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17D-056 (2) F Y { f I ell t ♦} `.-'1 ..: _.. _... p,1 ..am f�. �,^yr r �./ �� �,� _.9' ... k t� City of Northampton 212 Main 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: The debris will be transported by: "�c N� t- E The debris will be received by: Building permit number: Name of Permit Applicant -7 /91 ' 1 H Date Signature of Permit Applicant City of Northampton Massachusetts F DEPARTMENT OF BUILDING INSPECTIONS ) T"{ 212 Main Street • Municipal Building Northampton, MA 01060 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 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 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 4 s Office of Investigations 600 Washington Street r Boston, MA 02111 x www.mass.g-ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name (Business/Organization/Individual): �e Address: Y Q Q� City/State/Zip: P[J,(t�e /114 010(_,'D Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1.❑ I am a employer with 4. 0 I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.F-1 I am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling ship and have no employees These sub-contractors have 8. F-1 Demolition working for me in any capacity. employees and have workers' g 0 Building addition [No workers' comp. insurance comp. insurance. required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs / insurance required.]t c. 152, §1(4), and we have no K Sri✓, 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. 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 $1,500.00 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 ains andiwnalties ofperjury that the information provided above is true and correct. Signature: Date: 7 OrY Phone# Official use only. Do not write in this area, to be completed by city or town official 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: Not Applicable £ Name of License Holder: �)Qs`J C S o--7-7 o License Number I _ �-i o [ � k - )�•-rice ca l G'6'l l 4? /©� / t S Address Expiration EAte (PLOO-1 re Telephone 9.Redstered Home.ImprovemenYContractor: Not Applicable £ Company Name Registration Number Address Expiration ate U►'1C CJ 14�b�— Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§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;11 H'`- ome Owner"Exempt on 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 WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks r§2!r Siding [0] Other[O] Brief Description of Proposed ! Work: l'},i���t OY► 3 X �� f�efr k, Alteration of existing bedroom Yes VN o Adding new bedroom Yes ----N o Attached Narrative Renovating unfinished basement Yes Plans Attached Roll -Sheet 6a. If New house and,or addition to existing housing, c'' flmplete 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 r+�s' r� y as Owner of the subject property /-I ► hereby authorize J e �7 gym" to act on my behalf, in all matters relative to.work authoriz d by this ilding permit application. h2Q Signature of Owner Da rlr1 � �V //1 as Owner/Authorized Agent hereby declare that the stateme a d in rmation on the foregoing applica on are rue and accurate,to the best of my knowledge and belief. Signed underthe pains and penalties of perjury. P'nt Name -7 Signature of Owner gent r Date � ^ Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning 'Mis column to be filled in by Building Department Lot Size Setbacks Front Rear Building Height Bldg.Square Footage Open Space Footage % (Lot area minus bldg&Paved V7.44 oFao #of Parking Spaces M. - (volume&Location) A. Has a Special Permit/Van ance/Fimdi been issued for/on the site? �� NO �_�~� DON7KNO/ \� ��' '�� �� |F YES, date issued:| i IF YES: Was the permit recorded at the Registry ofDeeds? NO � UUN | Knuv �c� IF YES: enter Bonk Page and/or Dncument# �� e B. Doesthesitecontain a brook' bodyofvvaterorwetiands? MO DONT KNOW �~/ YES �~�� � IF YES, has u permit been or need to be obtained from the Conservation Commission? Needs tobeobtained �~\ Obtained x�� Date Issued: v�� �� ' C. Du any d �� NO gn�exi�ton �heprnperty7 YES K ) �-J _ IF YES, describe size, type and location: 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 bon. nr filling)over 1 acre oriait part ofa common plan ' that will disturb over 1 acre? YES NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. c - Department use only City of Northampton Status of Permit W ` "� D �# Building Department Ctrrl�Cut/Dnyeyay Perrrli# s "` 212 Main Street SewerlSepticAvaitabllrty' 3 0 Room 100 Water/WelrAvatlablllty` orthampton, MA 01060 TwaSel ofS#rt[ctural Plans t E ectr c hone 13-587-1240 Fax 413-587-1272 Plofislte Plans P1i, -- -coons QtherzSpecify } APPLICATION TOZ°ONSTRUCT,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 Overlay D�strtct Elm St f]istrict C BiiD istrict SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: C Nam _ Current Mailing Address: Telephone �S, 6— Signature V (� I 2.2 Authorized Agent: /1 u� �►�' c7. ter. � LceqS / M Name(Print) ,�`' Current Mailing Address: Telephone ECT ON 3 -ESTIMATED CONSTRUCTION COSTS. Item Estimated Cost(Dollars)to be Official Use Only completed by ermit 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=0 +2+3+4+5) C,heck Number : - This Section For Official Use Only Date Building Permit Number Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0128 ��t APPLICANT/CONTACT PERSON JESSE MONTGOMERY ADDRESS/PHONE 40 OAK ST FLORENCE (413)585-8482 � Any PROPERTY LOCATION 12 VERONA ST MAP 17D PARCEL 056 001 ZONE URB000)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildina Permit Filled out Fee Paid Typeof Construction: CONSTRUCT 5 X 4 REAR DECK&STAIRS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building-Plans Included: Owner/Statement or License 077410 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO MATION PRESENTED: r pproved__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 Demoliti n Delay Si re of uilding 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. 12 VERONA ST BP-2015-0128 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-056 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ADDITION BUILDING PERMIT Permit# BP-2015-0128 Project# JS-2015-000227 Est. Cost: $3500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JESSE MONTGOMERY 077410 Lot Size(sq. ft.): 12501.72 Owner: NAGY CHRISTINE A Zoning: URB(100)/ Applicant: JESSE MONTGOMERY AT. 12 VERONA ST Applicant Address: Phone: Insurance: 40 OAK ST (413) 585-8482 FLORENCEMA01062 ISSUED ON.81412014 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 5 X 4 REAR DECK & STAIRS 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 8/4/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner