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07-060 (4) 373 NORTH FARMS RD BP-2018-1394 GIS 4: COMMONWEALTH OF MASSACHUSETTS Mali.-Block:07-060 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL C.142A) Cateeorv:renovation BUILDING PERMIT Period 4 BP-2018-1394 Pro ject# JS-2018-002475 Est.Cost: $150000.00 Fee:$975.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor., License: Use Group: HANS DALHANS 101628 Lot Size(so.ft): 32582.88 Owner: LEVINE BRIAN&AMY zoninz RR(100)/WSP(IOG)/ Applicant: HANS DALHANS AT: 373 NORTH FARMS RD Applicant Address: Phone: Insurance: 11 CHERRY ST (413) 977-6094 EASTHAMPTONMA01027 ISSUED ON:7/9/2078 0:00:00 TO PERFORM THE FOLLOWING WORK.RENOVATE EXISTING WING OF HOME WITH KITCHEN, LAUNDRY & MUDROOM. REPLACE ALL WINDOWS & SIDING 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 Occuoancv Shmarure: FeeTvpe: Date Paid: Amount: Building 7/9/2018 0:00:00 $975.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2018-1394 -� s D/✓/rG�% APPLICANT/CONTACT PERSON HANS DALHANS ADDRESS/PHONE 11 CHERRY ST EASTHAMPTON (413)977-6094 PROPERTY LOCATION 373 NORTH FARMS RD MAP 07 PARCEL 060001 ZONE RR(100)/WSP(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid TvueofConstruction RE ING WING OF HOME WITH KITCHEN LAUNDRY& MUDROOM. REPLACE ALL WINDOWS&SIDING New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 101628 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 em lition Delay ve of Builds g Q 1 ial ]-)are /J 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 -'s MR Status of Permit: Curb CutfDriveway Permit Sewer/Septic Availability WaterNYVellAvailability 60 Two Sets of Structural Plans poD -5 -1272 Plot/Site Plans NORTHAMPTON.MA01060 Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH /"AA.ONE OR TWO FAMILY DWELLING LI SECTION 1 -SITE INFORMATION / tel/ l bd— 1.1 Properly Addrear This section to be completed ce teed by offi Map Lot OIL CJ Unit 37 3 N rarms Rd- Florence, M iq v i o &"I Zone Overlay District Elm SL District CB Dlatdct SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: n Lev 31 a N FL, ms 20 Name(Print) Current Mailing Address: 413 - ,1 f.,,- 4145 Telep me Sign re 2.2 Atdhorlletl Agent: �j 11 \ n(� j� J S�' ( tiS 1 V�51vh�F1TV.�tl"'h1 . Name( nit Current Mailing Add 413 U3 6r�iJ ature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by Peit applicant 1. Building / l O�Q (a) Building Permit Fee 2. Electrical I C� (b)Estimated Total Cost of 1 �D9 Construction from 6 3. Plumbing 1 UVB Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection & Total=(1 +2+3+4+5) OOo 1 Check Number This Section For Official Use Only Building Permit Number: IDssued: Signa re: Building Ca // i wnerMspector of Buildings Date / a'q sea rpl)Lr L @ ,C/�4/. Coy✓\ �\ The Commmnwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 0211 4-2 01 7 www.em ss.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Avyllicant Information Please Print Le ibl Business/Organization Name: Address: 0 14 - City/State/Zip: A 0101�1 Phone #: r1 t Are you an employer?Check the appropriate box: Business Type(required): 1.❑ 1 am a employer with employees(full and/ 5. ❑Retail or part-time).' 6. E]Restaurant/Bar/Eating Establishment 2.❑ 1 am a sole proprietor or partnership and have no 9, ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] g. ❑Non-profit 3.10 Weare a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152,§I(4),and we have 10.❑Manufacturing no employees. [No workers'wrap.insurance required]• I 1 ❑ Health Care 4.❑ Weare a non-profit organirffiion,staffed by volunteers, with no employees. [No workers'wrap. insurance req.] 12.0 Other *Any applicant that checks bon 41 must also fill ran the section below showing ihe'uworkers compensation policy information. **nas,mrpmme oRcershive exempted @emcelves,but the coryornion has otheremployecs,a workers'compensation policy is required and such an organ'vation should check box pl. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lia# Expiration Date: 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-y 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 violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA fo uranw age verification. 