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32C-277 (5) 84 WILLIAMS ST BP-2017-1195 GIS#: COMMONWEALTH OF MASSACHUSETTS Mac:32C-277 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Deck BUILDING PERMIT Permit# BP-2017-1195 Project# JS-2017-002024 Est.Cost: $7000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 10410.84 Owner: CLARK RICKI D&MARCIA M ROE CLARK Zoning: URC(I00)/ Applicant: CLARK RICKI D & MARCIA M ROE CLARK AT: 84 WILLIAMS ST Applicant Address: Phone: Insurance: 84 WILLIAMS ST N O RT H A M PTO N MA01060 ISSUED ON:4/2 7/2 01 7 0:00:00 TO PERFORM THE FOLLOWING WORK:NEW DECKS 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 Occu.anc SUnature: FeeTvpe: Date Paid: Amount: Building 4/27/2017 0:00:00 $65.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner em- p>u File#BP-2017-1195 APPLICANT/CONTACT PERSON CLARK RICKI D&MARCIA M ROE CLARK ADDRESS/PHONE 84 WILLIAMS ST NORTHAMPTON PROPERTYOet- LOCATION 84 WILLIAMS ST MAP 32C PARCEL 277 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: dU ) alp PERMIT APPLICATION CHECKLIST P ~ ILCLISCLATh ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid `� Building Permit Filled out '�j Fee Paid Typeof Construction: NEW 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 F LLOW ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INMATION PRESENTED: Approved Additional permits required(see below) THE 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 Comminee Permit from Elm Street Commission Permit DPW Storm Water Management II ems . ion Delay '—r 97 72 Sure of C Lidding ffrcial 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. Department use only r City of Northampton Status of Permit APR 2 1 ''',iii Building Department Cud)OWOr, eway Permit 212 Main Street Sewer/Septic Availability Room 100 WaterfWell Avada0ilsy Northampton, MA 01060 Two Sets of Stnanwal Plans phone 413-587-1240 Fax 413-587-1272 PloUSite Plans Other Speary APPLICATION TO CONSTRUCT,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 df 111/f4,4rSf Map JA(. Lot x777 unit Ain,QSe.-Utitc,[ r/ 144c.ro(ua Zone Overlay District � Elm SL District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: I, Q// , / �/� A BILK Lk4rk V7 M/l/,Ia(Y �t< xL%ctayi .ai/"///'O/G GO Name(Print) Conary Mailing Address: �I ) 4/3'—S 3/- ORCIL Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: 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) 0 O Check Number /5p O 7 This Section For Official Use Only Building Permit Number: Dale saved: Signature: Building Commissioner/Inspector of Buildings 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 "/o Open Space Footage (Lot arca minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO er DONT KNOW O YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO er 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 er IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,ex lion,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 [p] � Deckss [� [CO / bIcs.s ,,,,Siding[0] Other[C Brief Description of Proposed a Peck 14 14c1/(e`/[ r(r y-4 e e I to Tie A Work: onrt .�c/Q /} Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes 7- No Attached Narrative Renovating unfinished basement Yes ✓ No Plans Attached Roll -Sheet Ga.Ifew house and or addition to existing housing.complete the following: a. Use uilding:One Family Two Family ✓ Other b. Number of rooms in each family unit: y� Number of Bathrooms c. Is there a garage attached?, No 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 Coippliance 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 CONTRACTORAPPLIES FOR BUILDING PERMIT I, '` i L.C.—K— C 'cc / r f_ ,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 offOwner Date I. 1` i cry C 14'(C ,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. R/Lhc_ e Ic,r k Print Na Signaturef Owner/Agent Da SECTION 8•CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: license Number Address Expiration Dale Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable 0 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(I) 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 1083.5.1. 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 stmctures 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 pemdt 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 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 disposalpo� facility, as defined by MGL c 111, S 150A. Address of the work: U7 /�/'/4ic C S� The debris will be transported by: SE.4u The debris will be received by: Building permit number: Name of Permit Applicant Date Signature of Permit Applicant The Commonwealth of Massachusetts .�— Department of Industrial Accidents i; =ft —.C'Wi_ Office of Investigations _ M,t_- 1 Congress Street, Suite 100 �i— Boston, MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: contractor and I Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general 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. 0 Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in anycapacity. employees and have workers' P ty 9. ❑Building addition [No workers' comp. insurance comp. insurance.: ,required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.u I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.�0[her ? comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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 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. Ido hereby certify under the pains and pen hies of perjury that the information provided above is true and correct. Signature: I^�` p � Date: 4/•to/l7 Phone#: ¢/3— 31- o572.. 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#: City of Northampton t,oh s6 , ' ;'•' Massachusetts 47 i 'e lei VA . & 4 ( ty'.r t' ` DEPARTMENT OF BUILDING INSPECTIONS � '�"� h 212 Main Seat Municipal Building cs Northampton, MB 01060 ssj:k vo`a 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 reaulredl 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 y I, R tctL C (cAc 1 ,' ( C�-ilk, understand the above. (Home owner/resident's signature requesting exemption) I will call ltto3 chedule all required building inspections necessary for the building permit issued to me. 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