R612.2 21. Egress and emergency escape requirements shall be strictly met. a. Basements,habitable attics, and all sleeping rooms require emergency escape.780 CMR R310 b. Windows within 44" of floor, DH 3.3 sqft min window size, Casement 20"x41" exception 5 sqft at 1st floor. Minimum clear opening 20"x24" or 24"x20".780 CMR R3m0a1 ured from the face of c. Two doors remote as possible at the normal level of travel,opening the slab to the stop with door at 90 degrees, one 32" and one 28" minimum 78" high.780 CMR R311.2 d. Landing at each door 36" out and the width of the door minimum 36 maximum step 7 3/" from the top of the threshold and only in-swinging doors. 780 CMR R311.3 City of Northampton a , Massachusetts :a DEPARTMENT OF BUILDING INSPECTIONS 1r 212 Main Street • Municipal Building Northampton, MA 01060 INSPECTOR June 24, 2014 Laurin Builders PO Box 437 Southampton, MA 01073 Subject Location: 231 Sylvester Road Map Block: 28-077 Mr. Laurin, Your building permit application dated 3-15-14 and plans dated 6-04-14 have been approved as drawn, noted, and per this memo.All work must meet all applicable codes whether noted or not included within this memo. Please follow up on the following items: These items will need to be accomplished as the project moves forward and before rough inspections; 1. All structural members must be sized to carry the appropriate loading. 2. All structural members must have a continuous load path to appropriate bearing. 3. The allowable bearing capacity of the soil without testing is 2000 lbs. per sqft supports must be sized accordingly. 4. All plan changes must be documented and provided to the building department. 5. Braced wall systems must meet the prescriptive code or be engineered. 6. Braced wall section must be inspected before being covered. 7. Elevation and sections do not appear to align,field changes within reason are allowed. 8. Structural components vary between drawings. Either engineered I-joist or conventional lumber can be used provided the system meets code requirements. 9. Landings are required at all doors to the exterior. 10. Stair clearance must be 3' after finishes. 11. The unconditioned 2nd floor section will need two heat detectors. 12. Final HERS rating is required before a CO can be issued. Do not forget the HERS raters required inspections, a failed HERS rating means no CO. Note:July 1 begins enforcement of the 2012 IECC with MA amendments and fire protection for non- dimensional lumber floor system frames,the new Stretch Code is pending. As of August 4th 2011 the 8th Edition MA code is the 2009 IRC with MA amendments. In the following are some generic requirements which seem to be problematic. This is not intended to be comprehensive, nor is it a substitute for purchasing and reading the MA codes. Read only international codes are available on line at http•// ublicecodes cyberregs.com/icod/one must also consider the MA amendments to these codes which can be found at www.mass.gov/dpslbb rs . The current relevant building codes are: 2009 IBC,2009 IEBC, 2009 IMC,2009 IRC, 2009 or 2012 IECC,AA115, MA amendments. 1. Structures shall conform to 780 CMR 8th Edition 1 and 2 family building codes with MA amendments. 2. Grading plan for structures being constructed required. 780 CMR R401.3 for drainage requirements. 3. A basement drainage system is required in all basements 780 CMR R405.2.3. except those in group I soils (table R405.1) proofing 780 CMR R406.1. 4. Foundations that retain earth and enclose interior space require damp p g I MAY - 12014 fElectric, Plumbing&Gas Ins City of Northampton _�. r: „pron, ti,A�„o 12 Lain Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: o�, S7 lye S� D The debris will be transported by: L--(,11,« a,-11Je1' . T-) c The debris will be received by: r)ry .cr.G 14 Building permit number: Name of Permit Applicant ;�Yh LuL-r14 L1-,,,,1 &11de,- 4 Date Signature of Permit Applicant Project Description/Location of Work Provide the following: Description'of purpose and exact location of proposed work including description of what is to be laid or repaired in the proposed trench(e.g.water pipe,sewer pipe,drainpipe,gas lure, power line,communication lines,etc Sketch or drawing showing all proposed work. Anticipated Start of Work Date. LA-»-k�A cl� --J dJVIII � 4 ---�M YES go Check here if Emergency. Describe. K /' V Work in Public Ri -of-Wa Work on Private Property Work within State Layout If yes,attach Stat p Permit Work within 100 of a wetland or 200 ft.of a stream or river.' attach Permit Work within Floo lain. es attach Permit Public Watm/Sewer/Drain Entry Permit Attach P if available Driveway Permit Attach Permit,if available F9MID Z31 SYLVESTER ROAD Pro ect Description/Location of Work.Provide the following: �f Description of purpose and exact location of proposed work including description of what is to be laid or repaired in the proposed trench(e.g. water pipe, sewer pipe, drainpipe,gas line, ❑✓ power line, communication lines, etc Sketch or drawing showing all proposed work. Q Anticipated Start of Work Date. INSTALL A NEW DRIVEWAY AND TRENCH FOR UTILITIES AT THIS LOCATION FOR NEW CONSTRUCTION YES NO X Check here if Emergency. Describe. X Work in Public Right-of-Way X Work on Private Property Work within State Layout If yes,attach State Permit Work within 100 ft.of a wetland or 200 ft. of a stream or river. If yes,attach Permit Work within Flood lain. f yes,attach Permit Public Water/Sewer/Drain Entry Permit Attach Permit,if available Driveway Permit Attach Permit,if available m Pg.?/4 T eted when approved permit is picked np By signing below,the applicant acknowledges and agrees to all the conditions of approval stated below and validates this permit: �l`t, _ l� Applicant Date For City Use—Do not write in this section Department�Approvals/Comm ent Other Referenced Permits + Water J- "I / / 19 G Sewer Streets Condition of road: )qq. ri.. Road last paved: Conditions of Approval ❑ Control Density Fill Required d - Refer to Engineering for plans ❑ Must install clean-out(See Attached) ❑ Subject to 5-yr.pavement moratorium ❑ Other requirements(See Attached) ❑ Wate l-SewerMTain Entry Pezmit Fee { ❑ $250 Permit Application Fee received(Check payable to the City of Northampton) ❑ Fee Waived. Reason: Permit Approval Director of Public Works Date ' •• Pg1tY10 • PENDING APPROVAL 23! CITY OF NORTHAMPTON,MASSACHUSETTS IN SYLVESTER ROAD DEPARTMENT OF PUBLIC WORKS 2014-361 125 Locust Street Trench Permit Number: { ' Northampton,MA 01060 413.587-1570 Date Approved: -^ Fax 413-587-1576 Expiration Date: . skl (for City Use Only) EXCAVATION/TRENCH PER1MT Pursuant to G.L.c. 82A and 520 CUR 14.00 et seq. (as amended) This permit must be fully completed prior to consideration.Submit completed form with permit fee to Northampton Department of Public Works, 125 Locust Street,Northampton,MA 01060. This permit is issued under the provisions of M.G.L.c. 82A, 520 CMR 14.00 and applicable sections of the Revised Ordinances of the City of Northampton,including,but not limited to, Section 285-21. Fee: $250 Check#: 646 Date Issued: 4/10/14 Name of Applicant Primary Phone# JEFFREY M.LAVALLEY 250-2264 Street Address Emergency Phone# 231 SYLVESTER ROAD City/Town State Zip Email FLORENCE MA 01062 Name of Excavator Primary Phone# MARK LAVALLEY &SONS 586-3779 Street Address ( Emergency Phone# 207 SYLVESTER ROAD City/Town State Zip Email FL;ORENCE MA 01062 Name of Property Owner(s) Primary Phone# JEFFREY M. LAVALLEY Street Address Emergency Phone# 231 SYLVESTER ROAD City/Town State Zip Email FLORENCE MA 01062 Insurance Certificate# Policy Expiration Date ON FILE Name&Contact Information of Insurer ON FILE Dig Safe# 2014-150-3952 ` Pg.1/4,Excavationffrench Permit Permit No. D10-14 Conditions: Driveway Permit In lieu of plan approved by the City Engineer I agree to the following added conditions: 1. I will contact the Department of Public Works and have an inspector check and approve the graded gravel base prior to paving to insure compliance with slope and location; 2. I further agree that if in the inspections, any of the permit conditions are not met that I will at no expense to the City remove and replace the driveway as directed by the City Engineer. By: ,y Petitioner Signature Name: Jeffrey M LaValley Address: 231 Sylvester Road, Florence, MA 413-250-2264 Note: The Public Works Department recommends that you provide a plan.showing the proposed driveway with grades and location in the future to avoid possible expense which you will incur by not getting approval of actual plans in advance. For Commercial and Industrial applicants, a plan showing the proposed driveway with grades, location and Planning Board permits are required. Cc: Building Inspector Permit No. D10-14 CITY OF NORTHAMPTON, MA DRIVEWAY PERMIT Date: April 8, 2014 Check#: 647 FEE: $250.00 THE BOARD OF PUBLIC WORKS Driveway must be staked and house & lot number posted The undersigned respectfully petitions your honorable body for: A new curb cut Permission to install a driveway at: 231 SYLVESTER ROAD, FLORENCE,MA Fifteen(15) foot maximum width at the street line. Gutter drainage not to be disturbed. All Drainage shall be directed off the driveway surface to adjacent land and not on the existing Roadway. Driveway surface to be paved as soon as possible if the grade of the proposed Driveway exceeds 3%or more. Homeowners will be held responsible for any cost to the City of Northampton in the event of a washout of this driveway. Code of Ordinances §350-8 8 providing standards for private, individual driveways as amended by the City Council on October 15, 2009,must be followed. By: Jeffrey M LaValley 231 Sylvester Road, Florence, MA 01062 aature: Proposed Location Inspection By: Gravel Base Grade Inspected By: Final Approval: THE BOARD OF PUBLIC WORKS voted that petition be granted. Edward S. Huntley, P.E. Director of Public Works Cc: Building Inspector (SUBJECT TO ATTACHED CONDITIONS 1 & 2) Home Energy Rating Certificate 231 Sylvester Rd Northampton, MA 01062 _11 Estimated Annual Energy Cost Use MMBtu Cost Percent 5 Stars Plus Projected Rating Heating 54.8 $2035 54% HERS Index: 70 � Cooling 1.9 $82 2% Hot Water 17.5 $649 17% Projected Rating: Based on Plans - Field Confirmation Required. Lights/Appliances 23.2 $999 27% General Information Photovottaics -0.0 $-0 -o•,O Conditioned Area 1837 sq. ft. House Type Single-family detached Service Charges $0 0% Conditioned Volume 29617 cubic ft. Foundation Conditioned basement Bedrooms 3 Mechanical Systems Features Heating: Fuel-fired air distribution, Propane, 95.0 AFUE. Cooling: Air conditioner, Electric, 13.0 SEER. Water Heating: Conventional, Propane, 0.65 EF, 50.0 Gat. Duct Leakage to Outside 110.22 CFM25. Ventilation System Exhaust Only: 48 cfm, 11.0 watts. Programmable Thermostat Heat=Yes; Coot=Yes Building Sheli Features Ceiling Flat R-40.7 Stab R-0.0 Edge, R-0.0 Under Seated Attic NA Exposed Floor NA Vaulted Ceiling R-29.0 Window Type U-Value: 0.300, SHGC: 0.270 TITLE Above Grade Watts R-21.0 Infiltration Rate Htg: 3.00 Clg: 3.00 ACH50 Company Foundation Watts R-10.1 Method Blower door test Address Lights and Appliance Features City, State, zip Phone# Percent Interior Lighting 50.00 Range/Oven Fuel Propane Fax# Percent Garage Lighting 0.00 Clothes Dryer Fuel Electric Refrigerator (kWh/yr) 575.00 Clothes Dryer EF 3.01 Dishwasher Energy Factor 0.66 Ceiling Fan (cfm/Watt) 0.00 The Home Energy Rating Standard Disclosure for this home is available from the rating provider. REM/Rate- Residential Energy Analysis and Rating Software v14.4.1 This information does not constitute any warranty of energy cost or savings. © 1985-2014 Architectural Energy Corporation, Boulder,Colorado. ( xrE1Z211Y2ITIT g8 ,�lassac3�usetfa `µ DEPARTMENT OF BUILDI7TG INSPECTIONS ? 212 M�un Street • -Municipal Buildula INSPECTOR Northampton,MA 01060 LOCATION r � ;' y/ve"Sfri- 1ji'61��.��c, ' SQUARE FOOTAGE AMOUNT BASEMENT @ .20 c5�S / 7` �� I3T FLOOR @.50J ND FLR @.50 FLOORS, FINISH ATTIC,GARAGE 9.20 /�e :20 DECKT ORCHES @ L�73, �� 1 % TOTAL. s �C, � d 11 �� City of Northampton S`5 { Massachusetts w{ k" k ' DEPARTMENT OF BUILDING INSPECTIONS �- , f 212 Main Street • Municipal BuildingJ� b, Northampton, MA 01060 ssy�-•;y�tila� INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner 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 any 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 pour) a rouqh 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 1, 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. Date Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 M www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information p Please Print Legibly Name (Business/Organization/Individual): LCAur!/1 &1 I�e rf Address: y,; 7 City/State/Zip: 4 a Phone -7- d 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 employees (full and/or part-time).* have hired the sub-contractors 6. �-'New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, F-I Demolition working for me in any capacity. employees and have workers' comp. insurance.$ 9. Building addition [No workers' comp. insurance P• required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself � ' per MGL o workers comp. right of exemption p y p 12.❑ 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 fill out the section below showing their workers'compensation policy information. tHo meowners 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie. #: 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: YD Date: Z/,S.1'r 1l —7 Phone#: `//3 sel. Official 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#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable £ Name of License Holder: a.7 L 4.0 f I/) C's — t16 7 4' S 'l License Number ` 0 4 AIA 0162f 3114 f 2016 Address Expiration Date Signature Telephone 9.Re4istered Home Improvement Contractor: ,_„ , Not Applicable £ Company Name Registration Number Address Expiration Date Telephone SECTION 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...... £ 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 faun 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 WORK(check all applicable) New House Q Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks (❑ Siding[O] Other[0] Brief Description of Proposed Work: 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 house and or`adtli4ion to exisfing,housin`g, complete the followi`nq' a. Use of building : One Family i' _ Two Family Other b. Number of rooms in each family unit: Number of Bathrooms .7 c. Is there a garage attached?�y6:�:S / d. Proposed Square footage of new construction. / -3scp Dimensions ?'`l X e. Number of stories? a f A f 1' Fireplaces or Woodstoves Number of each f. Method of heating? 4=� g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction O'- r' i. Is construction within 100 ft. of wetlands? Yes _No. Is construction within 100 yr. floodplain Yes r'_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 k _ 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 prope y hereby authorize 2an LavrJo �,cs[,rl11 �vil�Cr.S' � TnC to act on my behalf, in all matters relative to work authorized by this building permit application. Signaturevpwr Date to r� 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 Sign ture of Owner A---' 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 Rear Building Height Bldg.Square Footage Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces A. Hasa Special Permit/Yahancp/Rmding ever been issued for/on the site? ��'x�� xr v��� NO ��/ DONTKNO\� YES IF YES, date issue d�| / IF YES: Was the permit recorded at the Registry ofDeeds? NO � DUw | KHuW 0 YES IF YES: enter Book and/or Document� B. Does the site contain a brook, body of water nrwetlands? NO DON7 KNOW 0 ES IF YES, has permit been or need to be obtained from the Conservation Commioion7 Needs tubeobtained v���~\ x��Obtained Date Issued: �~x ' C. Do any signs exist on the property? YES «���� NO __ iFYES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES �-\ NO _ ` IF YES, describe size' type and location: f ' E. Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre oris it part ofo common plan 1ha�wiUdi��dbmer1aoa? YES NO ' W IF YES,then a Northampton Storm Water Management Permit from the DPW is required. - ' - -� ? r �Aepartment Ilse only I 4 City of Northampton StatusofPermd n? � �� y �I E r; ! < 4 r s ah 1 1r. 'E kaF 2 Q Lu:- Building Department Ctrr�E;utlDriyewayPerrrsi#uj }F, r y n k V ti ,35 f•I a the r}Y,, + , r, + s 212 Main Street er�septGAya��rab�llty Room 100 We te�/VltelEASa�la�lhty tJ° + 4`' Pn l 1 A' ec: a ion , �; i N rthampton MA 01060 rwalSts otStrtr2ra1 Ptan's �� 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.INFORMA TION This section to be completed by office 1.1 Property Address: " a ovs Ac i Zone Overlay District + ? Elm St,Distract CB Distract SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) C rrent Mailing ddress: LQW Telephone Signature 2.2 Authorized Agent: & 2 Z—C4L(jr14 "12-1��fis� Name(Print) Current Mailing Address: y/3 - 7 - Signature Telephone-T SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be q Official Use Only completed b ermit a licant 1. Building (a)Building Permit Feb Cho, C 0 0 2. Electrical (b)Estimated Total Cost of f l O O cy Construction from 6 3. Plumbing �`� Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) 3 0 0 Od Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/inspector of Buildings Date File#BP-2014-0970 APPLICANT/CONTACT PERSON RONALD LAURIN SAP<<C 1 ADDRESS/PHONE P O BOX 437 SOUTHAMPTON (413) 527-6980 ( ) ED PROPERTY LOCATION 231 SYLVESTER RD MAP 28 PARCEL 077 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out d 4 all Q v Fee Paid Typeof Construction: CONSTRUCT SINGLE FAMILY HOUSE W/ATT GARAGE/DECK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF RMATION 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 De liti ela 6�e�- re of Bu ding fficial 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. 231 SYLVESTER RD BP-2014-0970 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 28-077 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:New Single Family House BUILDING PERMIT Permit# BP-2014-0970 Project# JS-2014-001690 Est. Cost: $230000.00 Fee: $1630.40 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RONALD LAURIN 067464 Lot Size(sq. ft.): 81282.96 Owner: LAVALLEY JEFFREY Zoning: Applicant. RONALD LAURIN AT. 231 SYLVESTER RD Applicant Address: Phone: Insurance: P O BOX 437 (413) 527-6980 WC SOUTHAMPTON MAO 1073 ISSUED ON.612512014 0:00:00 TO PERFORM THE FOLLOWING WORK.CONSTRUCT SINGLE FAMILY HOUSE WATT GARAGE/DECK 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 Sisnature: FeeType• Date Paid: Amount: Building 6/25/2014 0:00:00 $1630.40 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner