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23D-168 (4) BP-2009-0415 GIS#: COMMONWEALTH OF MASSACHUSETTS ����► CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2009-0415 Project# JS-2009-000559 Est. Cost: $4200.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 144837.00 Owner: HARRIS EDWARD S&FAYE C Zoning: URB(100)/ Applicant: HARRIS EDWARD S & FAYE C AT: 134 MAPLEWOOD TERR Applicant Address: Phone: Insurance: 134 MAPLEWOOD TER FLORENCEMA01062 ISSUED ON:10/14/2008 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL FIREPLACE INSERT 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 10/14/2008 0:00:00 $25.003669 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo Department use only M'-____—rs:.City of Northampton Status of Permit: `Building Department Curb Cut/Driveway Permit �� �� 212 Main Street Sewer/Septic Availability � c�' --- ""/' .': Room 100 Water/Well Availability p. 2008 Norhtlampton, MA 01060 Two Sets of Structural Plans OCI 1phone 413- 87-1 40 Fax 413-587-1272 Plot/SitePlans ,. , Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address. l 341 m 0 pL e. 1cx 0 Trie• Map Lot Unit f L 0 (Z ),r./ e Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT i 2.1 Owner of Record: Fnw14 /Z0 S./hew/ais 13fr( /°14PLEcfvt> i_ -y�e , Name(Print) Current Mailing Address: CA /I /4114A.,%... Telephone /� S y (0 5 5-3Sign1;14.4....1 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED'CONSTRUCTION COSTS Item I Estimated Cost(Dollars)to be Official Use Only completed by permit aoolicant 1. Building I (a)Building Permit;.Fee 2. Electrical (b) Estimated Total Cost of Construction from(6) 3. Plumbing • Building Permit Fee 4. Mechanical(HVAC) 0. qp'�..0© • o C 5. Fire Protection 6. Total=(1 +2+3+4+5) 11 ;)--00•✓4 I'Check Number 14(0 SSW This Section For Official Use Only Date Building Permit Number Issued: Signature: Building Commissioner/Inspector of Buildings Date r 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:____ i i Rear __ • — Building Height — - , I _ Bldg. Square Footage —._._.._.._ I t Open Space Footage __ % _ __ (Lot area minus bldg&paved ___._.___ _,,,, naridne) #of Parking Spaces —` -- (volume&Location) —-- A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW Q YES C 4 IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW 0 YES C IF YES: enter Book Page. and/or Document# B. Does the site contain a brook, body of water or wetlands? NO J DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q Date Issued: C. Do any signs exist on the property? YES 0 NO 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,excav ion,or filling)over 1 acre or is it part of a couunun plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water -anM agemenfPennitfrom the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) i _ New House ❑ Addition 7 Replacement Windows I Alteration(s) 7 I Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition U New Signs f ] Decks [tom Siding[pj Other[)4 Brief Description of Proposed Work: =its rpc.- L A 7-1 aAl o 4.- (41 00'13 [).eu 1- fLF P1,-Ace Lhr re r Alteration of existing bedroom Yes )( No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes )t No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing.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? d I L - /1—&-r Gv 4-t I/ . Fireplaces or Woodstoves 1/ Number of each J 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? I/ Yes No. I. Septic Tank City Sewer Private well City water Supply 1/ SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETELY 141W OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PE MIT I, , 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 of Owner Date I , 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. ? ZI i - e ....i _// 1 e...-./2 . „ 6,:t.....-1....----C,„ fa — ef q — 0 .ticnature of ent Date SECTION 8-CONSTRUCTION SERVICES c.i Licensed Construction Supervisor. Not Applicable 0 Name of License Holder: License Number =.ccress Expiration Date signature Telephone Registered home improvement Contractor: Not Applicable 0 :omoanv Name Registration Number .ddress Expiration Date Telephone ECTION 1.0-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,::§:25C(G)) I 'orders Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result the denial of the issuance of the building permit.• gned Affidavit Attached Yes 0 No 0 11. Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellinzs 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 10335.1. 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,von 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 / ,,,,c4_c/ , f f _`' 4 The Commonwealth of Massachusetts =- M _. Department of Industrial Accidents - - ' Office of Investigations 600 Washington Street Boston, MLA 02111 F www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lesibly Name(Business/Organization/Individual): _ Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 4. 0 I am a general contractor and I spa.employees (full and/or pan-time).* have hired the sub-contractors 6. ❑New construction 2. a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9 0 Buildi g 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 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 2 yt c. l f2, §i(4),and we have no 1_❑Roof repairs insurance required.] 13.0 Other employees.[No workers' j comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T 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.Lie.:: 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 S 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 DL4 for insurance coverage verification. I do hereby certi under the pains and penalt of perjury that the information provided above is true and correct. Signature: tit r'a, ,,,.,/. `it..,.--t/J Date: `C? 1 y �4C . Phone#: g ` b 675 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 i Contact Person: Phone#: . . 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 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 I, e U w R r?-1) s I-1 4 iafai S 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 ( 3 (11 R/9L e-wcv o T-1' L02 b