1 do hereby ceand pe aLties of perjury that the information provided above is nue and correct Si a Dat Phone#: Official use only. Do not write in this area,to be completed by city or town ofjrciaL City or Town: Permit(License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Citytfown Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: SECTION E-DESCRIPTION OF PROPOSED WORK(check all applicable) New House 0 Addition Replacement,}\'Intlows Atte atlon(s) Roofing { Or Doors �, Accessory Bldg. ❑ Demolition Y/N New Signs [O] Decks [0 Siding y] Other[OJ Brief c=SI Proposed [ l� I — 1�I t �� f, p�U I�nm ,r1e�1 ,11 S Work. nJ 'r-.r _ A-�,11'Wn hgl U 6hyp W/ (L�Tr. eye , molly .raJ fA R II WI Alteration of existing bedroom es No Adding new bedroom YesNo Attached Narrative V' Renovating unfinished basement Y Nc 1 Plans Attached Roll -Sheet ty9j 1 ea. If New house and or addition to existing housina, 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 R.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. SepticTank CitySewer 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, n all matters relativd10 wo&authoriz d by this building permit application. Q✓?_ � ' .e 3/3a I i8 Signature Date I, G G ,as Owner/Authorized Agent hereby declare that Ihe statements and inforrnation on the foregoing ap ication re true anq qgodurate,to the best of my knowledge and belief. iPdht under the ins and aloes of perjury. l �v a SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su ervisc, 1 Not Applicable 0'1 Name of License Holder: 1 r ! �`� CSS ra License Number ur M� 1 oilll �Il �antR tu-te 77 Telephone !IR Istere0 Home Im rovement Contractor: Not Applicable ❑ GvS � a� opFan ��`1'4 Com Nam T I�9istration Number Address q �I Brp ti Date O/ n Telephone 13 ti I km SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submined with this application.Failure to provide this affidavit will result in the dgnial of the issuance of the building permit. Signed Affidavit Attached Yes....... Ci- No...... ❑ 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 Dnpanmcnt Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg.Square Footage Open Space Footage % (Int an,a minus bldg&paved padurno #of Parkin,Spaces Fill: o.I..a tnsatioo A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O 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 O 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 O IF YES, describe size, type and location: E. Will the construction activity disturb(Gearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton Massachusetts D212 M,n S ee BUILDING al a`i TIONS 212 Main 9CceaG HuMici010 0uilrling NoxH,empWn, Hx 01060 V i-h x�Po AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, orconstruction of an addition to any prs-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which am adjacent to such residence or building"be done by registered contractors. Note:/jthe homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work: Est.Cost: Address of Work: Date of Permit Application: I hereby certify that: Registration is not required for the following resson(s): Work excluded by law(explain): _Job under$1,000.00 _Owner obtaining own permit(explain): _Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed uAury: I hereb pe d as th agent of the own <{J D Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton Q, z' ( � Massachusetts �L`' A w x DEPARTMENT OF BUILDING INSPECTIONS 212 Hain Street • d icipal QSuilainq 1.Fs doct},emptoo, N 01060 t• O W soy^ Massachusetts Residential Building Code Section 110.R5.1.2 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. Section 110.R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. 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. City of Northampton Massachusetts DEPARTDfENT OF BUILDING INSPECTIONS "fit 212 Win Stra t •W cipal H ild ng j. Northampton, b 01060 Debris 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. The debris from construction work being performed at: (Please print house number and street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in aIdulmpster onsiterentedor leased from: p p (Company Name and Address) ck) ) gnature of Pe d Applicant or-Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed.