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32C-189 (3) t r 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: ,9' Qnum The debris will be transported by: (►'C� The debris will be received by: vs,_1 te"4 At'6L,C li'V14 Building permit number: Name of Permit Applicant Date Sign-atur f Permit Applicant City of Northampton _ Massachusetts I J .•. I�V.�.t .,,, T i �{ DEPART1=T OF BUILDING INSPECTIONS x 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 i 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 l 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 I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information P Please Print Legibly Name (Business/Organization/Individual): Address: t`- City/State/Zip: 6101,Z, Phone#: � v27 Are you an employer? Check the abpropriate box: Type of project(required): 1.❑ I am a employer with 4. 7 1 am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2.M I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g, []Demolition working for mein any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ 9. Building addition required.] 5. F� 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.El 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 employees. [No workers' 13.7 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 certi d the pains and lties ofperjury that the information provided a ove ' true and correct. Sim afore: Date: Phone#: Of facial 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: ►-(. Cs — �6 a -V License Number V0 511-712,:A-7 Address ''') Expiration D e I/A Signature Telephone 9.Re isteredHo 'I' rovement Contractor „ Not Applicable £ Comr)an-v Name Regist ton umber eo 513 w s o Address /f Expir tion ate 2Q I Telephone d(7S ' 7l q V 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 s.. ... £ No...... £ 11 Home Owner.: aemp.ion 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. I 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 [[] Siding [p] Other[0] Brief Description of P posed I , Work: e�l� �tnv /lryw"� Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement es _Na Plans Attached Rolf -Sheet sa;if New house and_or addit�on.to'exisiing houslna complete the followlncE: 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 as Owner of the subject property hereby au prize to act on alf ' all matter at a to work authorized by this building permit application. Sig er at I, At C' L 1.4j— ��' 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 un a the pains nd penalties of perjury. LCi GC Print Name Signature of Owner/Agent D t 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 3 Frontage Setbacks Front Side L•' R:_ I L 1 R:= L� Rear Building Height Bldg. Square Footage % u F Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: I (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW YES Q IF YES, date issued:! IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES Q _ IF YES: enter Book j µ Pagej_ ` and/or Document#1 i L B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO Q IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading, excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. i ! ' e f3epartment use only City of Northampton Stafus,ofPermrt k f t; t Building Department Cgrh CutfDriverivay Permit l 212 Main Street SeWerfSepticAvaifabilrty " Room 100 ii+fater/U�elA�ailabihty N rthampton, MA 01060 TwaSetsafstr�ctural Plar}s' �' 11 p n� o 587-1240 Fax 413-587-1272 P[o/SiCe Plans U "�, r X15' to p;u� ton,wit- Qther Specify �, PLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This sectiorr to be complefed by office ' 1.1 PropertyAddress: r - Map Lot r Unit ' too c,1:� vim_ 01- i!*0200- 6 © _Efm St Distrvct 7CB Distncf SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT: 2.1 Owner of Record: 5. 2-11 Name(Pr' t) Current Mailing Address: ' C) I r Telephone�l� Signat 2.2 Au oriz d A en Q S cs Name(P Current Mailing Address: Signature Telep one SECTION 3 -ESTIMATED CONSTRUCTION COSTS. . Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a).Building Permit Fee 3 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) Check Number This Section For Official Use'Onl Date Building Permif Number; Issued: Signature: Building Commissioner/Inspector`of Buildings Date File#BP-2016-0354 APPLICANT/CONTACT PERSON NICHOLAS JONES ADDRESS/PHONE P O BOX 515 WHATELY01093 (413)665-7927 PROPERTY LOCATION 5 HOCKANUM RD MAP 32C PARCEL 189 001 ZONE GB(100)/WP(64)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: REMODEL BATHROOM(UPGRADES) New Construction Non Structural interior renovations Addition to Existin Accessory Structure Building-Plans Included: Iq Owner/Statement or License 066878 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOR ION PRESENTED: 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 e y 74n e of Build g i 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. 5 HOCKANUM RD BP-2016-0354 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C- 189 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category renovation BUILDING PERMIT Permit# BP-2016-0354 Project# JS-2016-000565 Est.Cost: $8000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: NICHOLAS JONES 066878 Lot Size(sq. ft.): 19253.52 Owner: PHELPS DANICA Zoning: GB(100)/WP(64)/ Applicant: NICHOLAS JONES AT: 5 HOCKANUM RD Applicant Address: Phone: Insurance: P O BOX 515 (413) 665-7927 WHATELYMA01093 ISSUED ON.9/17/2015 0:00:00 TO PERFORM THE FOLLOWING WORK.REMODEL BATHROOM (UPGRADES) (NO WALL CHANGES) 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 9/17/2015 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner