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AT 4 an Massachusetts a�� € q ` h I; DEPARTMENT OF BUILDING INSPECTIONS a 'P z r, Ks w r +�_., 212 Main Street •Municipal Building ° a'�,b'' " ,,.w Northampton, MA 01060 1 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 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 an inspection:. - ade , /� ��/-- understand the above. ome o ner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date /z& I Address of work location • » The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations �, 4 600 Washington Street w • it , Boston, MA 02111 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: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction listed on the attached sheet. 7. ❑ Remodeling 2. ❑ I am a sole proprietor or partner- ship and have no employees These sub - contractors have 8. El Demolition for me in any capacity. employees and have workers' working Y P tY• 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions 7 ' nyself. [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' 13.0 Other 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. 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. Z o hereby certify un, 'r th , I . 'ns and penalties of perjury that the information provided above is true and correct Si afore: - . Date: i Or / Phone #: 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 #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable El Name of License Holder : License Number Address Expiration Date Signature Telephone :w, a is eredm3oine mp Ke romt, en ontractor: >; * ... Not Applicable ❑ 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 ❑ 1 1 : liome E xemption 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,,, s and State of Massachusetts General Laws Annotated. Homeowner Signature ./11161 ( t J SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) r. New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing I 1 Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [D Siding [D] Other [d1 Brief Description of Proposed 1 Work: p p � ��5 � t / 2 (SL f JCS Alteration of existing bedroom Yes No Adding new bedroom Yes,- No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa if Ne 44tIQUe aa rad o r additionto: exiEGCltha i otnpletelihe folliii4 r g: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: g Number of Bathrooms 2 c. Is there a garage attached? 1 ,,rr ( 1 d. Proposed Square footage of new construction. 'T� Dimensions ."t* 2-'2_ $ V e. Number of stories? NIA l f. Method of heating? di V\ L r Sk t96 / 1c Fireplaces or Woodstoves Number of each ' g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction ��fi� C� i. Is construction within 100 ft. of wetlands? Yes V No. Is construction within 100 yr. floodplain Yes V 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 V 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 authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date , 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. Print Name 7 �( Signa ur- , Owner /Agent D. e .... ...__.. ... . . Section 4. ZONING All Information Must Be Completed. Permit Can e Denied Due To Incomplete Information, 4, Existing Proposed Required by`Loning This column to be filled in by Building Depa j' . ent (; . w Lot Size 1 I i___ ! } Frontage Setbacks Front = 3 i Side L ° R:i L:' a R:i ` i Rear I Building Height i i 1 3 Bldg. Square Footage 7- 1 F-1 % 1-1 Open Space Footage f %���_ - (Lot area minus bldg & paved $ I �� ' parking) I I # of Parking Spaces Fill: i_____.. (volume & Location) I A. Has a Special Permit /Variance /Findin ever been issued for /on the site? NO 0 DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book ' I Page; i and /or Document # i B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained l Obtained ,Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: t D. Are there any proposed changes to or additions of signs intended for the property ? YES (0 NO e' IF YES, describe size, type and location: 1 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 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 4 F A 4 d e t #5 # y a�e�lclrtm e43 ty a5 f „:i„...,-.----k.4 _ y Cit of Northampton , S 4K- f- t ` 4R0r i � � � ` 2 �' Building Departmen c � r � ® a 7,,7...,..„..... 212 Main Street Serge en tc ° .ara »r f Room 100 3 a e a_ ea; a u �, N MA 01060 r � v � �,, p 4a3- 587 -124 Fax 413 - 587 -1272 ', Other oec ,, APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be completed b office ;, k fit, t ?. r w J eY x�c. ?, `rv” 1.1 Property Address: , � e ig This, tior i s �; s r s' x, d � 3I.. x _`c* ; ` a' "?? s�x a ,, yk fit, �r.3' €Ys E €^ .. .`v'` " ` Z'l l 5 y h a- > t " r " ,7 `wsa "' - 4k" ` i P# . L a '' otk ''.4 'r.: a Uni E s' ,P £' rr !r /�7 �1� � � . 740 '�y�� 114, �. l x : -„ 7 - . nay 'd` + "' Z one x Overlay D�strtct El m St_ , Di s trict ; . . • .z . . ° ; GB Distric 46 SEC TION 2 - PROPE OWNER /AUTHORIZ AGENT 2.1 Owner of Record: 1 1 -t Goc:),614*'1 ?IfY' Name (Print) C urrent Mailing Addr t js I . -, �� 2.2 Authorized Agent: Telephone lf 0 c) _.: Signature (' � �- l Name (Print) Current Mailing Address: Signature Telephone SECTION 3 = •ESTIMATED CONSTRUCTION TS Item Estim COS Cost (Dollars) to be Offic Use Only , completed by permit appli ° 1. Building (a)°Building'Pemiit 2. Electrical ( b) Estitst 0 0 Construction ed Total from Co t6 of t 3. Plumbing Bu ilding Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) � I) � � � Check Number ' This Sect For Official Use Only Date Building Permit Number:'. I ssuetl: Signature Building m Comissionerilnspector of Build Date • S File # BP- 2012 -0293 APPLICANT /CONTACT PERSON PHILLIPS MICHELLE J & ANDREA L PORTER ADDRESS/PHONE 36 GREGORY LN FLORENCE (413) 586 -5740 0 PROPERTY LOCATION 36 GREGORY LN MAP 29 PARCEL 529 001 ZONE URA(100) //WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out i� Fee Paid Typeof Construction:_FINISH 1/2 BASEMENT 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFQRMATION PRESENTED: L.- 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 Demolition Delay /1—'49 7/z 7t Signa re of Building Official 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. V s 36 GREGORY LN • BP- 2012 -0293 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29 - 529 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- 2012 -0293 Project # JS- 2012- 000476 Est. Cost: $10000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 8058.60 Owner: PHILLIPS MICHELLE J & ANDREA L PORTER Zoning: URA(100) //WSP Applicant: PHILLIPS MICHELLE J & ANDREA L PORTER AT: 36 GREGORY LN Applicant Address: Phone: Insurance: 36 GREGORY LN (413) 586 -5740 0 FLORENCEMA01062 ISSUED ON: 9/27/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: FINISH 1/2 BASEMENT 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 9/27/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner