Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
11C-017 (7)
I/ Py.act.ss A11510 t= IE_C E I V E DepartmaM we only ' City of Norham w Permit Building part en yPermi€ 212 Mai Stmt AvadablMy Room 100/11 JUN 20 P019 r 'ell Avauawl6y Northampton MA 1060 T Be of Structural Plans Z. phone 413-587-1240 Fa ,r_ , ,tin oinir,ivs� Sin Plans I_ of HA' '70N %'4 rJV6m er S readily APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Proopenv Ad""d��resss'. `1MaTThiis section to be completed by office u�',f hLs�v�, J`• Map C-- Lot 0 r Unit � 5( .�Lcc.55 Zone Overlay District Elm SL District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: h i 5e-<-nOLCLe- S(-. Name(P- ) Current eleMailin Atltlress yy - �3r -Ae9`� Tphone Signature 2.2Authod.e Acant: �I1 �wtA �L4C�fuNs� r A?.i 30„ D09 0,04,, Jl is Name PP t Current Mailing Address: �w YO —a30 9V60 Sig t reTelephone SECTION 3-E TIMATED 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 Cast of Construction from 6 3, Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) CS7Sd Check Number This Section For Official Use Only Date Building Permit Num be - Issued p Signature: L-ZO ZOry Building Commissionerinspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column m be filled in by Building D y nu meet Lot Size _...... Frontage Setbacks Front " Side L:-R: L R Rear —- Building Height Bldg.Square Footage Open Space Footage (La area minus bldg&pavoi adun #ofPa,kiag S aces -- Fill: (volume&i.ocation) _... 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 if B. Does the site contain a brook, body of water or wetlands? NO O DON'T 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 © NO O 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 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 ❑ Replacernent Windows Alteration(s) ❑ RooFlng Or Doors ED Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [O Siding [0] Other[0j 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. M New house and oraddition to existing housing, complete the Wowing. a. Use of building: One Family Two Family Other It. Number of rooms in each family unit: Number of Bathrooms a Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f Method of healing? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? In Type of construction 1. Is construction within 100 ft. of wetlands?_Yes No. Is construction within 100 yr. Floodplain_Yes No j. Depth of basement or cellar Boor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No L 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 I, J '6eyk 5y] ''\ as Owner of the subject property hereby au ze n (^ 1 to act o y bhhalf i all mattelati a elbrk authorized by this building permit 0plic ion. 04l Signatu�reoo wrier Date V1 as Owner/Authorized Agent hereby declare that the s t ments and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Sig^ne�d under the pains y\rid penalIties ofperjury, 1/0.vrU YnO.CZlv�sk Print Na Sigglitture of Own IAB nl Dat SECTION 8-CONSTRUCTION SERVICES 8.7 Licensed Construction Su ervisor: Not Apppp�Qlicable{{y�❑(� Nameof License Holder'. Z(n W- �l-0VQtp� License le, 'P, &,x C?Q I ? 5.. lr c-4,CtA M� n n m(n(n Ms I ExpluationilDatef Sign u� r Telep6dre 9.Re istemd H me Im r0" en Conk otor. Not Applicable ❑ S e1, l870ey Company Name le istrati n N bar .2 Adtlress ExpualonD e6[ r/ _ cCn(L� Telephone �^^ KTP.0 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(e)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this atfitlavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....._ No...... ❑ r _ City of Northampton S ''L Sim Massachusetts e3 c { IIBPaBTMENT OF BUILDING INSPECTIONS 212 Mein Sczeat • W. Cipal suiid., N.ith� n, MA 01060 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, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by reeistered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work: '12a IC .� � Est.Cast+1 Address of Work: 1 IY.evt c�4 �� I.-Ceps _Mas5. Date of Permit Appheation: 466 1 hereby certify that Registration is not required for the following reason(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 under the penalties of perjury: I hereby pp�y for a building permit as the agent of the owner: 4)11 z4d �4Iz/yIxk Date]—�� Contractor Na 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 Massachusetts .�. DEPARTMENT OF BUILDING INSPECTIONS 212 Nain Stx.et • tlunicipal Buildinq p .< Nartha tcn, M 01060 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 I I O 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 DEPARTMENT OF BOILDING INSPECTIONS \R' 212 Hain Street alNnicipal Baildir, q Northampton, . 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: 1 -Sr. Le ad NtKSs (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 a dumpster onsite rented or leased from: AAt,ft S �o l�a c r Ztnvn! S Wa r �as lWl ns) 0(03-) (Company Name and Address) Sig a re of ger i pplicant 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. The Commonwealth ofMassaehusetts Department of Industrial Accidents 04 1 Congress Street,Suite 100 Boston,MA 02114-20177 wway.mass.gov/dia w1liorkers'Componsation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Nalne(Busineessss/Organ afioNlndividual)I £ S �o'��'Ot\ �s^d` T 1�e.wafx�,e4la"5 e 4r1(s� Address: C- City/State/Zip: rttQ ✓ lk5_-.bene#: yf 3� a3�� 91�n(� Are you an employer'Cheek the appropriate men Type of project(required): I. aemsolpit,,with employees[full and/or pmt-time)' 7. []New construction ,,9::c . 1 am a e pmpnemr or panmrship and have no employees working for me rn g. E] Remodeling any capacity.[No worker'comp.insurance be uhed.] 3 I am a homeowner doing all work myself(No workers comp.insurance required 1 9. ❑Demolition 4.❑l am a homeowner and will be hirmg comments to conduct all work on my pro 10 E] Building addition perry. I will ens pre that all contractors either heveworkers'wmpensatiom insmvnemraresole ILE]Electrical repairs or additions pmpomor withno employees. 12.❑Plumbing repairs or additions 5am a general consomme and I have hired the sub-commanders listed on me attached sheet 13.�ROOf repairs lI mse sub-contractors have employees end have workers'comp_in.mon.c 6 El We am a omronamed and midmost,have exercised Nea dghcef exenpuon pe MOL a 14.❑Other 152,Oft),and we have no employees.(No workers'comp_imodume requiredJ bMy applicant that checks box#[must also till out the section below showing Ihdr workers compensation poliev information. i Homeowners who subrit this andavit indicating they ate doing all work and men him outside contractors must submit a new affidavit marching sucn. kontmeors that check has box an edached an additional sheet showing the mare of the sub contractor,and stare whether or not Nose critics have employees. If the sub-contractors have employees,they must provide theta workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy anal site information. Insurance Company Name: 0 Policy R or Self-ins. Lia?t77: �j19— d Expiration Date Jab Site Address: City/State/Zip'lfl (nf S Attach a copy of the workers' compensation policy declaration page(showing the policy number and a pira[ion date). Failure to secure coverage as required under MGL c. 152,g25A is a criminal violation punishable by 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 tine of up to$250.00 a day against the so efor.A copy ILL statement may be forwarded to the Office of Investigations of the DIA for insurance coverage vert£ at, n. I do hereby er ' and r e a' sand penalties ofperjury that the information provided a ve isinue and correct Si nature: q Date: Phone k: (' ' (l Q Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermiNLirense# 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written" An employer is defined as-an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer, or the receiver,or trustee of an individual, partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant ofthe dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,425C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states`Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence ofoompliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)unreels),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised thin thus affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that most submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write`all locations in,(city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proofthat a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The DepzrtmenC s address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston. MA02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia 612012019 IMG_3360.PNG 10:54 9 LTE n G hic.oca.state.ma.us questions that® submitted are required and is for this being application. reviewed. Upload any The required application documentation has been ..documentation DBA submitted Certificates and is and Proof of being Incorporation. ,reviewed. The application Submit the has been .. - application for submitted approval. and is being reviewed. The application is being Pay online for reviewed. the registrationPayment using a credit will need card or to be electronic made after check. the application has been approved. © 2019 Commonwealth of Massachusetts https:/lmail.gwgle.com/maiVul01#inboxlFWcga ChJmKNMNhllhnLLCrJw TZUm?projector=l&messagePartld=0.1 1l1